BRIEF REVIEW ON

DOCUMENTATION &
MEDICOLEGAL
By Dr Muhammad Nur Awis Bin Azizan
 Prelude
 The words “doctor”, “physician”, “medical practitioner” and
“practitioner” are used interchangeably, and refer to any person
registered as a medical practitioner under the Medical Act 1971. The
words “hospital” and “healthcare facility and service” are used
interchangeably and refer to any premises in which members of the
public receive healthcare services. Words denoting one gender shall
include the other gender. Words denoting a singular number shall
include the plural and vice versa.
 Case Scenario
 Case scenario 1
 Can medical practitioner withhold any information from the patient regarding patient illness?

 Case scenario 2
 Can patient request patient’s RVD status being kept secret from spouse?

 Case scenario 3
 Can the employer ask for the employee medical report?

 Case scenario 4
 Should the medical practitioner write “alcohol smell” or “under alcohol influence”?
 Ethical Principal
 Confidentiality
 Respect to patient privacy equals maintaining confidentiality
 Allow people to seek treatment & discuss

 Justification
 Recognition of patient autonomy
 Protects doctors/personnel integrity
 Medical confidentiality

 Duty of confidentiality
 Patient expectation
 Professional expectation
 Doctor – patient relationship
 The clinical import of “confidentiality” is often confused with the legal concept of
“privilege”.
 The term confidentiality involves the ethical duty of the clinician not to disclose
information about a patient without authorization. As it applies to healthcare
information.
 The term privilege involves a legal rule of evidence that gives a patient the right to
exclude from a legal proceeding certain communications made by the patient to a
clinician .
 Confidentiality (“co”) is the clinician's obligation not to disclose confidential
information about a patient, while privilege(“pr”) deals with the patient's right to
exclude from a legal proceeding communications made to a treating clinician.
 While the ethical duty of confidentiality is universal, the legal concept of privilege is not
uniformly recognized or applied in all jurisdictions.
 Duty of Confidentiality
 Not absolute
 Breaching confidentiality – Five C’s
 Consent
 Court order
 Continued treatment
 Comply with law
 Communicate a Threat
 Breaching Confidentiality
 Consent—A clinician may release confidential information with the consent of the
patient or a legally authorized surrogate decision maker, such as a parent, guardian, or
other surrogate designated by an advance medical directive.
 Court Order—A clinician may release confidential information upon the receipt of an
order by a court of competent jurisdiction. (Note: Unless issued by a judge, a
subpoena should not be considered the equivalent of a court order in many
jurisdictions.)
 Continued Treatment—A clinician may release confidential information necessary for
the continued treatment of a patient.
 Breaching Confidentiality
 Comply with the Law—A clinician may reveal confidential information in order to
comply with mandatory reporting statutes (e.g., child abuse), law enforcement or
administrative agency investigations, business operations, and other such lawful
purposes.
 Communicate a Threat—This is the well known Tarasoff exception to confidentiality
that involves the clinician's duty to protect others from violence by a patient. The
Tarasoff exception exists in a variety of forms in many jurisdictions
 Breaching Confidentiality
 Disclosure of HIV / AIDS status
 Under common law
 Can be disclosed provided:
1. There is real risk to the people to be informed.
2. Disclosure is the only way to protect them.
 In Malaysia (HIV/AIDS Charter)
 “Doctor should, without prejudice & discrimination, when carrying out or other test, ensure that
adequate pre- & post- test counseling is conducted to ensure consent to testing”.
 “Shall be encouraged to inform the attending medical personnel of their HIV status & info about a
patient’s HIV status shall be restricted to medical professionals and other authorized personnel on
need to know basis”.
 How to DEAL
 Duty—Does the clinician have a duty to maintain confidentiality in the context of a
treatment relationship or for some other reason?
 Exception—Does an exception exist? (Use the Five C's as a guide)
 Ask—Consider asking for help, such as a consultation from a colleague, risk manager,
or attorney.
 Law—Be familiar with the law of the jurisdiction and the confidentiality policy of the
facility or organization
 Take Home Message
 Respect patient privacy & confidentiality
 Be mindful who is around you when communicate with patients
 When we can disclose;
 FIVE C’s
DOCUMENTATIONS
 Documentations
 Integral part of medical practice
 “Any written or electronically generated info about patient that describes the care or
service provided to patient”.
 Need to be adequate, accurate, unambiguous notes as circumstances warrant.
 MEDICAL DOCUMENTATION
 Medical record - documented information about the health of an identifiable individual
recorded by a practitioner or other healthcare professional, either personally or at his or her
instructions.

sufficient information
 identify thepatient
 support the diagnosis based onhistory
 physical examination andinvestigations
 justify the professional managementgiven
 record the course and results
 MEDICAL DOCUMENTATION
 Meticulously and laboriously recordedto ensure that anytime in the future these records
can be completely relied upon to provide a comprehensive and satisfactory explanation to
what happened at that material time.

 Proper and appropriate Medical Documentation is the hallmarkof good medical practice
 The problem as well as the solution..
 Medical documentation will not come into play in the near future but will be called into
questions years later (court, internal or external inquiry) when the practitioner or members of
the healthcare team that provided the care will no longer be at the scene, or even if they are
there they will not be able to recollect exactly what happened to that particular patient,
having attended to hundreds, if not thousands of patientssubsequently.
 Only the actual records will be there to tell the story
 Common Problem
 Illegible handwriting
 Incomplete entry(date, time, name of doctor/nurse)
 Unorganized entry
 Lost or missingrecords
 Late delivery of documents when requested by AG’s Chambers
 CTG tracing – not clear
 Copy and paste
MEDICAL DOCUMENTATION
 Medico Legal Evidence And Documentation
 Medical examination = Forensic
 Forensic = evidence and documentation
 One chance and only once, to examine and collect forensic evidence
 Contemporaneous notes, medical records, medical report = documentary evidence
 Doctors give oral evidence under oath or report submitted as documentary evidence
 Konsep Rekod Perubatan Lengkap

Catatan:
Maklumat Pindaan maklumat
lengkap, jelas
mengenai tidak dibenarkan.
& senang arahan lisan, Sekiranya ada
dibaca pemeriksaan kesilapan ia perlu
dan rawatan dipotong dan
perlu ditandatangan
Catatan: masa didoku menkan. dengan tarikh.
dan tarikh
serta Hanya
ditandatangani menggunakan
dan dicop. ringkasan
perkataan yang
standard
Sebarang maklumat
tambahan pada masa Setiap muka
dan tarikh berbeza
surat
hendaklah diletakkan
sebagai “addendum” hendaklah
dan ditandatangani ditulis nama
beserta tarikh. dan no. IC
pesakit
 Konsep Rekod Perubatan Lengkap

1 - Catatan lengkap, jelas dan senang dibaca.

2- Catatan hendaklah dinyatakan masa dan
tarikh serta ditandatangani dan dicop.
3 Maklumat mengenai arahan lisan,
pemeriksaan dan rawatan perlu
didokumenkan.
4 Pindaan maklumat tidak dibenarkan.
Sekiranya ada kesilapan ia perlu dipotong
dan ditandatangan dengan tarikh.
Konsep Laporan Perubatan Lengkap
 Medical Records Issues
 Use of abbreviations
 Generally need to be avoided

 Correction to notes
 Erasure or blacking out entries – to be avoided
 Suggest neatly crossed out, but still readable, then make a new entry and signatories
 The tampering of clinical notes should be avoided as this may be interpreted as a member of the
management team making alterations to cover up some mistakes in the management of the patient.

 Patients right to medical records

 While patients have right of such access to their Medical Records, they may be permitted to inform the
practitioner of any factual errors in the personal patient information.
 They should not seek to change any entries made by the practitioner in the course of consultation,
diagnosis and management as these are made by the practitioner based on his clinical judgement.
 Medical Records Issues
 Disclosure of information
 Release of information from the Medical Records to Third Party Payers and Managed Care
Organisations, and through them to the employers, should only be made with the informed consent of
the employee/patient.
 Informed consent for disclosure must be on a case-by-case basis and should be obtained by the
practitioner personally from the patient.
 This is to safeguard the patient’s right as some points in the disclosure may adversely affect or
influence the patient’s employment status.

 Ownership – belong to the practitioner

 Medical Records of patients, intellectually to the practitioner (and the healthcare facility or services) and
ethically to the patient.

 Denial of disclosure
 The practitioner may deny disclosure of the contents if released may be detrimental or disparaging to
the patient, or any other individual, or liable to cause serious harm to the patient’s mental or physical
health or endanger his life.
 Medical Report
Duties & Responsibility When Preparing
 Independent product of expert
 uninfluenced

 Independent assistance to court

 Unbiased opinion
 State the facts or assumptions upon which his opinion is based

 Clear if any issue falls outside his/her expertise

 Know our boundaries of expertise

 If expert opinion is not properly research because he considers that insufficient data is
available…therefore should state that the opinion is a provisional.

Source : National Justice Compania Naviera SA v Prudential

Assurance Company Ltd (1993) Lloyd’s Rep 68 at 81-81 ; The Ikarian
Reefer
 Case Scenario
 Case scenario 1
 Can medical practitioner withhold any information from the patient regarding patient illness?

 Case scenario 2
 Can patient request patient’s RVD status being kept secret from spouse?

 Case scenario 3
 Can the employer ask for the employee medical report?

 Case scenario 4
 Should the medical practitioner write “alcohol smell” or “under alcohol influence”?