The Importance of Proper Medical Registration

Author: Guy Makmel
  • Best practice
  • Customer case

Certain occurrences do not come to the mind of a medical practitioner who is focused mainly on the task at hand. However, missing out on important non-medical aspects of the treatment process, such as proper medical registration, can end up having dire consequences.

A legal dispute in the Netherlands could have landed an aesthetic practice in a financial and publicity disaster, the primary reasons being improper registration and a lack of information about the procedure and its possible complications. What could easily be fixed with streamlined medical records and procedure documentation ended up in court, with all the associated bad PR and trouble of trying to prove innocence. Let’s briefly touch on the case in question.

The Case

During a consultation meeting, the patient and the practitioner agreed upon a correction of the lower eyelids. Shortly after the procedure was done, the patient complained about her right eyelid not being able to close completely and feeling a burning sensation in her eye. The complaints were expressed via several WhatsApp messages and verbally during various checks. The practitioner conducted an exploratory repair operation free of charge. However, the causes of complaints remained.

Ultimately, the case landed in the Dutch court, with a part of the issue being that the patient was not properly informed about the possible complications and that the medical file was incomplete.

In Dutch regulation, as well as in most other countries in the world, the practitioner is strongly obliged to clearly inform the client about the intended examination and procedure, even more so if there is no medical necessity for the treatment. The accused claimed that the information was given verbally, but there was no record of this in the patient’s file and thus could not be proven.

Furthermore, the medical file should contain at least all primary data, the diagnosis, the prescribed treatment, the progress of the treatment, and the information given to the patient. The file in question lacked the motivation based on which the accused practitioner advised an eyelid correction, and, again, there was no proof that any warning about possible complications was issued to the patient.

A Lesson to Be Learned

Ultimately, the claim for financial compensation was rejected (as the part concerning the medical act was deemed to be unfounded), but not before the whole issue caused significant inconvenience to the aesthetic practice. The ruling of the Disputes Body has clearly put a strong emphasis on the importance of good information provision and reporting in the medical file.

In most cases, medical experts are not also experts in law and regulations. It is their task to help patients, not to think about possible legal repercussions of such a seemingly minor task of reporting an oral advice given to the patient.

No practitioner wants to find themselves in this situation, and neither do the clinics. This is precisely where Clinic Management Software (and EMR) comes into play. With optimized and automated medical records, the CMS takes over and cares for virtually every aspect of medical reporting and patient data management, according to strict rules and regulations that would have never allowed a case such as this in the first place.

The importance of proper medical registration is beyond vital, but tasking the medical experts with non-medical tasks decreases their efficiency and deflects their attention from what really matters. Therefore, the CMS comes as an ideal solution that streamlines medical registration reports and leaves practitioners burden-free and focused on the treatment at hand.

Here at Clinicminds, we uphold the importance of proper medical registration. This is reflected in the structured medical records and strict compliance with security and privacy standards. If you’re interested to know more, please contact us