ATTY. ANTONIO D. REBOSA, M.D.,BSCrim M.D .,BSCrim FCLM CASTRO REBOSA REBOSA Law Offices
PHYSICIAN-PATIENT RELATIONSHIP !
Contract (Oral)
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D u t i e s / O b l i g a t i o n s are imposed on both the physician and patient Consensual and and fiduciary fiduciary
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R I G H T S S o f p a t i e n t s a n d physicians
PHYSICIAN-PATIENT RELATIONSHIP !
Contract (Oral)
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D u t i e s / O b l i g a t i o n s are imposed on both the physician and patient Consensual and and fiduciary fiduciary
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R I G H T S S o f p a t i e n t s a n d physicians
DUTIES and OBLIGATIONS Imposed on the Physician in the Physician-Patient Relationship
1. He should posses the knowledge and skill of which an average physician; General practitioner vs Specialist 2. He should use such knowledge and skill with ordinary care and diligence; 3. He is obliged to exercise the best judgment ; 4. He has the duty to observe utmost good faith.
LEGAL BASIS FOR MOONLIGHTING ! !
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MEDICAL ACT OF 1959 as amended ( registered physician) STATUS of a moonlighter
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PRC PMA Philhealth HMOs BIR
REASONS WHY PATIENTS SUE AND FILE COMPLAINTS AGAINST DOCTORS
1.
2. 3. 4. 5.
PERCEPTION THAT THE DOCTOR IS MONEYED AND SCARED OF SCANDALS AND LAWSUITS DOCTOR IS ILL-MANNERED AND ARROGANT DOCTOR NEVER APOLOGIZED OR ADMITTED HIS MISTAKE DOCTOR WAS GROSSLY NEGLIGENT INSTIGATION BY FELLOW DOCTORS
TIPS ON HOW TO AVOID LAWSUITS 1. 2. 3. 4. 5. 6. 7. 8. 9.
GOLDEN RULE GOOD RECORD KEEPING GOOD PR LEARN THE ART OF SAYING SORRY GET TRUSTED LAWYERS KEEP A MODEST LIFESTYLE KNOW THE LIMITS OF YOUR SKILL GET YOUR ACTS TOGETHER KNOW YOUR RIGHTS AND THAT OF THE PATIENT
Laws governing medical/hospital practice Sanitation Code Clinical Laboratory Hospital Licensure Law Environmental Code Law
Pharmac y Law Child Abuse Law (PD 603 R.A. 7610)
Value Added Tax Law
Generic Act
Senior Citizens Act Fire Code Sexual Harassment Act
E-Vat Anti-Detention Law
Philippine Medical Act of 1959 Civil Code of Philippines Family Code
PD 169 (Physical Injuries) R.A. 6615 / R.A. 8344 (Emergency Law)
Revised Revenue Code (Income Tax / PTR)
PTR
Revised Penal Code of the Philippines
AND MORE THAN ONE HUNDRED OTHER RELATED LAWS…………..
ARTICLE 3. Civil Code of the Philippines
Ignorance of the law excuses no one from compliance therewith.
Common Issues at the ER........... ! ! ! ! ! ! ! !
Dead/Dying on Arrival Transfer / Admission of Patients Consent Medical and Death Certificates Documentation of Injuries Hospital Deposit Collection and Preservation of evidence Autopsy
DEAD OR DYING on ARRIVAL Or DOA ! ! ! !
Diagnosis Certification Treatment Documentation
Transfer / Admission of Patients
Admission A person has no absolute right to be admitted in a hospital or to avail of hospital services. The relationship between the hospital and the patient is contractual. ! A government has no absolute privilege of choice of patients inasmuch as it is established and maintained by public funds except for justifiable grounds. !
Transfer of patients !
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It must be premised on desire and consent of the patient and when the condition of the patient would permit to do so. DO’s and DON’Ts Referral system Referral notes Ambulance conduction
Discharge of patients !
After evaluation of the patient’s condition, considers that further h os pi ta li za ti o n is no lo ng e r indispensable, a physician may order the discharge with or without condition.
Premature discharge !
The attending physician and the hospital may be held liable to the patient if the latter is discharged from the hospital in spite of the fact that f u r t h e r h o s p i t a l i z at i o n i s s t i l l necessary.
BASIC PRINCIPLES ON
CONSENT
Legal Requisites of a Valid Consent ! !
Age of majority Sound mind
Ethical Requisites of a Valid Consent Informed or enlightened consent Voluntary Subject matter must be legal
WHO CAN GIVE CONSENT?
PATIENT
BROTHERS SISTERS
NEAREST KIN
SPOUSE
GRANDPARENTS
CHILDREN
PARENTS
STATE
CONSENT . . .
WHO HAS THE DUTY TO EXPLAIN?
DOCTOR
NURSE
MEDICAL PROCEDURES
NURSING PROCEDURES
PATIENT
Admitting
Emergency Operations Without Consent !
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-When the situation is such that an immediate action is necessary to save the life or preserve the health of the patient, and getting a consent is prejudicial to the patient, the physician can legally proceed with his contemplated life-saving procedure. The law gives him the right to act under the Theory of Implied Consent or that the physician is privileged to do whatever is sound for the benefit of the patient. The refusal of the patient who is of legal age and of sound mind to submit to medical treatment shall prevail even if the danger to his life is eminent.
Medical and Death Certificates
The Medical Certificate Personal circumstances Date I hereby certify that _____ consulted (personally seen and examined by) the undersigned last (…from)______ because of _ _ _ _ _ _ _ _ _ _ _ _ . C l i n i c a l I m p r e s s i o n i s ____________.I have prescribed ______ and advised patient to rest for _________days/weeks. This medical certificate is issued for _______ purpose only and not intended for medicolegal/court use. (sgd)
NAME: ______________________________________________________ Address: Age: _________ Sex:___________ Civil Status: ______________ Date Admitted: ___________________Room No. _____________ Alleged Place, Date and Time of infliction: Date and time of examination: Findings: CONCLUSION: Under normal condition, without subsequent complications and/or deeper involvement present, but not clinically apparent at the time of examination, the above-described physical injuries shall require medical attention or shall incapacitate the victim for a period not less than ______days but not more than _______days REMARKS: Respectfully submitted: ALBERT D. REBOSA, M.D., Ll.B. Medico-Legal Consultant Lic. No. 86553
Myths and Truths of Medical and Medico-legal Certificate ! !
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Within 24 hours (x) Medical certificate can not be used for medicolegal purposes (x) Only Medico-legal officers can issue (x) Both can be the subject of sub poena (/) Awaits ancillary/laboratory results prior to give conclusion as to number of days (x) Only ER Officers can issue (x) Must have actually examined patient (x) To whom will it be released? Others . . . .
PRESCRIPTION / Rx ! ! ! ! ! !
Legible Understandable Clear and Complete Compliance with Generics Law Layman Do not use medical acronyms
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A Death Certificate is an official document setting forth particulars relating to a dead person, including the name of the individual, the date of birth and the date of death.
________________________________________ _____________________________________ ____________________________________ _________________________________________ _________________________________________ Date ___________________________________________ REVIEWED BY: ____________________fy__________ Signature over printed name of Health Center ______________________ Date 21. CORPPE DISPOSAL _____ 1 Burial _____ 3 Others ( Speci) _____ 2 Cremation __________________ 22. BURIAL / CREMATION PERMIT Number __________________________ Date Issued _______________________ 23. AUTOPSY _____ 1 Yes _____ 2 No 25. INFORMATION 8 Signature _______________________________________ Address __________________________________________ Name in Print ___________________________________ __________________________________________ Relationship to the deceased _________________________ Date __________________________________________ 26. PREPARED BY: Signature ______________________________________ Name in Print___________________________________ Title or Position__________________________________ Date __________________________________________ 27. RECEIVED AT THE OFFICE OF THE CIVIL REGISTRAR Signature _____________________________________ Name In Print _________________________________ Title or Position _______________________________ Da te ______________________________________ 9 OR OCRG USE : opulation Reference No. !"#ONLY %&'( ) *+ , -%.( TO BE FILLED UP AT THE !=" <'&-($ () $'>+?',@ OFFICE OF THE CIVIL REGISTRAR !!" $%&' () *+,&1 !:" %;' () &-' <(&-', AAAAAA! B4930CD EF4560584GE H8968I AAAAAA: ./012 .345672 .18092 8 (6789E .JF8KLM12 AAAAAAAAAA 9 4 !N" >'B;&- () O,';B%BP@ AAAAAAAAAAAAAA K43FC868/ Q88RE 9 !S" &@O' () *+,&!V" +) &+O>' *+,&-U P-+>$ X%J 5 9 AAAAA ! JL5TC8 AAAA : &QL5 AAAAA = &9LFC86U 86K" AAAAA ! )L9E6 AAAAA : J8K45/ AAAAAA = (6789 .EF8KLM12 AAAAAAAAAAAAAAAAAAA 0 3 /'-01%2 1'#30!01%3' 5 !!" P%WJ'J () $'%&86 50 51 0" <0L5 /LE80E8YK45/L6L45 4M L5M056 AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Z" 65 (6789 /LE80E8EYK45/L6L45E 4M L5M056 AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA K" <0L5 82 30689L0C /LE80E8YK45/L6L45 0MM8K6L5T L5M056 AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA /" (6789 0 30689L0C /LE80E8 YK45/L6L45 0MM8K6L5T L5M056 AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA 8" (6789 POSTMORTEM CERTIFICATE OF DEATH 98C8H056 KL9KG3E605K8E AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA I HEREBY CERTIFY that I have this _____________day of __________________, ________________performed an autopsy upon the body of the deceased and that cause of death was as follows 1"43045' 3" !022 56 03'/ 78 _____________________________________________________________________________________ _____________________________________________________________________________________________________________________________ Signature _____________________________________ T itle/Designation____________________________________ Name in Print __________________________________ Address ___________________________________________ ___________________________________________ CERTIFICATION OF EMBALMER I HEREBY CERTIFY that I have embalmed _______________________________________________________________________________ after having followed all the regulations prescribed by the Department of Health. Signature ____________________________________________ Name in Print _________________________________________ Address ______________________________________________ ____________________________________________________ Title/Designation_____________________________________ License No. __________________________________________ Issued on _________ at ________________________________ Expiry
_____________ __________________ ________________ _____________________________________________________________________________________ ________________________________________________________________________________________________________________ Signature _____________________________________ Title/Designation____________________________________ Name in Print ____ ___________________________________________ ___________________________________________ CERTIFICATION OF EMBALMER I HEREBY CERTIFY that I have embalmed _____________________________________________________________________________ Department of Health. Signature ____________________________________________ Name in Print _________________________________________ Addres ____________________________________________________ Title/Designation_____________________________________ License No. __________________________________________ Issued on Date __________________________________________ Republic of the Phili ppines ________________________________________ ) Province of ____________________________________________________ City/Municipality ____________________________________ AFFIDAVIT FOR DELAYED REGISTRATION OF DEATH I, _________________________________________________________________________________, of legal are, single/married, after and say:
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SUBSCRIBED AND SWORN to before me this _____________day of ______________________________, _________________________ !:" %;' () &-' <(&-', AAAAAA! B4930CD EF4560584GE H8968I AAAAAA: __________________________________________________________________________________________________ , Philippines. (6789E .JF8KLM12 AAAAAAAAAA ___________________________________________ (Signature of Administering Officer) ___________________________________________ (Name in Print) !N" >'B;&- () O,';B%BP@ AAAAAAAAAAAAAA K43FC868/ Q88RE _____________________________________________ (Title/Designation) !S" &@O' () *+,&!V" +) &+O>' *+,&-U P-+>$ X%J _____________________________________________ (Address) ) S. S. AAAAA ! JL5TC8 AAAA : &QL5 AAAAA = &9LFC86U 86K" AAAAA ! )L9E6 AAAAA : J8K45/ AAAAAA = (6789 .EF8KLM12 AAAAAAAAAAAAAAAAAAA ./012 .345672 .18092
/'-01%2 1'#30!01%3'
!!" P%WJ'J () $'%&0" <0L5 /LE80E8YK45/L6L45 4M L5M056 AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Z" (6789 /LE80E8EYK45/L6L45E 4M L5M056 AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA K" <0L5 30689L0C /LE80E8YK45/L6L45 0MM8K6L5T L5M056 AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA /" (6789 30689L0C /LE80E8 YK45/L6L45 0MM8K6L5T L5M056 AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA 8" (6789 98C8H056 KL9KG3E605K8E AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA 1"43045' 3" !022 56 03'/ 78
Certification of Death . . . who should sign? . . .Ideally, the one who pronounced death.
Death Certificate . . .
Cause of Death !
Immediate cause
Antecedent cause ! Underlying !
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Contributory
Death Certificate
Immediate Cause . . .
direct ! no intervening event !
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directly causing cardio-respiratory arrest
Death Certificate . . . Antecedent Cause of Death ! !
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Leads to immediate cause of death May or may not be the main disease condition / injury may or may not be direct
Death Certificate . . .
Underlying Cause ! !
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another disease entity or injury may or may not be related to immediate or antecedent cause no direct relationship with cardiorespiratory arrest may be independent
Death Certificate . . .
Contributory cause/s !
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Any other disease condition or injury may or may not be related to any of the other cause/s death never directly related to cardiorespiratory arrest
Death Certificate . . .
Cause/s of Death ! ! !
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Immediate : Antecedent : Underlying : wound, chest, right Contributory:
Septicemia Pneumonia Gunshot
Renal failure
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The most recent condition written on top line of the certificate that directly leads to death is the immediate cause. Other intervening cause (or causes) of death occurring between the underlying and immediate causes is called the antecedent cause. Depending on the number of entries or causes of death reported in the Medical Certificate portion of the Certificate of Death, there can be one, or more than one reported 19b CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death antecedent causes of death. It is even possible not to have an intervening I. Immediate cause :a. Hypovolemic shock 1 HOUR Antecedent cause :b. Multiple fractures 5 HOURS Underlying cause :c. Pedestrian hit by a truck 5 HOURS II. Other significant conditions contributing to death: cause at all if only one line (immediate cause) or two lines (immediate and underlying cause) are filled out.
Dismembered Body Parts !
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In cases when a dismembered body part which is non-viable for attachment is brought to the ER, such body part shall be forwarded to the surgical pathology section of the laboratory for gross and microscopic examination and documentation. The surgical pathology report signed and issued by the pathologist shall serve as the Certificate of Dismembered Body Part which may be used for burial purposes or proper disposal. Body parts surgically removed (e.g., amputated foot due to diabetes mellitus or accidental chopping o the hand of a machinist because of a technical machine problem) are not considered as death of a person. Hence, document containing such body parts should not be registered since these are for burial purposes only. The practice of issuing a Certificate of Death by the attending physician for the dismembered body part is not necessary.
For Death that Occurred in the Hospital !
When a death occurs, the physician who last attended the deceased or the administrator of the hospital or clinic where the person died is responsible to prepare the COD and certify as to the cause of death.
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The certificate is forwarded, within 48 hours after death, to the local health officer who will review the certificate and affix his signature in the “Reviewed By” portion and direct its registration at within 30 days.
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For Death in Hospital Emergency Room (ER)
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Emergency Room deaths refer to deaths of patients occurring in the ER, including patients who were revived by initial resuscitative measures at the ER but eventually died there, regardless of the time of stay in ER. In such cases, the Certificate of Death shall be accomplished by the ER officer if he can provide a de nite diagnosis. Otherwise, the death should be referred to the medico-legal officer of the hospital or the local health officer who shall cause the issuance of the Certi cate of Death.
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For Death that Occurred in the Ambulance When a death occurs in the ambulance while the patient is being transferred to another healthcare facility, the attending physician during the transport of the patient shall accomplish the Certificate of Death.
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For Death under Medico-Legal Examination
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When faced with the duty of completing the Medical Certi cate portion of the Certi cate of Death, the physician has to determine rst and foremost whether the death is reportable or not and then, determine whether another physician is more quali ed to complete the certi cate especially if the deceased was attended by another physician prior to his death. If the physician has reasons to believe or suspect that the cause of death was due to violence or crime (or that he is dealing with a medico-legal case), then he is duty-bound to immediately report to the authorities of the Philippine National Police (PNP) or the National Bureau of Investigation (NBI). There is violence or crime when the cause of death was due, but not limited, to the following: Stab wounds Gunshot wounds Suicide of any kind Strangulation Accident resulting to death Actual physical assault in icting injuries upon a person resulting to death Any other acts of violence upon a person resulting to death Sudden death of undetermined cause.
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Who certifies the Certificate of Death? "
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If there is a medical attendant at death, the certifying officer is the attendant at death. If there is no medical attendant at death, the certifying officer is the Local Health O cer. In medico-legal cases, the certifying o cer is the medico-legal officer.
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No matter what you do, the patient can give you problems whether he is ALIVE, DYING or DEAD!
Documentation of Injuries
DOCUMENTATION ALLEGED place, date, time of infliction Nature(?) Date and time of examination (important in the determination whether injuries are compatible/ consistent with the date and time of infliction)
INJURIES ! ! ! !
NATURE SHAPE MEASUREMENT ANATOMICAL LOCATION
CONTUSION/BRUISE (pasa) HEMATOMA (Blood Cyst/tumor/ bukol) ABRASIONS ( gasgas) LACERATED/AVULSED WOUND INCISED (SLICED/CUT) WOUND STAB WOUND HACKING WOUND PUNCTURED WOUND GUNSHOT WOUNDS BURNS .. Due to flame or fire SCALDING.. Due to boiling liquid
HOSPITAL DEPOSIT - NO DEPOSIT LAW - Prohibiting the Detention of Patients in Hospitals and Medical Clinics on Grounds of Non-Payment of Hospital Bills or Medical Expenses
PRESIDENTIAL DECREE NO. 169
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MANDATORY REPORTING OF CASES BY PHYSICIANS INVOLVING LESS SERIOUS AND SERIOUS PHYSICAL INJURIES TO POLICE AUTHORITIES penalty of 1-3 years imprisonment, P1,000.00-3,000.00 fine and revocation of license
When May the Contents of the Record be Disclosed 1.
When requested by the patient or by someone who could act in his behalf which must be made in writing; 2. When the law requires such disclosure; 3. Upon a lawful order of the court. N.B. ! The attending physician has no legal right to determine who shall and who shall not see the record. At the most, his approval or permission is only a matter of courtesy. ! Members of the resident staff, student and attending medical staff may freely consult such records as pertain to their work.
Malpractice cases
Fault or Negligence Attributed to the following . . . !
Clinicians
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Administrative
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Ancillary
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Etc.
Specialties . . . 2006-2011 • •
OB-GYNECOLOGY SURGERY
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PEDIATRICS ANESTHESIOLOGY OTHERS
Profile of complainant patients (review of 60 cases ) . . . .
Visayas
Mindanao
Luzon
Metro manila
Place of Incident
Profile of complainant patients (review of 250 cases ) . . . .
others Gov’t / relative Doctor Relative
Relatives (within 6th degree)
Lawyer / relative
GOLDEN RULES Document properly medication sheet - Explain to patient purpose and importance of medications - Communicate with patient about medications - Document efforts to communicate especially non-compliant patients. -
Chart notes should be easy to read - NEVER alter records - NEVER intentionally misdate notes or enter signatures and initials or reports later than the date reviewed unless the correct date is also entered. - Secure and document CONSENT always. -
SEXUAL HARRASSMENT ! ! !
PROPER SET-UP – PE CONSENT MANNERS
Professional Fees ! ! ! ! ! !
How to charge Rebates and referrals Factors affecting professional fees Non-payment of fees PTR Issuance of receipts
Factors in Determining Fees ! ! ! !
Time allotted Difficulty of the case Social standing of the MD Financial capability of the patient
MALPRACTICE SUITS
Usual Cases ! ! ! ! ! !
Death of the patient Failed surgery Surgical complications Laparoscopic complications Complications of Appendectomy Retained gauze / foreign bodies
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Anesthetic accidents Uterine atony Placenta accreta/previa Dengue Cases Anaphylactic reactions Wrong blood/medications/route
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Wrong/misdiagnosis Interchanged results Hospital acquired infections Necrotic IV Site Sexual Harassment
Inappropriate remarks/ behavior Immorality Sexual Harassment/manner of examination
Unusual Cases ! ! ! ! ! ! !
Wrong organ remove Improper attire Baby falls during delivery Wrong baby assigned to the mother Retained spinal needle Rape Expired drugs
BIZZARE CASES ! ! !
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Lost specimen Treating a patient in the Casino Injury sustained due to defective ceiling/wall fan/drop lights Wrong baby assigned to the mother
SOME UNETHICAL PRACTICES OF PHYSICIANS… !
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Breach of confidentiality/Consent issues Fake training/misrepresentation and unusual practices Fees/Piracy Unethical advertisements Relationship with other specialties Engaged in private practice (government physician) Obscene language Ghost Specialist
Peculiar Factors That Lead To Malpractice Suits ! ! !
Took place on a Sunday or holiday Appendectomy Walk-in patients
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MARAMING SALAMAT PO!!!
•Atty. Tony D. Rebosa,MD,BSCrim !
Castro Rebosa Rebosa Law Office
Retr
Maniacs
RJ Bar at DUSIT HOTEL, HOTEL, Makati City City every other Saturdays
good Rapport!
EAST AVENUE MEDICAL CENTER, March 27, 2008
