Medical risk is also an important issue. In general, courts release doctors from liability in this regard, provided that the risk covers only the normal consequences of treatment. The Bialystok Court of Appeal ruled as follows on this issue: “The phenomenon called medical risk is still inextricably linked to the determination of the reasons for the doctor’s liability, because even when the case is considered in accordance with current legislation. medical knowledge and diligence, the risk of damage can not be ruled out.
Medical failure is also included in the concept of tolerable risk. The risk that the patient accepts by accepting the operation is covered only by the usual postoperative complications. The patient’s risk does not extend to complications arising from the doctor’s mistake, negligence or clumsiness. ” (13). The above-mentioned judgment stated that the patient must consent to the given treatment due to the risk posed by the usual consequences of the treatment.
That is why the provision of correct and correct consent by the patient is extremely important for the legal certainty of the patient. The consent obtained from the patient must be:
- expressed by a person authorized to dispose of goods protected by law;
- is expressed by a person in an appropriate mental state (volunteering, full awareness, awareness);
- expressed in an appropriate form (implicit, oral or written for a high-risk treatment or diagnosis a patient);
- spoke before the procedure.
The basis of consent must be provided by the doctor – in an accessible and comprehensive way – with information about the real condition, depending on the patient’s situation. In addition, the doctor is obliged to inform the patient about the state of health and diagnosis, including the proposed and possible methods of diagnosis and treatment, about the expected consequences of their use or inaction, as well as about the prognosis for the future. It is very important to drive the car correctly
a way of medical documentation, which in the case of any medical negligence procedure will play a significant role in the so-called silent witness. Untrusted medical records are usually a serious probationary issue in medical error litigation, although they may be useful to the physician if kept carefully. When completing his medical records, the physician should consider the following:
- the registration in the documentation is made immediately after the provision of the medical service, legible and in chronological order;
- each record in the documentation must be identified by the person making the record;
- the entry made in the documentation cannot be deleted from it and, if it was made incorrectly, it is deleted and an annotation is included about the cause of the error, as well as the date and name of the person who made the annotation;
- the documentation pages stored in paper form are numbered and form a single whole in chronological order. In the case of a printout of electronically stored documentation, the printed pages are numbered.
Strictly established standards for keeping medical records aim to avoid errors and treatment errors that occur due to the lack of exchange of information between medical staff. It should also be remembered that unbelievable or illegible documents can pose a threat to the patient (for example, if immediate medical attention is required) and can lead to medical errors.