The questions below offer a general framework on important records in medical errors, the liability of physicians and healthcare institutions, patient rights and avenues of application. In a specific case, time limits, documents and the regulations in force are assessed separately.
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Which records are important in a claim of medical error?
In a claim of medical error, all medical records, informed consent, the treatment timeline and an expert assessment are important.
Article 16 of the Patient Rights Regulation contains the basic provisions on the examination of records relating to health status. The discharge summary (epikriz), examination, test, surgery, medication administration, consultation, intensive care and nursing follow-up records must all be assessed chronologically. An unexpected adverse medical outcome does not, by itself, prove that the physician was at fault; a complication must be distinguished from a claim of deviation from medical standards. Which intervention the informed consent covered, whether the risks were explained and the competence of the person performing the procedure are examined separately. Where it is claimed that a record is incomplete or was created afterwards, verifiable technical data relating to the record system must be preserved.
How is the legal liability of a physician or healthcare institution determined?
The liability of a physician or healthcare institution is determined according to whether the service was provided in a public or private institution, the medical fault, the loss and an adequate causal link.
In private healthcare institutions, the possibilities of contractual and tort liability are assessed; in public healthcare services, the administrative service fault and the regime of the full remedy action are assessed. Under additional Article 18 of the Basic Law on Health Services, the investigation permit and recourse conditions relating to certain healthcare professionals may also be examined separately. Criminal liability, disciplinary proceedings and claims for pecuniary and non-pecuniary damages are not the same process. Whether the complication defense is supported by explanations and records in line with the medical standard, and the duties of disclosure, consent, follow-up and referral, must be assessed. The competent court, the application procedure and the time limit for the action must be determined according to the legal nature of the institution.
If the patient gave informed consent, is the physician not liable in any way?
No; duly given consent does not remove the obligation to perform the medical intervention in line with professional standards.
The scope of the information provided, the timing of the consent, the alternatives, the known risks and the conformity of the practice with the medical standard are investigated. Distinguishing a complication from an avoidable medical error requires expert examination.
Is an unexpected result after surgery always malpractice?
No; a bad outcome does not, by itself, mean that the physician was at fault.
The initial state of the illness, the risks, the indication for the intervention, and the surgery and follow-up records are assessed. Deviation from the medical standard, fault, loss and causal link must be examined separately.
Can a copy of the patient file be requested from the healthcare institution?
Within the framework of patient rights and personal data provisions, there may be a right of access to health records and to request a copy.
The capacity of the patient, the legal representative or the authorized attorney must be verified; the discharge summary, test, consent and surgery records should be requested explicitly. Confidentiality limitations on the health data of third parties are taken into account.
How are patient rights and remedies assessed in a health dispute?
A patient has the right to access medical records, to obtain information, to consent or, under the conditions set by law, to refuse, and to apply on the basis of an alleged violation of rights.
The Patient Rights Regulation governs the patient’s rights to request information, to review records, to privacy, to be informed and to give consent. Depending on the specific case, the procedures for applying to the health institution’s patient rights unit, administrative authorities and the relevant professional bodies may be used. These do not automatically replace a judicial claim for compensation or a criminal complaint. In claims raised on account of a service at a public hospital, the conditions of an administrative application and a full remedy action are examined separately, while in private institutions the possibility of the ordinary courts may arise. Correct legal characterization of the claim from the outset is decisive in terms of jurisdiction, time limits and proof. Taking into account the confidentiality of health records, only the necessary documents should be shared.