May 12, 2015
1 min read

Quality of medical records, informed consent and expert reports influential on judicial decisions

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In cases where malpractice claims were brought against plastic surgeons, researchers found the factors most influential on judicial decisions were the quality of the patient medical records, whether written informed consent was obtained and the conclusions provided by the expert report.

The researchers obtained data for 98 malpractice claims from a state court of justice in Brazil that were filed between 2000 and 2008, with 39 closed cases selected for analysis within the study. For each case, the researchers reviewed the date of decision, the complaint or complaints made, conclusions from the expert reports, the presence of absence of informed consent, patients’ medical records and the judicial decision. Data were then compared using the chi-square test, Cramer’s V coefficient, Fisher’s exact test and the Cochran-Armitage test.

Most cases were associated with breast surgery (32%), followed by abdominoplasty (24%) and rhinoplasty and liposuction (22% each). Results of the analysis showed the majority of complaints filed were related to scarring and resulting contour (48.9%), followed by general dissatisfaction with the results (25.6%) and postoperative clinical complications (25.2%).

The researchers found a significant association between the presence of a verifiable, written informed consent and a decision in favor of the surgeon. In all cases where the judge considered the patient’s medical records to be well-maintained, the surgeon was found not guilty, and in all cases where the judge found the patient’s medical records poorly maintained, the surgeon was found guilty.

The researchers recommended improving the quality of informed consent documentation by reviewing the documents with a lawyer and ensuring that the content is clearly written for ease of understanding. - by Abigail Sutton

Disclosure: The researchers report no relevant financial disclosures.