The primary complaint of patients shall be specified on medical records or excerpts of medical records, which is a necessary component of correct medical procedure undertaken by medical practitioners(Taiwan)

2016.07.12
Tiffany Wu

The Taiwan High Court rendered the 103-Yi-Shang-33 Civil Decision of July 22, 2016 (hereinafter, the “Decision”). The decision held the primary complaint of patients shall be specified on medical records or excerpts of medical records, which is a necessary component of correct medical procedure undertaken by medical practitioners.

According to the facts underlying this Decision, the Appellees, who were the spouse and children of the patient, asserted that the patient had sought medical attention at the Appellant’s premises due to recurrent hemorrhoids. After ordering the patient to be hospitalized for hemorrhoidectomy (hereinafter, the “Surgery”), the Appellant arranged for the patient to stay in a regular ward after the Surgery to continue recovery and treatment. However, after subsequently contracting necrotizing fasciitis as a result of hospital-acquired infection, the patient shortly died of cardiopulmonary failure and sepsis in the hospital the following day. A complaint was filed for damages since the attending surgeon of the patient committed medical negligence as he had failed to assess the diabetic history of the patient before the Surgery and elected to perform the Surgery while misjudging the danger of the Surgery, increasing the probability of patient to contract necrotizing fasciitis after the Surgery. The first instance decision was rendered in favor of the Appellees. An appeal was filed by the Appellant.

It was first pointed out in the Decision that the primary complaint of patients shall be specified on medical records or excerpts of medical records, which is a necessary component of correct medical procedure undertaken by medical practitioners

It was further pointed out in the Decision that the patient in this case had mentioned that he had no diabetic history before his hospitalization and the pre-hospitalization nursing assessment did not indicate such prior history. The patient also stated that he had no diabetic history in his pre-anesthesia assessment dated July 15, 2008 and signed the assessment for confirmation. Therefore, since the patient informed the attending surgeon on all occasions that he had no diabetic history and had no diabetic symptoms, the absence of the attending surgeon to administer other medical treatments meets reasonable medical practice. Therefore, it was held that there was no medical negligence in this case, and the Appellant’s appeal was well-grounded. Hence, the first instance decision was reversed, and a decision was rendered against the Appellees.