Doctor not writing necessary details in prescription-Whether it amounts to medical negligence?

Arvind Shah (Dr.) v Kamlaben Kushwaha [III (2009) CPJ 121]

Date of Decision: 30.04.2009

The complainant alleged that her deceased son, aged 20 years and otherwise healthy, died as a result of medical 

negligence on the part of the appellant doctor (original opposite party) who administered wrong treatment. The 

State Commission awarded to the complainant a compensation of Rs. 5 lakh with interest and costs. In appeal, 

the National Commission, on consideration of the material on record, came to the conclusion that the two 

medical prescriptions, which the doctor sought to deny, could have been written only by him. It also observed 

that though, in the appeal, the doctor admitted for the first time to having treated the patient; he did not produce 

any prescription on record. More important, the two prescriptions available on record did not mention any of the 

patient's complaints/symptoms, the doctor's clinical observations on examining the patient or his diagnosis of 


the ailment. Even the ordinary vital parameters like temperature, blood pressure, pulse rate, etc., were not 

noted. The Commission observed that the Medical Council of India or the State Medical Council, 

with one of which the doctor had to be registered to practice modern (allopathic) medicine, 

required, through their respective codes of ethics/guidelines/ regulations, to make some minimal 

record even for outpatients. Such a record would ordinarily include a summary of the history of 

illness and current complaints/symptoms of the patient and clinical observations of the doctor. If 

the doctor considered none of the above as essential, he would need to at least record a provisional 

diagnosis of the patient's ailment in the prescription while advising further diagnostic test(s) or 

treatment (medicines/injections). This was one of the primary duties of disclosure owed by a 

physician of ordinary skills to his patient. The Commission held that in line with the Apex Court's 

decision in Samira Kohli v Dr. Prabha Manchanda [I (2008) CPJ 56 (SC)] regarding need for valid prior 

consent of the patient for his treatment by a doctor and the doctor's corresponding duty of 

disclosure, it was essential for the doctor to write a prescription with such necessary details and 

failure to do so would constitute medical negligence. The Commission further observed that if a 

patient found that the doctor's treatment did not help ease his felt problem and wanted to consult 

another, a prescription with such details would be necessary. On the other hand, a prescription 

meeting these basic requirements would also assist a doctor in demonstrating that he had treated 

his patient with due care, if charged with a wrong/false allegation of negligence by the patient. 

While returning a finding of medical negligence against the doctor, the Commission found that the material on 

record case was insufficient to attribute the patient's death directly and wholly to the doctor's negligence. 

Accordingly, it scaled down the compensation to Rs. 2.5 lakh along with interest.

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