Importance of Medical Records in Medico-Legal Cases

Importance of Medical Records in Medico-Legal Cases

By

Prof. M. Habeeb Ghatala

Dean and Member of the Board of Directors

Princess Durru Shehvar Children’s & General Hospital

HyderabadC: 99484040701/ E: [email protected]

2015

mailto:[email protected]

Importance of Medical Records in Medico-Legal Case

Importance of Medical Records in Medico-Legal Cases

Documents provide official information or evidence. In the context of medico-legal aspects of medical

records, it is said that “Nothing is more devastating to an innocent physician’s defense against the

allegations of medical malpractice than an inaccurate of skimpy medical record.”

Medical Record

Medical record is not only a statement providing an official information or evidence about a patient, but

is a clinical, scientific, administrative and legal document related to patient care. Medical record

contains significant data recorded in the sequence of events to justify the diagnosis and warrant the

treatment and the end results.

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Medical record should be clear, concise, correct, complete and chronological record of the patient’s

illness. It should also include course of the disease, the investigations done with results, diagnosis,

treatment measures instituted, and the extent of recovery there from.

What is a Medico-Legal Case?

Any case of medical injury or ailment where some criminality is involved is called a Medico-Legal Case

(MLC). A MLC is where a person is injured or harmed in any way and needs medical attention for it.

Injury cases which suggest some criminal offence also come under the MLC.

MLC can be defined as a case of injury or ailment in which investigations by law enforcement agencies

are essential to fix the responsibility regarding the causation of the said injury or ailment. In simple

language, it is a medical case with legal implications for the attending doctor, after eliciting history and

examining patient, thinks that some investigation by law enforcement agencies is essential.

Sample of Medico-Legal Cases

There is no specialty which is immune from being the target of litigation. The most common specialties

which have medico-legal issues are Orthopedics, Obstetrics/Gynecology, Plastic and Reconstructive

Surgery and Radiology. Some examples of MLCs include: Burn and thermal injuries, vehicular accidents,

suspected homicide/murder, poisoning and suicide, sexual assault, and criminal abortion.

Following are examples of a few specialties which are vulnerable to malpractice suits:

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Obstetrics and Gynecology

In the U.S., 80% of Ob/Gyn can expect to be sued one or more times in their career. An increasing number of Obstetricians have quit practicing obstetrics. Errors in antenatal care resulting in wrongful birth, wrongful life (birth of a damaged child),

wrongful conception and wrongful death.Orthopedics

In order to avoid malpractice suits, especially in trauma cases, orthopedic surgeons should take

complete initial history and conduct thorough examination; order correct radiographs; patient

must be seen by a Consultant in A&E or orthopedic; have complete treatment plan; timing of

the surgery must be right; and operation should be carried out by appropriate level of surgeon.

Orthopedic surgeon should have a thorough understanding of diverse aspect of medico-legal

issues in clinical practice.

Radiology

It is extremely important not to miss radiological findings and look for radiological error reports.

Radiologist should be alert and observant at all times. Timely and comprehensive communication

with referring physician and patient can minimize law suits.

Anesthesiology

Death on operating table (DOT) calls for postmortem, and police investigation. It is a MLC. Police

can seize belongings of the deceased, broken ampoules of drugs used and even seal the

operation theater after taking over the dead body. In spite of continuing advances in

anesthesiology, the profession has inherent risks and there can be complications. Outstanding

communication with the surgeon and preoperative communication with the patient and family

is the key, to minimal lawsuits. Adhering to the standard of care is a prerequisite to being a

successful anesthesiologist.

Causes of Patient Injury

The top factors that actually contributed to patient injury, based on expert review of the data are:

1. Problems with clinical judgment (38%)

2. Technical skills (23%)

3. Communication (22%)

4. Patient behaviors (20%)

5. System failures (14%)

6. Documentation (13%)

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Medico-Legal Register

A medico-legal register should be maintained in the casualty of every hospital.

Details of all MLCs should be entered in this register including the time and date of examination

and the name of the doctor who is dealing with the case.

This would be of immense help when the patient through the court/the police, requests for a

copy of the medico-legal report.

A case may be register as an MLC even if it is brought several days after the incident.

Conclusion

Ignorance of medico-legal aspects of medical care is no longer a bliss to physicians or hospitals. A lot has

changed since the landmark ruling in Parmanand Kataria vs. Union of India (Supreme Court, 1989) which

was the basis of framing the Right to Life Act. Medical care must be provided to the patient in need of

it! Several research studies have concluded that refined communication with the patient and the family

can reduce the possibility of MLC in a high majority of cases. It is recommended that medical students

during their undergraduate studies as well as hospitals include the essentials of effective communication

as an integral part of studies and continuing medical education programs sponsored by the hospitals,

medical associations as well as the respective medical councils at the state and national levels. By taking

this recommendation seriously and implementing it with the assistance of professionals in

communications will be the best investment that can be made to save the dedicated medical

practitioners from un-imaginable mental stress which can take a toll on their medical practice.

Reference: V. P. Singh (Editor), Legal Issues in Medical Practice: Medico-legal Guidelines for Safe

Practice, New Delhi: Jaypee Brothers Medical Publishers, 2016.

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