Importance of Medical Records in Medico-Legal Cases

By
Prof. M. Habeeb Ghatala
Dean and Member of the Board of Directors
Princess Durru Shehvar Childrens & General Hospital
Hyderabad
C: 99484040701/ E: habeeb.ghatala@gmail.com
2015

Importance of Medical Records in Medico-Legal Cases

Importance of Medical Records in Medico-Legal Case

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 physicians 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.

Importance of Medical Records in Medico-Legal Case

Medical record should be clear, concise, correct, complete and chronological record
of the patients 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

Importance of Medical Records in Medico-Legal Case

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:
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

Importance of Medical Records in Medico-Legal Case

The top factors that actually contributed to patient injury, based on expert review of
the data are:
1.
2.
3.
4.
5.
6.

Problems with clinical judgment (38%)

Technical skills (23%)
Communication (22%)
Patient behaviors (20%)
System failures (14%)
Documentation (13%)

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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Importance of Medical Records in Medico-Legal Case

Importance of Medical Records in Medico-Legal Case

Importance of Medical Records in Medico-Legal Case