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A study to assess completeness of the documentation of medicolegal cases in the mlc register in a tertiary care hospital

Author: 
Dr. Syed Salman Ahmed, Dr. Lakshmi Bhaskar, N., Dr. Jonnala Sindhu and Dr. Nimma Satyanarayana
Subject Area: 
Health Sciences
Abstract: 

Hospital being the first point of contact for the MLC cases, proper documentation of the cases is vital for the hospital to fulfill the legal responsibilities. Keeping clear, accurate and contemporaneous patient records is a prime responsibility of all medical practitioners. A good medical record should be comprehensive and accessible, legible and pinned to a particular date in a legal context, good patient records are always more valuable than memory. Aim: The aim of the study is to assess the completeness of the documentation of medico-legal cases in a MLC register in a tertiary care hospital. Objectives: To study the pattern of distribution of different mlc cases To study the age and gender distribution of mlc cases To study the area wise distribution of cases- urban vs rural Methodology: A total of 1530 cases were registered as medicolegal during the year 2020. Sample Size is 312 obtained from Raosoft Inc. (sample size calculator). These cases were studied by stratified random sampling (26 cases from each month) • The relevant details in the hospital mlc form were analyzed, grouped, tabulated and assessed for completeness by taking various parameters like Name, Age, Address, Brought By, Identificaton marks, Type of Injury, Diagnosis, Details of the Doctors, Overwriting, Striking Results: Out of 312, A total of only 74 mlc records were having all the parameters completely filled. 232 were males, 72 were females, 160 were from urban area and 146 were from rural area. Only 138 records had name and signature of the doctor and 174 records had only the signature of the doctor. Most common manner of injury was the RTA (172 cases out of 312). Conclusion: Vigilance and proper documentation while attending to MLC is instrumental in preventing grave consequences to the patient, the doctor or even the health institution in the court of law. Good notes corroborate evidence given in court and will enhance your credibility. Reorientation courses and Continuing Medical Education programs of medical practitioners are recommended for getting acquainted with the management of medicolegal cases

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