Medical Records legal aspects

1. Medico Legal Aspects
Of Medical Records
SUBJECT – MEDICAL RECORDS MANAGEMENT
SEMESTER – III
MBA HCA
MUHS
ASHOKA INSTITUTE OF HEALTHCARE

5. Who can label case as MLC
Casualty doctor (emergency physician) attending the case. The doctor who
has -First contact with patient should prepare an ML case report.
In rape victims the examination and preparation of MLC is done by A female
doctor.
Indoor treating doctors can also make the case MLC if they think it should
have been made but it wasn‟t made
Patient or their relatives request to label a case MLC or not, shall have no
effect on doctor’s decision

6. Background
 1985 „‟Decision Of The Committee‟‟ The committee under the
chairmanship of the Director- General of Health Services had taken the
following decisions:
Whenever any MLC arrives the hospital, the medical officer on duty should
inform the duty constable, name, age, sex of the patient and place and
time of occurrence of the incident, and should start the required treatment
of the patient.
 Zonalisation for the hospitals to deal with medico-legal case will only apply
to those cases that are brought by the police.
 All government hospitals, medical institutes should be asked to provide the
immediate medical aid to all the cases irrespective of the fact whether they
are medico legal cases or otherwise

7. Medicolegal aspect of Demographic
information of patient in MR
 Particular case may have a distinct profile in demographic and clinical terms.
 Increased scientific attention is hoped, particularly focused on addressing a better definition of
diagnostic criteria, whose correctness and accuracy are critical, especially in situations with
medicolegal implications.

8. Medicolegal aspect of Pt’s Reg. in
HIS
 Unique Identification No. is provided to patient which is permanent in nature. With
the help of which the patients status and other information in hospital can be
tracked
For eg. Permanent birth marks of the patient can stored as permanent information in
this record which can be studied later in forensic investigations in case needed in
future in legal cases.

9. Information for fullfilmaent of legal
documents requirement
 Birth Certificate
 Death certificate
 Fitness Certificate
 Informed Consent forms
 PM report
 Pathological Reports

10. Legal documents in case of Claimed
Cases
 Admission Notes
 Admission Record
 Investigation Reports
 Consents – Informed consent for specific procedure

11. Legality in case of Indemnity
 All the information and treatment progress reports duly signed by doctors
maintained by the hospital
 All copies of consent with signature of patient/relative

12.  THANK YOU