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LEGAL ASPECTS OF
MEDICAL RECORDS
PREPARED AND PRESENTED BY
R. MAHENDIRAN, M.B.A (H.A) M.com, B.M.R.Sc., PGDCA.
Sr. Manager-Medical Records,
Medical Records Department,
Apollo Hospitals, Bhubaneswar-Odisha, India
LEGAL ASPECTS OF MEDICAL
RECORDS
INTRODUCTION
• Medico legal cases (MLC) are an integral part of
medical practice that is frequently encountered by
Medical Officers (MO). The occurrence of MLCs is
on the increase, both in the Civil as well as in the
Armed Forces. Proper handling and accurate
documentation of these cases is of prime importance
to avoid legal complications and to ensure that the
Next of Kin (NOK) receive the entitled benefits.
• All medical officers working in hospitals / field
medical units / non medical units encounter medico
legal issues which should be handled in accordance
with the law of the land and directives issued by
service headquarters.
LEGAL ASPECTS OF MEDICAL
RECORDS
MLCs in Medical Practice:
• MLC. A MLC is defined as “any case of injury
or ailment where, the attending doctor after
history taking and clinical examination
considers that investigations by law
enforcement agencies (and also superior
military authorities) are warranted to
ascertain circumstances and fix
responsibility regarding the said injury or
ailment according to the law”.
Labeling a case as MLC.
• RMO / Casualty medical officer / MO in
charge of MI Room / Duty Medical Officer
(DMO) / MO In charge ward, who is
WHAT IS MEANT BY MEDICO
LEGAL CASE ?
WHAT IS MEANT BY MEDICO
LEGAL CASE?
Medicolegal is something that involves both
medical and legal aspects, mainly:
Medical jurisprudence, a branch of medicine
Medical law, a branch of law
Medico-Legal Case: can be defined as a
case of injury or ailment, etc., in which investigations
by the law-enforcing 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
where the attending doctor, after eliciting history and
examining the patient, thinks that some investigation
by law enforcement agencies is essential. Or a legal
What are the incidents will
comes under the MLC?
What are the incidents will comes
under the MLC?
The following are some of the examples of
MLCs and medical officers should use their
professional judgment to decide any other cases
not enumerated in the list:(a) Assault and battery, including domestic
violence and child abuse
(b) Accidents like Road Traffic Accidents
(RTA), industrial accidents etc.
(c) Cases of trauma with suspicion of foul play
(d) Electrical injuries
(e) Poisoning, Alcohol Intoxication
(f) Undiagnosed coma
(g) Chemical injuries
(h) Burns and Scalds
(j) Sexual Offences
(k) Criminal abortions
(l) Attempted suicide
(m) Cases of asphyxia as a result of hanging,
strangulation, drowning, suffocation etc.
(n) Custodial deaths
(o) Death in the operation theatre
(p) Unnatural deaths
(q) Death due to Snake Bite or Animal Bite
(r) Fire Arm injuries
(s) Drug overdose
(t) Drug abuse
(u) Dead brought to the Accident and
Emergency Dept / MI Room (Found dead) and
deaths occurring within 24 hours of
hospitalization without establishment of a
diagnosis
What are the incidents not
comes under MLC?
What are the incidents not
comes under MLC?
Battle Casualties (BC) and Battle
Accidents (BA) are not to be reported as
MLCs. The medical cause of death in
these cases may however be certified by
the RMO. RMOs must obtain the
certification of BC / BA from the unit, duly
signed by the CO, before mentioning the
same in the medical documents.
Death of a service person, in an
accident involving a military aircraft will not
be reported as a MLC to the civil police.
The enquiry conducted by the competent
military authorities will suffice. As per Govt
of India, Ministry of Home Affairs Letter
No. 8/179/71-GP A, dated 25 Nov 72,
there is no need for an inquest under
Section 174 or 176 of Cr PC in deaths due
to an accident, in which the aircraft
belongs to the Navy, Army, Air Force or
Para military forces and the deceased
POLICE INTIMATION
The police should be informed. Under
Section 39 of Criminal Procedure. Code, the
attending MO is legally bound to inform the
police about the arrival of a MLC. Any failure to
report the occurrence of a MLC may invite
prosecution under Sections 176 and / or 202 of
I.P.C. Simultaneously, the information should be
given to ADH, Station Headquarters (HQ), Corps
of Military Police (CMP) and to the unit
concerned (by telephone). The verbal
communication should invariably be followed by
communication in writing subsequently.
In case of discharge / transfer / death of such a
case in the hospital, the police should be
informed.
Generally 3 copies are available in the
Police Intimation book
• 1st copy to nearest police station
• 2nd copy to Incident occurred place - police
station
• 3rd copy for Medical Records or in the Police
intimation Book itself.
Generally 3 copies are available in the
Accident Injury Book
• 1st copy to nearest police station
Guidelines for Preservation of
Medico legal Evidence or Foreign
body handing over procedure:
1. Medico legal evidence should be preserved
and subsequently sent or handed over to the
investigating authorities for forensic examination
and production as evidence in a court of law. All
evidences will be identified, sealed and labeled
properly. They will be kept in safe custody and
handed over to the investigating officer of the case.
Once collected, loss / destruction of evidence is a
punishable offence. Failure to collect, destruction
or loss of such an exhibit is punishable under Sec
201 of I.P.C.
2. The evidence required to be preserved
is related to the nature of a case. In injury
cases, the following articles should be
preserved in sealed envelopes:
• Clothing worn by the patient showing evidence
of injury such as tears, bullet holes, cuts, blood
stains etc.
• In case of multiple tears, cuts or holes etc., each
piece of evidence will be encircled and
numbered with matching description in the MLC
report and case sheet.
• Bullets recovered from a body should be
marked by etching an initial or a mark on the
bottom before preservation.
• All evidence collected should be mentioned in
3. In cases of suspected poisoning the
following articles will be preserved and
ensured that they are forwarded for
forensic examination:
• Gastric lavage / gastric contents / vomitus
and soiled clothing
• Blood, urine and any other relevant body
fluid depending on the poison ingested.
4. In cases of Burns and Carbon Monoxide
poisoning the following articles should be
preserved in sealed envelopes:
• Articles soiled with inflammable substances
5. In Sexual offences, the following
articles should be preserved in sealed
envelopes:
• Clothing worn by the patient and showing
evidence of blood stains or seminal stains,
stains of mud, tears/cuts etc.
• Vaginal swab preferably from posterior
fornix / anal swab.
Guidelines for preservation of
Medico legal documents
1. Medico legal documents should
be considered as confidential records
and should be stored under safe
custody to avoid tampering. Medical
records must be thorough, complete
and should document each and every
significant event in the course of care of
the patient. All the documents including
case sheets, X-rays and investigation
reports will be preserved meticulously in
the medical record section indefinitely
and handed over to the concerned
authorities (Police Investigating Officer /
Court / Court of Inquiry) as and when
required. Prompt attention, correct
• Original copies of all medico legal documents
will be produced whenever asked for in a court
of law.
• All original copies of certificates and reports
issued for medico legal purposes are to be
preserved till the finalization of case in the court
of law.
• Commandant/CO of the hospital will ensure that
the documents are kept in the custody of an
appropriate officer till the case is finally decided
or cleared by the police and judicial authorities.
In the case of units other than hospitals, the
SUBPOENA OR COURTS
SUMMON
• A subpoena is a writ issued by a government
agency, most often a court, to compel
testimony by a witness or production of
evidence under a penalty for failure. There are
two common types of subpoena:
• Subpoena ad testificandum orders a person
to testify before the ordering authority or face
punishment. The subpoena can also request
the testimony to be given by phone or in
person.
• Subpoena duces tecum orders a person or
Who May Issue a
Subpoena?
Who May Issue a
Subpoena?
In most instances, a subpoena can
be issued and signed by an attorney on
behalf of a court in which the attorney is
authorized to practice law. If the
subpoena is for a high-level government
official (such as the Governor or agency
head), then it must be signed by an
administrative law judge. In some
How a Subpoena is served?
• A subpoena is typically requested by an
attorney and issued by a court clerk, a
notary public, or a justice of the peace. Once
a subpoena is issued, it may be served on
an individual in any of the following ways:
• Hand-delivered (also known as “personal
delivery” method)
• E-mailed to the last known e-mail address of
the individual (receipt acknowledgement
requested)
How to Respond to a Subpoena?
How to Respond to a Subpoena?
• The first thing you should do if you
receive a subpoena is not ignore it. A
subpoena is part of a court’s legal
process and failure to respond to a
subpoena is considered contempt of
court in most state.
• The next step is to read through the
subpoena to determine what is being
requested and or who is being asked
to appear. Subpoena request for
• Lastly you should look to see who is
requesting the information and for
what purpose, so you can adequately
prepare for any testimony you are
required to give at a trial or other
proceeding. Finally, you should check
the hearing date and time to avoid
potential penalties and other
consequences.
• A person who receives a subpoena
should otherwise consult with a
Penalties
• Because a subpoena is court-ordered
command, a person who fails to obey it is
subject to civil or criminal contempt of court
charges. Civil contempt occurs when you
knowingly fail to produce papers or
documents requested or otherwise fail to
obey the terms of a subpoena and, thereby,
hinder the judicial process. Criminal
contempt, which is usually, intended a
punishment, generally refers to disruptive
conduct disrespectful behavior at court.
Criminal contempt can also include refusal to
turn over documents or other data.
Conclusion
The information found in the Medical
Record is more important and evidence in
the court to prove the cases as mentioned
above. The professionals who come
across the patient care & treatment
including the Hospital Administrator
should be very alert in all aspects
regarding the Law and its latest
amendments issued from time to time. So
that they can record all the necessary
information in the Medical Record. Also
R. MAHENDIRAN, M.B.A (H.A) M.com, B.M.R.Sc., PGDCA.
Apollo Hospitals, Bhubaneswar .

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LEGAL ASPECTS OF MEDICAL RECORDS

  • 1. LEGAL ASPECTS OF MEDICAL RECORDS PREPARED AND PRESENTED BY R. MAHENDIRAN, M.B.A (H.A) M.com, B.M.R.Sc., PGDCA. Sr. Manager-Medical Records, Medical Records Department, Apollo Hospitals, Bhubaneswar-Odisha, India
  • 2. LEGAL ASPECTS OF MEDICAL RECORDS INTRODUCTION • Medico legal cases (MLC) are an integral part of medical practice that is frequently encountered by Medical Officers (MO). The occurrence of MLCs is on the increase, both in the Civil as well as in the Armed Forces. Proper handling and accurate documentation of these cases is of prime importance to avoid legal complications and to ensure that the Next of Kin (NOK) receive the entitled benefits. • All medical officers working in hospitals / field medical units / non medical units encounter medico legal issues which should be handled in accordance with the law of the land and directives issued by service headquarters.
  • 3. LEGAL ASPECTS OF MEDICAL RECORDS MLCs in Medical Practice: • MLC. A MLC is defined as “any case of injury or ailment where, the attending doctor after history taking and clinical examination considers that investigations by law enforcement agencies (and also superior military authorities) are warranted to ascertain circumstances and fix responsibility regarding the said injury or ailment according to the law”. Labeling a case as MLC. • RMO / Casualty medical officer / MO in charge of MI Room / Duty Medical Officer (DMO) / MO In charge ward, who is
  • 4. WHAT IS MEANT BY MEDICO LEGAL CASE ?
  • 5. WHAT IS MEANT BY MEDICO LEGAL CASE? Medicolegal is something that involves both medical and legal aspects, mainly: Medical jurisprudence, a branch of medicine Medical law, a branch of law Medico-Legal Case: can be defined as a case of injury or ailment, etc., in which investigations by the law-enforcing 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 where the attending doctor, after eliciting history and examining the patient, thinks that some investigation by law enforcement agencies is essential. Or a legal
  • 6. What are the incidents will comes under the MLC?
  • 7. What are the incidents will comes under the MLC? The following are some of the examples of MLCs and medical officers should use their professional judgment to decide any other cases not enumerated in the list:(a) Assault and battery, including domestic violence and child abuse (b) Accidents like Road Traffic Accidents (RTA), industrial accidents etc. (c) Cases of trauma with suspicion of foul play (d) Electrical injuries (e) Poisoning, Alcohol Intoxication (f) Undiagnosed coma (g) Chemical injuries (h) Burns and Scalds (j) Sexual Offences (k) Criminal abortions (l) Attempted suicide (m) Cases of asphyxia as a result of hanging, strangulation, drowning, suffocation etc. (n) Custodial deaths (o) Death in the operation theatre (p) Unnatural deaths (q) Death due to Snake Bite or Animal Bite (r) Fire Arm injuries (s) Drug overdose (t) Drug abuse (u) Dead brought to the Accident and Emergency Dept / MI Room (Found dead) and deaths occurring within 24 hours of hospitalization without establishment of a diagnosis
  • 8. What are the incidents not comes under MLC?
  • 9. What are the incidents not comes under MLC? Battle Casualties (BC) and Battle Accidents (BA) are not to be reported as MLCs. The medical cause of death in these cases may however be certified by the RMO. RMOs must obtain the certification of BC / BA from the unit, duly signed by the CO, before mentioning the same in the medical documents.
  • 10. Death of a service person, in an accident involving a military aircraft will not be reported as a MLC to the civil police. The enquiry conducted by the competent military authorities will suffice. As per Govt of India, Ministry of Home Affairs Letter No. 8/179/71-GP A, dated 25 Nov 72, there is no need for an inquest under Section 174 or 176 of Cr PC in deaths due to an accident, in which the aircraft belongs to the Navy, Army, Air Force or Para military forces and the deceased
  • 11. POLICE INTIMATION The police should be informed. Under Section 39 of Criminal Procedure. Code, the attending MO is legally bound to inform the police about the arrival of a MLC. Any failure to report the occurrence of a MLC may invite prosecution under Sections 176 and / or 202 of I.P.C. Simultaneously, the information should be given to ADH, Station Headquarters (HQ), Corps of Military Police (CMP) and to the unit concerned (by telephone). The verbal communication should invariably be followed by communication in writing subsequently.
  • 12. In case of discharge / transfer / death of such a case in the hospital, the police should be informed. Generally 3 copies are available in the Police Intimation book • 1st copy to nearest police station • 2nd copy to Incident occurred place - police station • 3rd copy for Medical Records or in the Police intimation Book itself. Generally 3 copies are available in the Accident Injury Book • 1st copy to nearest police station
  • 13. Guidelines for Preservation of Medico legal Evidence or Foreign body handing over procedure: 1. Medico legal evidence should be preserved and subsequently sent or handed over to the investigating authorities for forensic examination and production as evidence in a court of law. All evidences will be identified, sealed and labeled properly. They will be kept in safe custody and handed over to the investigating officer of the case. Once collected, loss / destruction of evidence is a punishable offence. Failure to collect, destruction or loss of such an exhibit is punishable under Sec 201 of I.P.C.
  • 14. 2. The evidence required to be preserved is related to the nature of a case. In injury cases, the following articles should be preserved in sealed envelopes: • Clothing worn by the patient showing evidence of injury such as tears, bullet holes, cuts, blood stains etc. • In case of multiple tears, cuts or holes etc., each piece of evidence will be encircled and numbered with matching description in the MLC report and case sheet. • Bullets recovered from a body should be marked by etching an initial or a mark on the bottom before preservation. • All evidence collected should be mentioned in
  • 15. 3. In cases of suspected poisoning the following articles will be preserved and ensured that they are forwarded for forensic examination: • Gastric lavage / gastric contents / vomitus and soiled clothing • Blood, urine and any other relevant body fluid depending on the poison ingested. 4. In cases of Burns and Carbon Monoxide poisoning the following articles should be preserved in sealed envelopes: • Articles soiled with inflammable substances
  • 16. 5. In Sexual offences, the following articles should be preserved in sealed envelopes: • Clothing worn by the patient and showing evidence of blood stains or seminal stains, stains of mud, tears/cuts etc. • Vaginal swab preferably from posterior fornix / anal swab.
  • 17. Guidelines for preservation of Medico legal documents 1. Medico legal documents should be considered as confidential records and should be stored under safe custody to avoid tampering. Medical records must be thorough, complete and should document each and every significant event in the course of care of the patient. All the documents including case sheets, X-rays and investigation reports will be preserved meticulously in the medical record section indefinitely and handed over to the concerned authorities (Police Investigating Officer / Court / Court of Inquiry) as and when required. Prompt attention, correct
  • 18. • Original copies of all medico legal documents will be produced whenever asked for in a court of law. • All original copies of certificates and reports issued for medico legal purposes are to be preserved till the finalization of case in the court of law. • Commandant/CO of the hospital will ensure that the documents are kept in the custody of an appropriate officer till the case is finally decided or cleared by the police and judicial authorities. In the case of units other than hospitals, the
  • 19. SUBPOENA OR COURTS SUMMON • A subpoena is a writ issued by a government agency, most often a court, to compel testimony by a witness or production of evidence under a penalty for failure. There are two common types of subpoena: • Subpoena ad testificandum orders a person to testify before the ordering authority or face punishment. The subpoena can also request the testimony to be given by phone or in person. • Subpoena duces tecum orders a person or
  • 20. Who May Issue a Subpoena?
  • 21. Who May Issue a Subpoena? In most instances, a subpoena can be issued and signed by an attorney on behalf of a court in which the attorney is authorized to practice law. If the subpoena is for a high-level government official (such as the Governor or agency head), then it must be signed by an administrative law judge. In some
  • 22. How a Subpoena is served? • A subpoena is typically requested by an attorney and issued by a court clerk, a notary public, or a justice of the peace. Once a subpoena is issued, it may be served on an individual in any of the following ways: • Hand-delivered (also known as “personal delivery” method) • E-mailed to the last known e-mail address of the individual (receipt acknowledgement requested)
  • 23. How to Respond to a Subpoena?
  • 24. How to Respond to a Subpoena? • The first thing you should do if you receive a subpoena is not ignore it. A subpoena is part of a court’s legal process and failure to respond to a subpoena is considered contempt of court in most state. • The next step is to read through the subpoena to determine what is being requested and or who is being asked to appear. Subpoena request for
  • 25. • Lastly you should look to see who is requesting the information and for what purpose, so you can adequately prepare for any testimony you are required to give at a trial or other proceeding. Finally, you should check the hearing date and time to avoid potential penalties and other consequences. • A person who receives a subpoena should otherwise consult with a
  • 26. Penalties • Because a subpoena is court-ordered command, a person who fails to obey it is subject to civil or criminal contempt of court charges. Civil contempt occurs when you knowingly fail to produce papers or documents requested or otherwise fail to obey the terms of a subpoena and, thereby, hinder the judicial process. Criminal contempt, which is usually, intended a punishment, generally refers to disruptive conduct disrespectful behavior at court. Criminal contempt can also include refusal to turn over documents or other data.
  • 27. Conclusion The information found in the Medical Record is more important and evidence in the court to prove the cases as mentioned above. The professionals who come across the patient care & treatment including the Hospital Administrator should be very alert in all aspects regarding the Law and its latest amendments issued from time to time. So that they can record all the necessary information in the Medical Record. Also
  • 28. R. MAHENDIRAN, M.B.A (H.A) M.com, B.M.R.Sc., PGDCA. Apollo Hospitals, Bhubaneswar .