This document discusses medicolegal cases and reporting procedures for doctors. It defines a medicolegal case as one involving injury or illness requiring legal investigation. It outlines doctors' legal responsibilities to properly document and report such cases. Proper procedures are described for receiving cases, registering them, preparing records including findings and opinions, collecting samples, and storing documentation long-term. Fear of legal entanglements can cause doctors to avoid these cases, so understanding proper procedures is important.

1. MEDICO LEGAL CASES
AND REPORTING

2. MEDICO-LEGAL CASE
It 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 case requiring medical expertise when brought
by the police for examination.

3. DOCTOR AND MLC
Every doctor under law bound by a contract to serve its patient
and can not refuse treatment.
Every doctor has to fulfill certain legal requirements in service
by compulsion or voluntarily as defined under law.
Medico legal case (MLC) examination and reporting is one of
the legal responsibility of all doctors working in a hospital.
Apart from his routine and usual “clinical” cases, a doctor will
come across certain ‘Medico-legal’ problems at one time or the
other during the practice of his profession.
The general belief that only the doctors working in the
government hospitals would be involved with such cases has
now been dispelled by the recent decisions of the Hon’ble
courts, particularly the Supreme Court.
A good working knowledge of the law in this regard, coupled
with a thorough understanding of the correct method of dealing
with such cases helps one to build confidence over
riding the fear of MLC .

4. FEAR OF MLC
Every medical practitioner at any time during the practice of
his profession, whether in a government setting or a private
one, will encounter certain cases, which at that given time or
subsequently, would be labeled as “medico-legal”.
Practitioners are usually apprehensive in dealing with these
cases as they feel, an MLC means entangling’ in police
cases , indefinite hours’ to be spent in the court, facing
‘unrelenting’ defense counsels.
Because of this “fear-factor”, they either try to avoid the
cases or try to manipulate them as non MLC.
The best way to deal with these cases is to understand them
clearly, analyze them thoroughly, and then act accordingly

5. Examples Of Medico-legal Cases
(THIS LIST IS NOT COMPREHENSIVE)
RTA, Rail accidents, Factory accidents or any other
unnatural mishaps
Suspected Homicides, Suicides
Suspected or evident poisonings, Alcohol
intoxication
Burn injuries due to any cause, Electrocution
Physical assault cases
Animal attack, Snake Bite
Mass food poisoning

6. CONTD…
•Suspected or evident Criminal Abortion
•Cases of Sexual Assaults
•Injury cases where foul play is suspected
•Injury cases where likelihood of death in near
future
•Unconscious cases where cause of it is not clear
•Brought dead cases where foul play is suspected
•Cases referred from Court

7. RECEIVING A MLC
A doctor can receive a medico-legal case in any of
the four situations:–
1. A case is brought by the police for examination
and reporting, or order of the court for medical
examination
2. The person in question was already attended to by
a doctor and a medico-legal case was registered in
the previous hospital, and the person is now referred
for expert management/ advice.
3.When patient himself expressing his intention to
register a case against the alleged accused.

8. CONTD…
4. After eliciting history and examining the patient,
the attending doctor feels that some investigation
by law enforcement agencies is essential to
establish and fix responsibility for the case in
accordance with the law of the land.
In the last situation it is the attending doctor has to
utilize his medical knowledge and judgment to
decide whether the case should be treated as MLC
or not, specially when the history is not completely
revealed, either by the patient or his relatives/
friends, due to some motive.

9. PROCEDURE OF REGISTERING A MLC
The responsibility to label any case as an MLC
rests solely with the attending medical practitioner.
In the casualty, while attending to an emergency,
the doctor should understand that his first priority is
to save the life of the patient. He should do
everything possible to resuscitate the patient and
ensure that he is out of danger.
All legal formalities to be suspended till the patient
is resuscitated. This has been clearly ordered by the
Hon’ble Supreme Court of India.

10. CONTD…
Every doctor is bound to provide medical aid to the
victims irrespective of the cause of injury; he cannot
take any excuse of allowing law to take its course”.
The next important duty is to identify whether the said
case falls under the category of an MLC or not, after
carefully analyzing the injuries on the person of the
patient, the history given, and the other circumstances
of the case.
If it does fall in this category, then he must register the
case as an MLC and/ or intimate the same to the nearest
police station, either by telephone or in writing.

11. CONTD…
An acknowledgement of receipt of such a message
should be taken for future reference.
A medico-legal register should be maintained in the
casualty of every hospital and details of all medico-
legal cases should be entered in this register in
duplicate/ triplicate. This would be of immense help
for future reference, when the patient through the
court/ the police, requests for a copy of the medico
legal report. No fresh MLC to be made if MLC has
already been made in other hospital to avoid
duplication.
A medico-legal case should be registered as soon as a
doctor suspects foul play or feels it necessary to
inform the police at arrival, at any time after
admission.

12. CONTD…
There should not be any unnecessary delay in doing so.
A case may be registered as an MLC even if it is
brought several days after the incident if suspected.
The casualty doctor (emergency physician ) attending
the case has the independent authority to label the case
as medico-legal or not. Patients’ or their relatives’
request or any external pressure to label a case medico-
legal, should not influence the doctor’s decision.
When the patient is admitted in the ward, indoor
treating doctors can also make a case medico-legal if
they think after obtaining additional information, that it
should have been made MLC but it was not made at
the time of admission.

13. PREPARATION OF MLC RECORD
An MLR comprises of three parts, namely:
a) Pre-amble: includes the date, time and place of
examination, name of the patient, his residential
address, occupation; name of the person(s)/police
official accompanying, DDR/FIR No., informed
consent of the person being examined, two marks of
identification, etc, wherever applicable.
b) Body (Findings/Observations): includes a
complete description of the injuries/any other
findings present; any investigations/referrals, etc,
asked for.

14. CONTD…
Post-amble (Opinion): includes the Nature of the
injury—whether simple or grievous.
Weapon/Force used—whether blunt or sharp or
fire-arms or burns, etc. Duration of the injuries—
based on the characteristics of the external
injuries. To be signed with full name of attending
physician in capital letter

15. PREPARATION OF MLC RECORD
They should be prepared in duplicate, preferably
with a ball-point-pen, in a clear and legible hand.
Cutting/ overwriting, etc should be avoided as
much as possible and all corrections should be
properly initialed.
Abbreviations of any sort should be avoided.
All the columns in MLC sheet should be filled in
legible hand writing and in complete words without
using shortcuts

16. CONTD…
Name and address of the person who has brought the patient
-Full name, fathers name, address (complete), age, sex, time
and date of accident, time and date of reporting in hospital
All examination findings as detailed in examination
Investigations advised and finding to be entered
Treatment given at the site or on reporting
The opinion to be recorded in MLC sheet, if opinion cannot
be given, under observation be given and signed by the
doctor with name written in block letters.
Final opinion be given by same doctor making MLC in the
original MLC sheet, after all investigations are completed.

17. Description Of Injuries And Investigation
Type of weapon used i.e. blunt or sharp if possible to mention
Nature of injury either simple or grievous giving size, shape,
depth and margin of injury.
Probable cause of injury/ condition like suspected poisoning,
traffic accident, burn, radiation etc.
The patient is admitted or discharged with advice be entered
into the case sheet
The doctor examining the patient must complete the MLC sheet
before leaving the hospital

18. CONTD…
All MLC X-rays be kept in department as evidence for
court of law
Special samples taken to be entered into the MLC sheet.
If the patient is dead or died, handed over to police for
post mortem and not to relatives.
A copy of MLC sheet be handed over to police for further
investigation against his signature and belt number on the
copy.

19. Collection And Preservation of Blood /Tissue
Samples :
If special investigation is needed like Vomits, vaginal swab DNA
sample to be collected preserved, sealed, name of Pt and regd .no.
written and signed by doctor to be handover to investigative officer
in exchange of a receipt.
While handing over to the police official concerned, along with the
medico-legal report a proper requisition letter detailing the tests to
be conducted on such samples.
If the samples have been collected on the request of the police, the
fact is to be mentioned in the report and no requisition is necessary.

20. Custody Of The Records
The records should be kept under lock and key, in the
custody of the doctor concerned or may be kept in a Central
Record Room, in hospitals where such facility is available; as
per the institution’s rules. Most hospitals have a policy of
maintaining all medico-legal records for variable periods.
However, as per law, there is no specified time limit after
which the MLRs can be destroyed. Hence, they have to be
preserved.
In view of the multitude of cases against the doctors under
the Consumer Protection Act, it is advisable to preserve all
the MLC records for a period of at least10years or till the
disposal of case by the court.

21. CONTD…
Always prepare three copies of the Medico-legal
report, one is kept as hospital record, other is kept in
the office of Medical Superintendent and the
original is given to police after getting proper
receipt. .
Hospital records or file of MLC should be kept as
confidential in Record Section till judgment by the
court of law pertaining to the case has been issued
(for practical purposes, no time limit

22. Medicolegal 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.
The complete available particulars of the patient should
be noted down along with two identification marks.
Particulars of the person accompanying the patient will
also be noted down.
One should not rely on memory while writing reports or

23. CUSTODY OF RECORDS
The records should be kept under lock and key, in the custody of the
doctor concerned or may be kept in a Central Record Room, in
hospitals where such facility is available; as per the institution’s rules.
Most hospitals have a policy of maintaining all medico-legal records
for variable periods.
However, as per law, there is no specified time limit after which the
MLRs can be destroyed. Hence, they have to be preserved.
In view of the multitude of cases against the doctors under the
Consumer Protection Act, it is advisable to preserve all the MLC
records for a period of at least10years or till the disposal of case by
the court.