AUDIT OF MEDICO-LEGAL REPORTS DOCUMENTATION IN THE EMERGENCY DEPARTMENT OF A TERTIARY CARE CENTER HOSPITAL

Abstract

This article discusses the critical role of emergency department (ED) physicians in managing Medico-Legal Cases (MLCs) and emphasizes the importance of proper documentation in such cases. The study focuses on the level of awareness among ED physicians regarding the appropriate documentation of MLCs encountered during their shifts.The study was conducted in the ED of a large tertiary care centre over one month. We collected 128 MLC forms, with the majority of cases involving patients between 18 and 60 years and occurring during evening hours. The most common causes of MLCs were two-wheeler-related road traffic accidents and pedestrian falls at ground level. The results showed that patient-related information was adequately documented in more than 90% of cases. This included essential details such as patient and bystander information, police station information, incident time, and examination time. However, some critical aspects of documentation, such as recording examination findings at presentation and determining triage priority levels, were lacking or incomplete. Vital signs and both systemic and local examinations were not properly documented in some cases. The forms also contained grammatical errors and abbreviated terms. Discrepancies were noted between documented admission status and actual patient admission. We noted that most physicians correctly documented their names, medical registration numbers, and dates, ensuring accountability. Patients were admitted to specialized units based on clinical and radiological findings, facilitating tailored care.In conclusion, while patient-related information documentation in MLC forms was generally accurate, there were deficiencies in recording examination findings and triage priority levels. Improvement is needed in ensuring complete and accurate documentation of all relevant information in MLC forms, as this is crucial for the proper investigation and management of such cases. The study suggests the need for further training and a follow-up audit to assess improvements in documentation practices.