Medico Legal Documentation in a Public Hospital in India: An Analysis of 100 Cases
Keywords:Medico legal cases, Medical Records, Medico legal record audit, Good Record Keeping
Introduction: Medico-legal audits are an integral part of hospital/clinical audits and involve examination
of the hospitalrecords. The clinical audits aim towards improvement of quality of care and hence are limited
to the scrutiny of patient’s clinicalrecords. On the other hand, a medico-legal audit aims at the prevention of
foreseeable litigations on the hospital and includes the perusal of all the hospital records.
Aim & Objective: To carry out the audit of medico legal documentation in a public hospital.
Methodology: A retrospective record-based study was conducted in a 2000 bedded public hospital in
the month of May-June 2012. 100 documented medico legal cases were considered using simple random
sampling. The quantitative data was collected by using a checklist for the audit of medico legal case files.
SPSS was used for the analysis of the data.
Results: Most of the MLC cases were found to fall in the middle age group of 21-35 years of age (32%)
and within that the maximum people contributing to the MLC cases was the sub- group of age between 21-
25 years (16.66%). Out of the total recorded sex of the MLC cases, 65.96% were males and 34.04% were
females. The highest number of cases recorded were of the RTA (20%) followed by the accidental injury
Discussion & Conclusion: Alarge number of the cases were of the road traffic accidents (20%)followed by
accidental injury (17%), so the emergency department should be kept well equipped to treat such cases. The
proportion of the male patients (65.96%)was double as compared to the female patients (34.04%), so the
human resource planning of the emergency department can be done accordingly.
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