Common errors In medico-legal reporting by the first responders at A tertiary trauma unit In North India

Abstract

Background

The Trauma unit deals with wide variety of medico-legal cases such as assaults, road traffic accidents, injuries due of self-harm, sexual violence, etc. The primary duty of first responders (attending physician/registered medical practitioner) is saving lives, besides recording the medico-legal report (MLR).

Objectives

To identify the frequently-encountered errors in medico-legal reporting by emergency physicians and also to signify the importance of efficient documentation of MLRs.

Methodology

Data acquisition done retrospectively from previous records after excluding the referral cases associated with outside hospital Medico-legal cases. A total of 400 MLRs were analyzed and score allotted based on the presence or absence of adequate documentation in MLRs. The minimum score is 1, while the maximum score is 5. Grading is done based on the cumulative score for each entity as Above average, average and below average.

Results

The treating emergency physicians documented injury in 343 out of 400 MLRs. A total of 309 were graded as "Above average" and injury-related description was deficient in 14.2 % (n = 57) cases. Size or dimensions of injury was not mentioned in 80.17 % (n = 186), age and colour of injury was described in none.

Discussion

Various factors lead of certain common errors while preparing such medico-legal reports. These errors lead to unnecessary courtroom visits and questioning of the medical fraternity during legal proceedings. Lack of standardization of uniform guidelines while writing an MLR across the nation leads to significant number of errors while documenting MLRs. We implemented a mandatory induction for all the first responders of each batch once in six weeks and observed mitigation of errors in documentation.

Conclusion

It is highly recommended to conduct fortnight training or induction of the first responders in preparing the MLRs and effectively enlighten doctors on the importance of medico-legal documentation. This would avoid unnecessary courtroom visits and questioning of the medical fraternity during legal proceedings.