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 attending to
the case, may label a case as a MLC.
The decision to label a case as MLC should be based on sound
professional judgment, after a detailed history taking and thorough
clinical examination.
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 case
requiring medical expertise when brought by the police for examination.
"Any case of Injury or ailment where some criminality is involved is called a Medico-
Legal Case (MLC)".
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 (l) Attempted suicide
violence and child abuse (m) Cases of asphyxia as a result of hanging,
(b) Accidents like Road Traffic Accidents strangulation, drowning, suffocation etc.
(n) Custodial deaths
(RTA), industrial accidents etc.
(o) Death in the operation theatre
(c) Cases of trauma with suspicion of foul play (p) Unnatural deaths
(d) Electrical injuries (q) Death due to Snake Bite or Animal Bite
(e) Poisoning, Alcohol Intoxication (r) Fire Arm injuries
(f) Undiagnosed coma (s) Drug overdose
(g) Chemical injuries (t) Drug abuse
(h) Burns and Scalds (u) Dead brought to the Accident and
(j) Sexual Offences Emergency Dept / MI Room (Found dead) and
(k) Criminal abortions 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 person is an active member of any
service at the time of accident. A certificate from the CO of the
deceased person or a Senior Armed Forces Officer to this effect
may be accepted for dispensing with the necessity of an inquest.
 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
2nd copy to Incident occurred place - Police station
3rd copy for Medical Records or in the Accident Injury Book.
 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 medicolegal documents to
establish the chain of custody in a court of law subsequently.
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 like burnt pieces of
clothing, scalp hair etc.
Blood (and not serum) for carbon-monoxide levels.
 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 triage and safe
transfer of a patient from one facility to another as required
should be carried out in all cases and not delayed because of
the medico legal nature of the case
 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 safe custody will be under unit arrangements.
Documents pertaining to admitted fatal MLCs are to be processed and
preserved as laid down in concerned policy letters.
 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 organization to bring
physical evidence before the ordering authority or face punishment.
This is often used for requests to mail copies of documents to the
requesting party or directly to court.
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
cases, a non lawyer may issue a subpoena if acting on his or
her own behalf (known as pro se representation)
 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)
Certified mail to the last known address (return receipt requested or
Hearing it read to you aloud.
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 courts 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 documents and other items
are usually very detailed and specific. Also, you should
make sure to protect and keep any documents in your
possession safe.
 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 attorney, who may assist you if you need
more time to gather the information or have any questions
about what is being asked of you.
 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.
Penalties for contempt of court often include payment of a fine,
imprisonment, or both. Contempt charges may apply until the party
in contempt agrees to produce the requested information or otherwise
perform his or her legal obligation.
 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 the MRD
personals should make it a point to inform all the concerned
regarding any such amendments which comes to their notice.
R. MAHENDIRAN, M.B.A (H.A) M.com, B.M.R.Sc., PGDCA.
Apollo Hospitals, Bhubaneswar .