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Medico-legal Reports
Medico-legal reports (MLR) are to be prepared immediately after the examination is done. 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.
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 descripttion of the injuries/any other findings present; any investigations/referrals, etc, asked for.
c) 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.
Here, it would be pertinent to add that when giving the duration of the injuries, the most common mistake that is committed is that undue/complete reliance is placed on the history given; while the doctor’s own observations regarding the features of the injuries are often not taken into consideration. This again, may prove disastrous, as far as the courts are concerned. As regards the accuracy of estimating the duration of the injuries, the Hon’ble Supreme Court, in Ramswaroop v State of UP8, said that “It is well known that a doctor can never be absolutely certain on the point of the time so far as duration of injuries is concerned”.
· Any other information that may prove to be helpful to the police.
· If for any reason, the opinion is to be kept ‘pending’, the same is to be documented properly in the appropriate column.
The Officer/CMO issuing the MLR register to any doctor should ensure that it is properly numbered and a certificate regarding the same (giving the number of forms contained there-in) should be given by him on the first page of the said register.
All investigation forms, X-rays, Case file, etc should bear the label “MLC” on the top, so that necessary precautions can be taken by all concerned.
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 in-patient records for a period of at least 5 years and OPD records for 3 years.9
Admission and discharge
Whenever a medico-legal case is admitted or discharged, the same should be intimated to the nearest police station at the earliest. It is always better to inform the police through the casualty of the hospital where the medico-legal register is usually maintained and necessary entries can be made in it. While discharging or referring the patient, care should be taken to see that he receives the Discharge Card/Referral Letter, complete with the summary of admission, the treatment given in the hospital and the instructions to the patient to be followed after discharge. Failure to do so renders the doctor liable for “negligence” and “deficiency of service”. In N. K. Kohli v Bajaj Nursing Home,10 the Madhya Pradesh State Consumer Disputes Redressal Commission said that “issuance of the discharge certificate is the mandatory duty of the treating doctor and the Nursing Home/ Hospital and the non-issuance of the same amounts to grave negligence and deficiency (in service) on the part of the doctor and the hospital”.
If the patient is not serious and can take care of himself, he may be discharged on his own request, after taking in writing from him that he has been explained the possible outcome of such a discharge and that he is going on his own against medical advice. Police have to be informed before the said patient leaves the hospital. Sometimes the patient, registered as a medico-legal case, may abscond from the hospital. Police have to be immediately informed, the moment such an instance comes to the notice of the doctor/ hospital staff.
