Errors and challenges in documentation of Medico Legal Cases (MLC): A hospital-based investigation from Jaipur, Rajasthan

Abstract

Background: Medical Legal Cases (MLCs), involve injuries or illnesses requiring law enforcement investigation. This study aims to identify the characteristics of MLCs, the errors while documenting and analyse challenges faced by health care workers while handling such cases. Materials and methods: A hospital-based investigation was conducted in a multispecialty hospital in Jaipur, Rajasthan. The research scrutinized 130 MLC case files from the past six months and interviewed 30 healthcare workers in the emergency department to understand the challenges in handling MLCs. Results: Findings show that 76% of cases were males, with road traffic accidents being the primary cause in 60% of cases. However, documentation errors included incomplete patient occupation records (75.4%) and details regarding mental status. Challenges reported by the healthcare workers included inability to differentiate MLC from Non-MLC cases and handling violent individuals and public. Conclusion: MLCs primarily involved road traffic accidents, predominantly affecting men in their productive years. Although errors in MLC documentation were fewer, they highlighted the critical need for training medical professionals to ensure the fair administration of justice. Despite numerous challenges, most MLCs were discharged on medical advice, with generally compliant medical records, except for some instances of missing patient information.