Adequacy and relevance of medical records of patients admitted following Medico-legally significant trauma

Abstract

INTRODUCTION: Details mentioned in Bed head ticket (BHT) and investigations are taken into consideration when an opinion is made with regards to the medico legally significant trauma. Shortfalls of documents can lead to misdiagnosis or wrongful diagnosis. This study was conducted to find out the adequacy of records on BHTs and availability of investigations on patients who had been admitted following trauma with medico legal significance. METHODS: A prospective descriptive study was carried out on patents who were admitted following medico-legally significant trauma during a period of one year, from Aug 2017 to Aug 2018 by perusing their records. The adequacy of the documentation was assessed according to a pre-prepared scale. RESULTS: Analysis of on admission historical and preliminary details revealed that out of 1102 records, only 26% (n=286) had mentioned the time duration since the incident. Recorded cardiovascular stability on admission was above 86% (n=950) though level of consciousness was not mentioned by 19% (n=211). Nature of the injuries were correctly recorded by 65% (n=720) while the location of them were correctly recorded only by 29% (n=316). Surgical procedures were adequately mentioned only among 39% (n=425). CONCLUSIONS: The study revealed that there are gross inadequacies with regard to the records on BHTs made by the doctors. This can lead to limitations in addressing medico-legal issues and sometimes can result in wrong opinions leading to injustice. Need for continuous professional training with special attention to record keeping is highlighted. Further, the quality of records can be further improved with regular audits, continuous professional developmental activities and introducing a common format for documentation in admission, surgical procedures and investigations. KEYWORDS: Medico-legal issues, Medical record keeping, Adequacy, Investigations, BHT