SOP for Medico Legal Case

SOP for Medico Legal Case
Sr. No.	Process Flow
1	All complaints and events shall be recorded.
2	Each event shall be recorded in detail including the date, time and place of the event and involvement of person and/or objects during the event.
3	Each case should be intimated to the relevant police station by phone after counselling the patient and relatives about the hospital policy and procedures. The name and buckle number with designation of the police personnel who has taken down the information along with date and time shall be noted. A written intimation shall be prepared and given to the police.
4	All MLCs after registration are to be issued for OPD/IPD cases and should be marked “MLC”, MLC number shall be stamped on all paper and patient records.
5	Clinical notes shall be entered in IPD/OPD case paper. a.    Examine the patient for all types of injuries. Take a detailed history of the event. Start the medical management as required. Inform the concerned Consultant accordingly; proceed further with the necessary investigations. b.    For all MLCs, the patient record must be filled up and all columns completed. c.     While filling the record, place special emphasis on identification marks, who the patient was brought by, the site of accident, name, age, sex, date, time of arrival and detailed examination of the injury. d.    In assault or trauma cases, the left thumb impression of the patient along with two marks of identification is mandatory to identify the patient – whether conscious or unconscious. e.     Obtain the consent of the patient and a declaration that “I have shown all my injuries to the Doctor on Duty”. This is mandatory in assault cases. f.      No information about any document or investigation shall be released in any MLCs unless an authority letter from the patient himself or court order, and/or a police requisition note is received.  Police requisition should pertain to queries.
6	A separate entry in the register shall be maintained for each MLC with the required information.
7	A counter-signature from the police station shall be taken from the representative in a patient’s MLC form/book.
8	The time of informing the police and time of arrival of the police shall be entered in the MLC form.
9	In case the police do not arrive within two to four hours of MLC report, a reminder shall be sent asking for an acknowledgement.
10	If any patient registered under MLC dies during hospitalization, post mortem is a mandatory procedure and the patient’s body shall not be handed over to the patient’s relative but to the respective police station in order for the post mortem to be conducted at the district hospital.
11	A case summary shall be provided to the police at the time of handing over the dead body for submission to the district hospital.
12	When MLCs are discharged, the relevant police station shall be notified.
13	A copy of all reports of investigations shall be kept in the MRD file before discharging the patient.
14	After handing over the documents and reports to the patient, the patient or relatives signature shall be obtained for the MRD file.
15	After discharge, MRD files of all MLCs shall be stored separately and be under the control of designated person.
16	Admin shall preserve the copy of the signed certificate in the patient’s record.
17	At the time of handing over the certificate to the police, the designation and the buckle number of the police shall be noted in the second copy and the signature of the police taken.
18	The original injury certificate shall only be issued to the police and not to the patient or relative.