Basic facts of medico legal case

Most important duty– The first and foremost duty of the treating doctor is to save the life of a patient and give necessary urgent treatment. Police should be informed as early as possible but the patient should not be allowed to suffer. For this he must not wait for the arrival of police.

Whenever a suspected medico legal case is brought in the emergency, it shall be the duty of the Medical Officer on duty to send information to the police station. Acknowledgement from the police officer receiving the information will be kept in the file of the patient and in other OPD cases it shall be pasted in the OPD register or with the Medical Officer for further reference.
The Medical Officer will make a note in the file of the patient as to the time and date of informing the police. He will then make a complete record of all injuries and also note the date and time of admission of the case therein. Name and addresses of the attendants who brought the patient should also be recorded in the file and admission O.P.D. register if possible.
The Medical Officer will also mark with red pen on the top of first page  of  the  file  of the patient  the letters  “M.L.C.”

Always take the consent of the injured person on the MLR Form. If the patient is less than 12 years, take the consent of the guardian/accompanying person and get his signature/thumb impression. If an unconscious/ semiconscious patient is brought in emergency along with family/guardian, the consent shall be taken from them. In case of refusal by the family/guardian the medical officer shall mention on the MLR that the consent could not be recorded. (Write brief reasons).

The preliminary entries like name of the hospital/institute, MLR No., with date, name of the doctor with full designation and place of posting, exact date and time of examination, name of the injured with complete address age/sex, caste/occupation, name of the accompanied person and relation with the injured, name and number of the constable/HC with police post/police station and district must be entered before the examination of the injured is started. If admitted, write the C.R. No. with date and name of the ward.

Identification marks – Two identification marks preferably on the exposed parts of the body be recorded for comparing the same for identification in the court while giving the evidence.

Brief  history  of  the  incident  be  recorded  as  stated  by  the  injured/ accompanying person regarding time, manner (accidental/ intentional) with weapon/ means caused and place of event of injury/poisoning, and the time sequence of symptoms/ incapacitation developed etc.

General condition of the person like pulse, BP, respiration, temperature, pupils, level of consciousness, posture, gait, speech, bleeding through natural orifices like ear, nose, mouth, rectum, vagina, etc., paralysis, urinary/faecal retention/incontinence, smell etc. be recorded. The condition of the clothes be recorded regarding their disorder, buttons(intact, undone, or torn), rents, tears, cuts whether coinciding with a  particular  injury,  presence  of  stains  like  blood,  mud/sand,  weeds, faecal, seminal etc., foreign matter, stippling, burns etc.