International Journal For Multidisciplinary Research

E-ISSN: 2582-2160   •   Impact Factor: 9.24

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An Evaluation of Medico-Legal Documentation Systems at AIIMS

Author(s) Dr. ANKI REDDY, Dr Shakti KUMAR GUPTA
Country India
Abstract Medico-legal documentation is crucial in trauma care centers, particularly in cases involving legal proceedings.
This study aimed to evaluate the existing medico-legal documentation system at Jai Prakash Narayan Apex Trauma Centre (JPNATC), AIIMS, and propose improvements. A descriptive study analyzed 12,532 electronic medico-legal records, highlighting the need for efficient and accurate documentation. As per results of analysis, it is seen that only 10 (18.2%) of the total 55 elements of the checklist were found to be well addressed with 100 percent compliance and (50.9%) of the total 55 elements were found to be partially compliant.
The study's findings emphasize the importance of standardized medico-legal documentation in trauma care centers, ensuring objective, self-explanatory, and reliable information for legal proceedings. Medico-legal reports must be meticulously documented to serve as admissible legal evidence in court. These reports should be objective, concise, and provide accurate information to all stakeholders upon review. The current electronic documentation practice at JPNATC has effectively addressed previous manual documentation issues, significantly enhancing the quality and reliability of the information.
Keywords Documention, Medico-legal documentation
Field Computer > Data / Information
Published In Volume 7, Issue 3, May-June 2025
Published On 2025-06-01
DOI https://doi.org/10.36948/ijfmr.2025.v07i03.46721
Short DOI https://doi.org/g9m2dp
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