1Professor and HOD, Department of Forensic Medicine and Toxicology, Malla Reddy Institute of Medical Sciences, Suraram, Hyderabad, Telangana
2Student of 3rd MBBS part-2, Malla Reddy Institute of Medical Sciences, Suraram, Hyderabad, Telangana
3Student of 3rd MBBS part-1, Malla Reddy Institute of Medical Sciences, Suraram, Hyderabad, Telangana
*Corresponding Author, Dr K Srinivasulu, Professor and HOD, Department of forensic medicine and toxicology, Malla Reddy Institute of Medical Sciences, Suraram, Hyderabad, Telangana. Email: drksrinivas1968@gmail.com
Online published on 6 March, 2023.
Medical record documentation is an integral part of the duty of medical practitioner, it is necessary to ensure that rightful information to be provided in all medico legal cases. Good medical records always provide a good defense in the court of law. A cross sectional study on Fallacies in wound certificate documentation was conducted in a tertiary care teaching hospital in Hyderabad, Telangana, 300 cases of wound certificate documents were collected from emergency department, casualty and analyzed for errors in documentation. The components of the certificate were divided into minor and major group. Majority of the errors were observed in major group. In major group, dimension of the wound and causative weapon was not incorporated precisely. In minor group address and identification marks are not mentioned accurately. Major group consist of 51.9% and minor group consist 23.3% of errors. Periodical workshops and CME's on medical documentation can minimize the errors.
Medico legal case, Wound certificate, Fallacies
