Chapter: 3.2.1 Medico legal Aspects of Communication

Medico legal Aspects of Communication

1. Prescription writing:

Prescription writing Jive Ascription is a written communication by a doctor containing the names of Drugs, dosage, the route of administration, precautionary advise if Rosary etc. This may be given to the patient to buy drugs from the pharmacist or written in the indoor case sheets for compliance by the nourishing staff. Bad illegible handwriting may result in wrong treatment.

2. Case Sheet, Discharge summary, Other Medical Records. .

For an indoor patient, elaborate medical records are created. The medical record is clinical, scientific administrative and legal documents relating to patient's case in which are recorded sufficient data written in the sequence of events to justify the diagnosis, the treatment and results. It is a document of facts which contains statement by the physicians Nures/Laboratory staff of condition found and the application and results of the examination of therapy. It indicates whether or not the efforts of the doctors, supplemented by the hospital and related facilities are in accordance with reasonable expectations of present day 'Scientific Medicine'.

Daily progress report, the advise of the physician regarding drugs etc, operation notes, the discharge summary are integral part of the case sheet and are written communication to be followed by the nursing staff as well as patient. Those are used in all cases of medical negligence against the doctors/ hospital. Great care is required to create precise and correct medical records.

3. Medical Certificates

A Registered medical practitioner is authorized to issue a number of medical certificates under the provision of the Indian Medical Council Act, 1956. These certificates include illness certificate, fitness injury certificates, death certificate etc. They are the examples of written communication and has legal value. The physicians are liable to face disciplinary action for falsifying any of the certificates by the State Medical Council as well as under appropriate provisions of the Indian Penal Code.