Indexing Title: NALUDINO’s Medical Anecdotal Report [04-3]

MAR Title: “Look before you leap “

Date of Medical Observation: June 10, 2004

Narration:

On June 3, 2004, a sheriff from a Makati Regional Trial Court approached me at the ER to serve a subpoena. This subpoena relates to a medico legal case which dates to May 11, 2004, approximately a year ago. I retrieved the patients chart but I failed to review it comprehensively.

On the day of the court hearing, while waiting for the judge to arrive, I started reviewing the medical record. It was only then that I found out the inconsistencies of the chart. There was no mention of the basics of medico legal like: (1) nature, time, date and place of the incident. There were even inconsistencies in the assessment and the illustrations. What is more surprising is that I apparently saw the patient, read the chart and affixed my signature.
 

Insights (Discovery, Stimulus, REINFORCEMENT):

It is really impossible for the surgical resident to remember all the cases he sees at the hospital. We tend to remember only those cases that are unique, interesting and those that gave us a hard time. Unfortunately, sometimes ubiquitous cases come back and haunt us in the form of court summons. What do we do now? We need to have proper medical recording.

All cases we see are potentially medico legal. That is why I see the need for us to use some form of medico legal chart at the Emergency Room aside form the regular chart. This would aid us in better recall of the events pertaining to the case and thus help in the resolution of the case.

It is also best to study all the documents you have before going to court.