Anomalies in Medico-Legal Reports at a Tertiary Care Hospital in Rawalpindi: A Retrospective Analysis of Documentation Errors and Their Implications

Authors

  • Shahid Iqbal Watim Medical & Dental College, Rawalpindi, Pakistan
  • Muhammad Yousaf Saidu Medical College, Swat, KP Pakistan
  • Muhammad Ikram Ali Ziauddin Medical College, Karachi, Pakistan
  • Sadia Abdul Qayyum Liaquat National Hospital and Medical College, Karachi, Pakistan
  • Naveed Ali Qadri Isra University, Hyderabad, Pakistan
  • Tanveer Afsar Malik Federal Govt. Polyclinic (PGMI), Islamabad, Pakistan

DOI:

https://doi.org/10.52206/jsmc.2025.15.4.1300

Abstract

Background: Medico-legal cases (MLCs) bridge medicine and law, requiring precise documentation to ensure justice. Errors in medico-legal reports (MLRs) compromise legal reliability and highlight deficiencies in physicians’ documentation practices.

Objective: To determine the frequency and nature of documentation errors in MLRs prepared at a tertiary care hospital in Rawalpindi.

Methodology: A retrospective descriptive study was conducted in the Department of Forensic Medicine, Watim Medical and Dental College, Rawalpindi, after ethical approval (REF NO: WM&DCR/R&D (ERB)2024/131) and CPSP synopsis approval (REF NO: CPSP/REU/FRM-2022-335-89). A total of 85 MLRs fulfilling inclusion criteria were reviewed using a structured checklist. Data were analyzed in SPSS v26.0 and presented as frequencies and percentages.

Results: Among 85 reports, 60 (70.6%) involved males and 25 (29.4%) females; young adults (18–35 years) were the most affected group (56.5%). Physical assault was the leading category (50.6%). Documentation anomalies occurred at all levels: missing police records (10.6%), incorrect addresses (68.2%), absent identification marks (83.5%), incomplete vital signs (88.2%), and missing final opinions (76.5%).

Conclusion: Anomalies in medico-legal documentation were frequent, reflecting inadequate physician training and lack of standardized formats. Structured medico-legal training, digital reporting systems, and regular audits are essential to improve documentation accuracy and legal reliability.

Keywords: Documentation Errors, Forensic Medicine, Legal Reliability, Medico-legal Cases, Pakistan, Report Quality.

References

Brahmankar TR, Sharma SK. A record-based study of the frequency and pattern of medico-legal cases reported at a tertiary care hospital in Miraj. International Journal of Community Medicine and Public Health. 2017;4(4):1348–52. http://doi.org/10.18203/2394-6040.ijcmph20171374

National Health Systems Resource Center. Guideline for medico-legal cases [Internet]. New Delhi: NHSRC; 2021 [cited 2025 Sep 5]. Available from: https://nhsrcindia.org/

Linares-González L, Rodríguez JS, Beltrán-Aroca CM, Girela-López E. Quality control of injury reports issued by primary health care and emergency medical services in the province of Córdoba. Spanish Journal of Legal Medicine. 2019;45(1):12–7. http://doi.org/10.1016/j.remle.2019.01.002

Madadin M, Alqarzaie AA, Alzahrani RS, Alzahrani FF, Alqarzea SM, Alhajri KM, et al. Characteristics of medico-legal cases and errors in medico-legal reports at a teaching hospital in Saudi Arabia. Open Access Emergency Medicine. 2021;13:521–6. http://doi.org/10.2147/OAEM.S341893

Aktas N, Gulacti U, Lok U, Aydin I, Borta T, Celik M. Characteristics of traumatic forensic cases admitted to emergency medicine and errors in the forensic report writing. Bulletin of Emergency & Trauma. 2018;6(1):64–70. http://doi.org/10.29252/beat-0601103

Akbaba M, Das V, As?lda? MK, Karasu M, Atan Y, Tataroglu Z, et al. Are the judicial reports prepared in emergency services consistent with those prepared in the forensic medicine department of a university hospital? Eurasian Journal of Emergency Medicine. 2019;18(2):79–85. http://doi.org/10.4274/eajem.galenos.2018.93723

Zaki MK, Bayoumi KA, Rawas MI, Alshutayri ZN, Kensarah EA, et al. Measuring the awareness of emergency medicine physicians toward the management of medico-legal cases in Jeddah, Saudi Arabia. Saudi Journal of Forensic Medicine & Sciences. 2018;1(3):61–7. https://doi.org/10.4103/sjfms.sjfms_13_18

Timsinha S, Parajuli SR, Pradhan A. Characteristics of medico-legal cases and errors in documentation of medico-legal reports at a teaching hospital in Nepal: a descriptive cross-sectional study. J KIST Medical College. 2023;5(10):39–43. https://doi.org/10.61122/jkistmc240

Kotze JM, Brits H, Botes BA. Medico-legal documentation: South African Police Service forms, Department of Justice forms, and patient information. South African Family Practice. 2014;56(6):16–22. https://doi.org/10.4102/safp.v56i5.4140

Rawat A, Govil P, Datta K. Evaluation of errors in medico-legal records in the Emergency Department of a tertiary care hospital in North India, New Delhi. Indian Journal of Emergency Medicine. 2023;9(4):183–7. https://doi.org/10.21088/ijem.2395.311X.9423.3

Chaudhary B, Shukla PK, Bastia BK. Role of the clinical forensic medicine unit in quality and standardization of medico-legal reports. Journal of Forensic and Legal Medicine. 2020;74:102007. http://doi.org/10.1016/j.jflm.2020.102007

Haridas SV, Pawale DA. A retrospective study of the pattern of clinical medico-legal cases registered at the tertiary health care center in Kolhapur district. Journal of Forensic Medicine & Science & Law. 2014;23(2):1–5.

Turla A, Ayd?n B, Sataloglu N. Mistakes and omissions in judicial reports prepared in emergency services. Ulus Travma Acil Cerrahi Derg. 2009;15(2):180–4.

Tadia VK, Jangale PS. Medico-legal documentation in a public hospital in India: an analysis of 100 cases. Medico-Legal Update. 2021;21(1):1168–70. http://doi.org/10.37506/mlu.v21i1.2476

Yildirim H, Kaya M. Forensic cases in the emergency department: associations between life-threatening risk, medical treatability, and patient outcomes. Diagnostics. 2025;15(11):1416. http://doi.org/10.3390/diagnostics15111416

Erdogan Çetin Z, Teyin A, Birben B, Çetin B, Gültekin ?ahiner G, Hamamc? M. Evaluation of judicial reports prepared in the emergency department. Bozok Medical Journal. 2018;8(4):34–40. http://doi.org/10.16919/bozoktip.413858

Acharya J, Shrestha R. Documenting injuries for medico-legal use: a “must-know” to doctors. Meleson News. 2017:6–9.

Rege S. Medico-legal cases across various hospitals: a review and understanding of procedures. Medico-Legal Update. 2011;11(2):71–3.

Davis EA, Lyter AH. Comparison of typewritten carbon paper impressions. Journal of Forensic Sciences. 1982;27(2):311–21. http://doi.org/10.1520/JFS11302J

Additional Files

Published

04-11-2025

How to Cite

1.
Iqbal S, Yousaf M, Ali MI, Qayyum SA, Qadri NA, Malik TA. Anomalies in Medico-Legal Reports at a Tertiary Care Hospital in Rawalpindi: A Retrospective Analysis of Documentation Errors and Their Implications. J Saidu Med Coll [Internet]. 2025 Nov. 4 [cited 2026 Nov. 10];15(4):685-92. Available from: http://jsmc.pk/index.php/jsmc/article/view/1300

Issue

Vol. 15 No. 4 (2025): Journal of Saidu Medical College

Section

Original Article

License

Copyright (c) 2025 The authors retain the copyrights. Authors are permitted and encouraged to post their work online (e.g. in institutional repositories or on their website), as it can lead to productive exchanges, as well as greater citation of published work.

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

Readers may “Share-copy and redistribute the material in any medium or format” and “Adapt-remix, transform, and build upon the material”. The readers must give appropriate credit to the source of the material and indicate if changes were made to the material. Readers may not use the material for commercial purpose. The readers may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.