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    Medico - legal

    Aspects

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    Law

    Ordinarily the term Law means a body of rules to guide

    human action.

    Definition:

    The lawis a system ofrights and obligations which

    the state enforces.

    Green

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    Law-Definition:

    Definition:

    Defined as the sum total of rules and regulations by

    which a society is governed, law is created by people

    and exist to regulate all persons

    Guido

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    Medico legal issues

    Any case of injury or ailment where some

    criminality is involved is called Medico legal

    cases(MLC)

    It is legal presumption that medical officer is

    capable of identifying such cases.

    Medico legality is judged by the history furnished

    by the patient coupled with the finding in the

    physical examination

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    Medico legal issues and emergency department

    Following categories of cases coming to casualty or brought to

    casualty are to be labeled as medico legal:

    1. Cases of injuries and burns, circumstances of which make

    itprobable that someone has committed an offence

    2. All cases of suspected or evident poisoning or intoxication

    3. Allvehicular, factory or unnatural accident cases,

    wherethere is likely hood ofpatients death

    4. Suspected or evidentcriminal abortions

    5. Suspected or evident sexual assault

    6. Unconscious cases where its cause is not clear or notnatural

    7. Cases brought dead with improper history, creating

    suspecion of an offence

    8. Cases referred from court or otherwise age estimation

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    Disposal of medico legal casesa) The above cases, whether brought by the police or somebody

    else ,must be labeled as medico legal in casualty department,

    if not registered else where.

    b) Request of the patient or the accompanying relatives or

    friends for not registering the case as medico- legal, should

    not be agreed

    c) Any case among the above list even if brought several daysafter the incident, shall be registered as medico-legal and an

    opinion regarding the case be given according to the present

    condition of the patient

    d) A fresh medico- legal report may not be prepared if the casebroughthad been registeredas medico- legal in some hospital

    e) Treatment in all medico- legal cases takes precedence over

    medico- legal formalities especially when the condition of the

    patient is serious

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    Procedure of medicolegal casesAll medico- legal cases are supposed to be register and then

    inform to the police. Appropriate prescription forms are to be

    filled for preparing medico legal reports. In such cases,

    identification data, date and time of arrival, date and time of

    examination, name and address of the attendant of the patient

    is to be recorded in each and every case.

    Specimens relevant to the case should be properly sealed,

    labeled and send for investigation, eg: in a stabbed victim theinjury should be encircled, signed and then the specimen should be

    handed over to the police in a sealed cloth parcel.

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    Negligence And

    Malpractice

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    NEGLIGENCE

    Negligence is the failure/ omission of an

    individual to do something which a

    reasonably prudent person would do, or

    doing something which a prudent &

    reasonable man would not do.

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    NEGLIGENCE

    In other words negligence is conduct that falls

    below the standard of care which is established

    by the law for the protection of others against

    unreasonable risk or harm

    It is characterized chiefly by inadvertence,

    thoughtlessness or inattention

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    What constitutes deficiency in service

    or negligence

    Deficiency of service means any fault, imperfection,

    shortcoming or inadequacy in the quality, nature

    and manner of performance which is required to be

    maintained

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    What constitutes deficiency in service or negligence

    Reaction of injection

    Patient left unattendedwhile there were complications.

    Leaving patient in care ofunqualified compounder.

    Foreign material left inside during operation

    Death during operation.

    Post operative care.

    Refusal to admit the patient.

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    What does not constitute deficiency in service or negligence

    Performance of duty to the best of ability.

    Adopting one out of two recognized schools of

    medicine.

    Complainant failed to establish deficiency in service.

    Patient having some medical history.

    Patient of heart attack.

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    Common problems for which the nurses are often found

    negligible are

    1. Failure to use aseptic technique where required

    2. Leaving a foreign object in a patients body during surgery,

    ie: errors in sponge, instrument or needle count in surgical

    cases

    3. Failing to respond promptly to patient symptoms of

    impending disaster

    4. Failing to protect an infirm patient from falling

    5. Administering wrong medicine to a patient

    6. Administering a medication inappropriately, IV therapy,

    errors resulting infiltration or phlebitis

    7. Administering a care in such a manner that apatient suffers

    injury, eg improper handling of hot water bagsburn to

    patient.

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    NEGLIGENCE

    If nurses give care that does not meet the standards, they

    may be held liable for negligence.

    Nurses are responsible for performing all procedures

    correctly and exercising professional judgement as they

    carryout doctors orders and duties not ordered by for

    which they have authority.

    Any nurse who does not meet accepted standards of

    practice or care or who performs duties in a careless

    fashion, runs a risk of being found negligent.

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    Malpractice

    Malpractice is a negligence or carelessness by a

    professional person. So, it concerns professional action and

    in the failure of a person , with professional education and

    skill to act in a reasonable and prudent manner.

    In other words , it is unreasonable professional conduct, lack

    of skill or fidelity in professional duties, evil practice or

    illlegal or immoral conduct.

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    Six elements of malpractice suit

    1. The nurse(defendent) owed a duty to the client(the plaintiff),

    ie. There should be an evidence that the nurse owed a duty to

    the client ,eg: failure to monitor clients response to treatment

    2. Breach of the duty of care owed to the patient, ie. There

    should be an evidence that the nurse failed to meet the

    prevailing standards of care. e.g. failure to communicate

    change in status to other care provider

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    Six elements of malpractice suit

    3. Foreseeability not maintained: Foreseeability include the concept

    that certain events may reasonably be expected to cause specific

    results. For example, in children wards, falling of children from

    bed is common, i.e. There should be an evidence that the client

    suffered due to lack of foreseeability by the nurse

    4. Evidence of causation which means that the nurses action or

    lack of action directly caused harm to the patients and not

    merely that patient had some type of harm. So there should be an

    evidence that nurses failure to meet their duty are likely to cause

    client injury, i.e failure to provide patient education

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    Six elements of malpractice suit

    5. Evidence that nurses failure was direct cause of client

    injury, e.g. if a client falls

    6. There should be an evidence of damage. Damages are valid

    as malpractice which is intentional and unintentional.

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    Measures to overcome malpractice

    Follow standard of care, give competent health

    care, and develop an empathetic interpersonal

    relationship with the client

    Follow careful and accurate documentation

    Be up to date with current practices

    Be sensitive to common sources of clients

    injuries like fall

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    Legislations And

    Regulations Related ToCritical Care

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    Legal safeguards in nursing practice

    Licensure: All nurses who are in nursing practice have to

    posses a valid licensure from State Nursing Council/INC

    Good Samaritan law: In response to health care professionals

    fear of malpractice claims, most states enacted Good

    Samaritan law that exempt doctors and nurses from legal

    liability when they render first aid during emergency. A nurse

    who renders assistance at an accident scene is to held same

    standard of skill, competence and judgement that would be

    applied to a reasonably prudent person with the same

    preparation.

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    Legal safeguards in nursing practice

    Good rapport: Developing good rapport with the client is

    very importantto prevent malpractice.

    Standards of care: All professionals practicing in medical

    field are held to certain standards when administering care. It

    is always better to follow standards of care to avoid

    malpractice and do not attempt anything beyond the level of

    competence.

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    Legal safeguards in nursing practice

    Contracts: It is a written or oral agreement between two

    people in which goods or services are exchanged. According

    to Section 13 to the Indian Contract Act, Contracts the

    word means saying that two or more person are said to

    consent which they agree upon the same thing in the same

    sense. Treating a person with out obtaining consent can

    lead to a charge of assault (unwillful attempt or threat to

    harm another)and / or battery(unauthorized touching of a

    patient)

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    Legal safeguards in nursing practice

    Drug maintenance : the two acts which control the use of

    poison in medicine are,

    Misuse of Drugs Act 1971

    Dangerous Drug Act 1965 & 1967

    The act aims at checking the unlawful use of the drugs

    liable to produce dependence or cause harm if misused.

    Drugs affected by this act is referred to as controlled drugs.Eg: Cocaine, Opium, Pethidine etc

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    Other Legal protection in nursing practice

    1. Civil rights act (CRA)-1964

    2. Americans disability act (ADA)- 19673. Occupational safety and health act (OSHA)- 1970

    4. National labor relations act(NLRA)-1974

    5. Sexual harassment- 1980

    6. Individual express contract7. Employees at will

    8. Good Samaritan law

    9. Age discrimination in employment Act(ADEA)- 1992

    10. Health insurance portability and accountability act

    Laws applicable to nursing practice

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    Laws applicable to nursing practice

    1. The right to refuse to treat except in emergency situation

    2. The right to sue for fees

    3. The right to add title or description to name

    4. Unregistered practitioners are not allowed to hold

    appointments in public or local hospitals

    5. The Indian Penal Code states that poisonous drugs be kept in

    separate containers, properly labeled and marked.

    6. There is a duty of secrecy to the patients records, it must be

    treated as confidential unless the practitioner is called upon to

    give evidence in court

    Laws applicable to nursing practice

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    Laws applicable to nursing practice

    7. Fundamental duties

    a. To exercise a reasonable degree of skill and knowledge intreating patients

    b. Once a relationship to a patient has been established,there is

    an obligation to attend to the patient as long as necessary ,

    unless the patient request for withdrawal or notice is givenof intension to withdraw

    c. A practitioner must give personal attention to his cases and

    answer calls with reasonable promptness

    d. Children must be protected from harming themselvese. Special prevention must be taken in case of adult who are

    incapable of taking care of themselves

    Laws applicable to nursing practice

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    Laws applicable to nursing practice

    8. Dangerous diseases must be reported

    9. Nurses are considered solemnly responsible for their own

    professional act irrespective of the employing agency

    A fine is the usual penalty imposed for disobeying the law

    stated above, although imprisonment also is possible.

    C P t ti

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    Consumer Protection

    Act (CPA)

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    Consumer Protection Act

    Health care delivery system has grown up into an

    industry today and health service consumers are

    better informed than in the past about health and

    illness. Through newspapers, magazines, televisions

    and other multimedia more information is available

    to the consumer

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    Consumer Protection Act

    Many of them are aware of their rights and demanding

    a voice and partnership in the delivery of health care

    services. Years ago, heath care professionals especially

    physicians were considered as all knowing experts. Very

    few patients questioned them. Now consumers of health care

    are demanding to have a say in matters affecting their health

    care.

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    Consumer Protection Act

    As consumers have become more aware of their rights,

    conflicts between patients and health care professionals and

    institutions have developed.

    Nursing is affected by this kind of situation in which

    nurses are also expected to answer questions, explain

    procedures and respect this rights and request of the

    patient. Nurses are challenged to become advocates for clients

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    Consumer Protection Act

    An act to provide better protection of the interests

    of the consumers and for that purpose to make

    provisions for establishment of consumer councils and

    other authorities for the settlement of consumersdispute and for matters connected therewith.

    It is enacted by the Parliament in 1986, has been

    drastically amended and its scope is greatly widened by

    the amendment of 1993.

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    Section 2 of the actConsumer means any person who hires or avails

    of any services for a consideration which has

    been paid or promised or partly paid and partly

    promised.

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    Section 2 of the act

    Servicemeans service of any description

    which is made available to potential users .

    Health care services will be service, if they

    are obtained for consideration.

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    Section 2 of the act

    and that in the event of any deficiency in

    the performance of such services , the

    aggrieved party can invoke the remedies

    provided under the act by filing a complaint

    before the consumer forum having

    jurisdiction.

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    ADVANTAGES OF CPA OVER CIVIL COURT

    1. Limited time is needed for decision and

    action (period of 3 months).

    2. No court fee is payable

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    COMPLAINT & COMPLAINANT

    Complaint: meansany allegations in writing made

    by a complainant .

    Complainant: means

    (a)a consumer

    (b) any voluntary consumer association

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    WHO IS LIABLE TO CPA

    1. Doctors with independent practice

    2. Private hospital charging all.

    3. All hospital having free as well as paying

    patients, they are liable to both.

    4. Doctors or hospitals paid by an insurance

    scheme for treatment of a client or an employer

    for the treatment of an employee.

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    WHO IS NOT LIABLE TO CPA

    Doctors in hospitals , which do not charge their

    patients.

    Hospitals offering free services to all patients.

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    (2) State level: At this level the claim for

    compensation is enhanced toRs: 520 lakhs &high

    court judge & 2 other members chair it.

    (3) National level: Here the compensation claimed

    is more than 20 lakhs .This forum constitutes ofasupreme court judge ,4 other members.

    PROVISION FOR APPEAL

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    PROVISION FOR APPEAL

    Within 30 days from the date of decision , appeal

    can be filed in the higher commision

    1. Appeal against district forum before state

    commision .

    2.Appeal against state commission before national

    commision.

    3.Against national commission before supreme

    court.

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    PREVENTIVE STEPS AGAINST LITIGATION

    Precautions may be summarized as Dos & Donts

    SOMEDOS

    -Mention your qualifications on the prescription.

    -Mention date & timing of consultation.

    -Mention age, sex, weight (child).

    -In complicated cases record history of illness &

    physical findings about the patient.

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    SOME DONTS

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    SOME DONTS

    -Do not hesitate to discuss the case with your colleagues.

    -Do not hesitate to discuss the case with patients or

    attendants.

    -Do not allow substitutions.

    -Do not attent a patient if you are sick, exhausted or under

    effect of alcohol.

    -Do not adopt experimental method in treatment

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    LIMITATION

    Limitation period : the district forum ,the

    state commission or the national

    commission shall not admit a complaint

    unless it isfiled within 2 yearsfrom the date

    on which the cause of action has arisen.

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    Bill of rights of a patient,

    Euthanesia

    Cli t Ri ht

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    Clients Rights

    Clients are protected by law (invasion of privacy)

    against unauthorized release of personal clinical

    data, such as symptoms, diagnoses, and

    treatments.

    Nurses, as well as other health care personnel, may

    be held personally liable for invasion of privacy .

    Litigation arise from the unauthorized release of

    client data.

    Clients Rights

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    Client s Rights

    Confidential information, however, may be released

    with the clients consent.

    Information release is mandatory when orderedby a

    court or when state statutes require reporting child

    abuse, communicable diseases, or other incidents.

    Nurses have a legal and ethical responsibility to

    become familiar with their employers policies and

    procedures regarding protection of clients

    information.

    Clients Rights

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    Client s Rights

    Medical records are the key written account of such client

    information as signs and symptoms, diagnosis, treatment, and

    responses to treatment.

    These records contain important data for insurance and other

    expense claims and are used in court in the event of litigation.

    Health professionals are becoming more aware of the

    implications of clients rights as society in general becomes

    more aware of every human beings basic rights.

    The Client Bill of Rights

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    The Client Bill of Rights:

    1. The client has the right to considerate and respectful

    care.

    2. The client has the right to obtain from his or her

    physician complete current information concerning

    diagnosis, treatment, and prognosis in terms the client

    can be reasonably expected to understand.

    The Client Bill of Rights:

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    g

    3. The client has the right to receive from the physician

    information necessary to give informed consent prior to thestart of any procedure or treatment. . . . Where medically

    significant alternatives for care or treatment exist, or when the

    client requests information concerning medical alternatives,

    the client has the right to such information to know the name of

    the person responsible for the procedures or treatment.

    4. The client has the right to refuse treatment to the extent

    permitted by law and to be informed of the medical

    consequences of his or her action.

    The Client Bill of Rights:

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    The Client Bill of Rights:

    5. The client has the right to every consideration of privacy

    concerning his or her own medical care program.

    6. The client has the right to expect that all communications

    and records pertaining to his or her care should be treated as

    confidential.

    7. The client has the right to expect that within its capacity a

    hospital must make reasonable response to the request of a

    client for services.

    The Client Bill of Rights:

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    The Client Bill of Rights:

    8. The client has the right to obtain information as to any

    relationship of the hospital to other health care and

    educational institutions in so far as his or her care is concerned [

    any professional relationships among individuals, by name, who

    are treating him or her.

    9. The client has the right to be advised if the hospital proposes to

    engage in or perform human experimentation affecting his orher care or treatment. A patient has the right to refuse to

    participate.

    The Client Bill of Rights:

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    The Client Bill of Rights:

    10. The client has the right to expect reasonable continuity of

    care.

    11. The client has the right to examine and receive an

    explanation of his or her bill regard less of source ofpayment.

    12. The client has the right to know what hospital rules and

    regulations apply to his or her conduct as a client.

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    Legal responsibilitiesof nurses

    Legal responsibilities of nurses

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    Legal responsibilities of nurses

    1. Responsibilities of appointing and assigning: Ns

    administrator must be aware of the legal restrictions affecting

    personnel appointment and assignment; she should screen the

    staffs appropriately before appointing them.

    2. Responsibility in quality control:Nurse administrator must

    ensure and report quality of nursing services.

    3. Responsibility for equipment: To protect the patient and

    employee from injury, the nurse manager must ensure that all

    patient care equipments are fully functional and defective

    equipments are promptly repaired or replaced.

    Legal responsibilities of nurses

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    Legal responsibilities of nurses

    4. Responsibility for observation and reporting

    5. Responsibility for record keeping and reporting

    6. Responsibility to protect the public

    7. Responsibility for death and dying

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    Role of nurse in legal

    issues

    Role of nurse in legal issues

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    Role of nurse in legal issues

    The following are the leadership roles and

    managerial functions of a nurse manager in legal and

    legislative issues. He or she;

    1. Serves as a role model by providingnursing care that

    meets and exceeds accepted standard of care

    2. Is current in the field

    3. Reports substandard nursing care to appropriate

    authorities

    Role of nurse in legal issues4 F t / ti t l ti hi th t

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    4. Fosters nurse/ patient relationships that are

    respectful, caring and honest, thus reducing the

    possibility of future lawsuits

    5. Joins and actively supports professional

    organizations to strengthen the lobbying efforts of

    nurses in health care legislation

    6. Practices nursing with in the area of individual

    competence

    7. Prioritizes patients rights and welfare first in

    decision making

    Role of nurse in legal issues

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    Role of nurse in legal issues

    8. Demonstrates vision, risk taking etc in

    determining appropriate legal boundaries

    9. Is knowledgeable while responding to legal issues

    related to nursing practice

    10.Delegateto subordinates wisely

    11.Understand and adhere to hospital policies and

    procedures

    Role of nurse in legal issues

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    Role of nurse in legal issues

    12.Monitors subordinates

    13.Uses foreseeability of harm in delegation and

    staffing decision

    14.Increases staff awareness in legal issues

    15.Provides educational and training opportunities

    for staff on legal issues affecting nursing practice

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    Records and reports

    Records and reports

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    Records and reports

    The medico- legal patients clinical record is a

    brief account of the personal and medical history

    of the patient, results of diagnostic tests, findings

    of medical examination, treatment and nursing

    care, daily progress notes and advice on discharge.

    Records and reports

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    1. The records are kept under safe custody of the nurse

    in each ward

    2. No individual sheet is separated from the complete

    record

    3. Records are kept in place, not accessible to patients

    and visitors

    4. No stranger is ever permitted to read the record

    5. Records are not handed over to legal advisors with out

    the written permission of the administration

    Records and reports

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    Records and reports

    6. All hospital personnel are legally & ethically obligated to keep

    in confidence all the information provided in the records

    7. All records are to be handled carefully, careless handling can

    destroy the records

    8. All records are to be filed according to hospital custom, so

    that they can be traced easily. Records can be arranged

    Alphabetically

    Numerically

    Geographically

    Records and reports

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    Records and reports

    9. All records are identified with the biodata of the

    patient such as name, age, ward, bed no, OP no etc

    10.Medico legal records are never sent out of the

    hospital with out the doctors permission.

    Reference is made by writing separate sheets and

    sending to the agency who requests for them Eg:

    discharge summary