MBVELEZ’S MAR [15-05]:A Firm Proof of Evidence

Medical Anecdotal Report
Indexing Title: MBVELEZ’S MAR [15-05]
MAR Title: A Firm  Proof of Evidence
Date of Medical Observation: February 2015
Tag: Attesting a medico-legal case
Category: Professional/Ethical – Reinforcement
After having lunch one from-duty day, I was personally called upon by the Director’s Office regarding a patient’s concern. Accompanied by a Junior Intern (JI) as I got there, I saw the Hospital Director talking to an old man in military uniform, and two guys who were a bit familiar to me. The military man, who claimed to be the father of one of the guys, immediately shook my hand as I approached them. On the other hand, the two other guys were just staring at me in a really arrogant manner. The Director then started talking, and told me that there was a bit of an issue between me and the two guys, who happened to be medico-legal patients I saw one morning on the previous month, when I was on-duty at the emergency room. According to the father, I saw the two guys brought by a group of policemen due to an alleged case of “Usurpation of Authority”, since they pretended that they were also policemen. The father then showed me a photocopy of the medical certificate that I issued with “No external signs of physical injuries at the time of examination” written on it. Then he showed me next a few pictures of the two guys, with multiple injuries on the face, body, and upper extremities, with another medical certificate from another hospital with a lot of physical findings of injuries written. However, the said paper was issued in the evening of the same date. The father was then questioning me if I was really able to examine the patients, or if I was just bribed by the policemen and persuaded to indicate a false finding of no injuries present. Although a bit difficult for me to fully remember the incident, I immediately negated the false accusations of the father towards me. Together with my JI, I told them that we always properly assess all patients for medico-legal examination, and that it would be quite impossible for us being not able to note such obvious physical findings that really looked visible to the naked eye. However, they insisted that they were violently inflicted with injuries by the said group of policemen. Calmly, I explained to them that I would never put my license at stake, as well as the surgery department and this hospital by doing such mistake. I added that what was written on the medical certificate, with my signature affixed to it, was exactly what I noted. Whatever happened prior to the patients being brought to this hospital, and even after it, was already out of my authority and responsibility. The hospital’s lawyer-physician then got there and helped me explained that if ever the incident happened prior to the physical examination, it may not immediately be visible externally. On the other hand, if the incident happened after, then something wrong might have happened while the patients were detained. Eventually, the meeting was adjourned with a lot of questions and issues clarified and agreed upon.

(Physical, Professional/Ethical, Psychosocial)
(Discovery, Stimulus, Reinforcement)
Medico-legal examination is a simple, yet a significant responsibility placed by this institution to our shoulders. A piece of paper of the medical certificate handed to patients or arresting officers may seem not-so-important to others, but to us who affix our name, license number, and signature to it, it’s even more than significant due to its legality. Although less prioritized than those patients who are ill and who need surgical expertise, medico-legal patients still need to be carefully examined, and given medical certificates with precise physical findings. It is a fundamental part of our residency training that we see to it that we ourselves are able to examine the patients, and everything written on the charts as legal documents, are exact and accurate. Correspondingly, everyone in the medical field writing on these charts should always be careful in transcribing, making sure that the words are readable, with even the corrections being well-addressed. These well-documented charts are our strong evidences pertaining to all patients, including all our taken part of the history, physical examination, diagnosis, as well as how we have managed them. We should always be reminded that every word written in there is a reflection of our credibility as licensed physicians. When summoned by a court of law, or even by the higher-ups in this institution, that simple paper is what we can hold on to, to stand firm as noble and trustworthy doctors, and for us to serve as truthful evidences for all our patients.
ROJoson’s Notes (17jan4):
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