MEDICAL ANECDOTAL REPORT
Index Title: RCABAD’S MAR [15-06]
MAR Title: Importance of Medico-legal Certificates
Date of Medical Observation: July 2015
Tag: Importance of proper documentation of Medico-legal certificates
Category: Professional / Ethical – Reinforcement
Slacks, long-sleeved shirt, and a pair of leather shoes plus my smock gown, I usually don’t wear these unless I have to. But that day, I wore them because once again, I would attend a court hearing regarding a patient I saw 3 years ago. The patient apparently was a 43-year-old female who allegedly was a victim of assault. The suspect was an American citizen. As I entered the room, I immediately saw two tall and huge men: one American and another, a Filipino lawyer. The fiscal immediately approached me and said that our case would begin immediately once the victim arrived. After hours of waiting, the victim finally arrived and the case was immediately started. I was then put to the stand. When the fiscal was cross examining me, it was easy; I thought to myself that there would be no problem. Then the defense started questioning me. The first thing they inquired about was regarding the handwriting on the chart, which had two different things, to which I explained as clearly as possible. Another thing they questioned was why my signature on the chart and the signature on the medical certificate were different. This led to me having to sign on both the chart and medical certificate to attest that the signatures were both mine. The examination lasted for more than half an hour, all of which were the result of what I felt was now a simple mistake of carelessness I did when I was in my junior years. The good thing was the fiscal was there to defend me.
(Physical, Psychosocial, Professional / Ethical)
(Discovery, Stimulus, Reinforcement)
How many times have we heard and been warned about how a simple mistake in writing or giving a medical certificate could cost us our medical license? When I was in my junior years I would issue medical certificates left and right, especially to those patients seen for routine medical examination prior to transfer to jail facilities. There were times when I would rely solely on the medical interns and clerks that they wrote the name of the patient accurately and after I examined the patient I would just sign the medical certificate. Now these mistakes are haunting me in, hopefully, my last year in this hospital as a resident. Issuance of medico-legal certificates is really a serious matter that we cannot put lightly. As I was reminded recently, we will never know who would file a complaint and would question the records presented. Even the discrepancy on the time, letter, and handwriting on the records of the patient could put our professional career at risk. With this, I’m really hoping this would be a reminder to our junior residents, especially the second year residents, to be careful in giving a medical certificate.
ROJoson’s Notes (17jan20):
An advice and reminder on the importance of medical certificates issued by physicians, medico-legal ones or otherwise.