Medical Records

When an injury becomes the subject of a legal proceeding, the medical record documenting that injury and its subsequent treatment becomes a central part of the court deliberations, which may include obtaining testimony from the physician that created that record. The defendant or the accused is entitled to cross-examine that physician to establish or refute the validity of the medical information presented to the court. Physicians must recognize the legal responsibility that society places on them and be prepared to provide competent, professional testimony when required. The proper documentation of injuries includes the description of the details previously specified under wound pattern. The use of anatomic diagrams, together with photographs, makes the record more representative of the injuries as a physician saw them and more understandable by the lay members of a court. These items (charts, diagrams, and cameras) should be essential equipment in an ED, and photographs should become part of the permanent medical record.

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