4.
General
Prac??oner
1. TAKE
A
RELEVANT
AND
ADEQUATE
HISTORY
FROM
PATIENT/BYSTANDER
(with
a
chaperon
beside
you)
2. NOTE
DOWN
THE
LEVEL
OF
CONSCIOUSNESS/
SMELL
OF
ALCOHOL/UNDER
INFLUENCE
OF
ALCOHOL
3. IF
THE
PATIENT
IS
DEAD
ON
ADMISSION
AND
NO
HOPE
OF
RECOVERY,
CERTIFY
THE
DEATH,
DATE
&TIME
OF
DEATH
4.
DESCRIBE
THE
NATURE
OF
INJURIES
ON
THE
BODY,
PRESERVE
ANY
PELLET/BULLET
ETC,
CLOTHES
WITH
MARKS/POISON
5.
IF
THE
PATIENT
DIES
KEEP
THE
BODY
IN
OPD,
A
&
E
FOR
2
HOURS,
ARRANGE
FOR
AN
INQUEST
6.
WRITE
DOWN
THE
NAMES/OTHER
DETAILS
OF
PERSONS
WHO
BROUGHT
THE
PATIENT
7. EXAMINATION
OF
THOSE
BROUGHT
BY
POLICE
FOR
DRUNKENNESS,
SUSPECTS
OF
CRIME
WITH
A
MLEF
8.
ISSUE
OF
MEDICAL
CERTIFICATES
SHOULD
BE
LIMITED
TO
THOSE
PATIENTS
EXAMINED
BY
HIM
AND
LEAVE
OF
ABSENCE
SHOULD
BE
DECIDED
ON
THE
INDIVIDUAL
CASE.
THOSE
WITH
SERIOUS
COMPLAINTS
ADMIT
TO
WARD
1. Detail
history
of
the
assault/accident
with
date
&
[me,
type
of
weapon
or
vehicle
etc.
In
sexual
assault
details
of
the
a_ack,
in
poisoning
type
and
[me
of
inges[on.
Any
item
relevant
to
the
incident
brought
/
recovered
from
the
pa[ent
should
be
handed
over
to
police
2.
Note
down
the
level
of
consciousness,
smell/
under
the
influence
of
alcohol
3. Detailed
history
of
the
incident
4. Complete
examina[on
of
all
the
systems
and
document
of
all
the
injuries/opera[on
findings
5. Order
relevant
inves[ga[ons/enter
in
BHT
6. Where
a
sexual
abuse
is
alleged
take
swabs
if
instructed
by
JMO,
hand
over
clothes
to
police
7. Inform
police
about
the
case
in
Assaults,
RTA,
Burns,
Poisoning,
Child
abuse,
Sexual
abuse,
when
criminal
abor[on
is
suspected
or
when
there
is
suspicion
on
an
injury
8. If
there
is
a
need
record
or
make
arrangements
to
record
a
dying
declara[on
9. If
pa[ent
dies
write
“THE
DECLARATION
OF
DEATH
FORM”
when
it
is
a
natural
death
with
no
requirement
to
conduct
an
Inquest
10.
Order
for
Inquest
when
indicated
11.
A_end
the
inquest
to
give
evidence
when
required
12.
On
discharge
make
sure:
JMO
had
seen
all
medico-‐legal
cases,
medical
cer[ficate
for
the
required
period
is
issued,
relevant
instruc[on
are
given
13.
Keep
the
BHT
up
to
date,
with
all
entries,
names
of
doctors
who
saw,
diagnosis,
referrals
and
send
to
the
record
room
up
on
discharge
of
the
pa[ent
1. To
give
his
opinion
on
a
case
when
referred
by
a
JMO/
medical
officer
for
medico-‐legal
purposes
2. When
injuries
need
to
be
altered
during
surgery
describe
the
original
injury
in
detail
including
those
of
organs
3. Record
all
foreign
bodies
recovered
during
surgery
such
as
pellets,
bullets
hand
them
over
to
the
police
4. Send
organs
removed
during
surgery
to
mortuary
for
examina[on
at
autopsy
of
the
case
5. Arrange
case
conferences
in
child
abuse
1. Cases
requiring
medico-‐legal
examina[on
should
be
referred
to
government
hospital
amer
providing
emergency
care
2. Forward
all
medical
records
maintained
for
a
pa[ent
for
a
medico-‐legal
inves[ga[on
when
requested
by
the
police
3. Dental
records
be
forwarded
when
requested
for
iden[fica[on
of
unknown
body