Criminal Law in Medical Malpractice: brain hemorrhage in Emergency Station: Is the Medical Record the Queen of Evidence?
The victim X has injured in his head, face, hand and foot. The physician Y as an accused didn’t take a neurological examination to the X, because X’s physical movements and speaking were normal, and had a clear consciousness as a result. The X was discharged after the nurse gave precautions in writing to his friends. However, the X was dead in his place because of cerebral hemorrhage and coma, which were caused by the hit. This case was litigated and identified for serval years. The court deemed finally that the X’s Glasgow Coma Scale (GCS) was 15 and there was no necessary to take an X-ray or a CT-Scan for the X. What the Y did, doesn’t again the medical rules and had consequently no fault.
Actually, local hospitals don’t record detailed. The Y in this case didn’t record the result of the neurological examination because the Y’s consciousness was recorded as clearness. It is a common falling in clinic medicine. Nevertheless, the medical records are very important evidence in medical litigations and have a high degree of proof, if each part of the neurological examination was filled in certainly. The medical record is in conclusion the queen of evidence.