Development of medical record formats in Forensic Medicine and forensic science for General Practitioner in Community Hospital

Abstract

The practice of medicine or the medical profession requires the recording of patient information and various treatments in each patient, which is called medical record. All doctors must be instructed in this part since they have studied at the university. In terms of duties, whether in hospitals, clinics, or other medical institutions, it appears that writing medical records is not as it should be. It lacks of details or incomplete. These cases would inevitably affect the patients in safety and standard treatment.

Moreover, they may affect doctors, recorders, and patients in the case of a complaint sue. Medical records are essential documents. Therefore, the doctor should know that medical records and related documents are essential.

          Forensic medicine is a person who plays a vital role in the treatment and takes care of forensic patients in the clinic. That requires knowledge expertise in forensic medicine and trauma care for patients, including dealing with forensic evidence and forensic science, which is noticed. Accordingly, doctors need to have knowledge and ability to understand forensic issues thoroughly, such as assessing the severity of the wound and wound types. There is also traumatic type behavior caused by accident, physical abuse, and self-abuse — finally, the awareness of the type of wound caused by sharp or blunt objects. The doctor should document the location of the wound on patient's body accurately.