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1. Medico-Legal Issues in Admission & Discharge, Roles & Responsibilities of Nurses Ms. Hrishita Patil Ms. Samiksha Salve Ms. Dipali Ms. Janhavi Nimankar Ms. Vaishnavi Patil Mr. Anugrah Biswas Ms. Samiksha Kulkule Ms. Shruti Magar Ms. Vedanti Madame

2. General Objective Specific Objective By the end of this session, the group will be able to understand about medico legal cases in admission and discharge and the role of nurses in it and will apply this knowledge in clinical & community settings. By the end of this session, the group will be able to:- Define admission & discharge. Understand its purpose and procedure. Know the articles required to admit & discharge. Enumerate the legal cases involving admission & discharge. Understand the roles of nurses and the risks involved. Objectives

3. 01 Process of accepting a patient into a healthcare facility, including documentation, consent and medical evaluation. 03 Formal process of releasing a patient from a healthcare facility with necessary documentation and instructions. 02 Cases involving medical treatment with legal implications, requiring documentation and adherence to laws. TABLE OF CONTENTS Admission Discharge Medico-Legal Cases

4. Admission

5. Definition: Admission of a client means allowing the client to stay in the hospital for observation, investigation and treatment of the disease that patient is suffering from. Admission is the entry of the patient into a hospital ward for therapeutic or diagnostic purposes.

6. Emergency Admissions Routine/ Elective Admissions Clients are admitted in acute conditions requiring immediate treatment. E.g. A patient with heart attack, poisoning, breathing difficulty, RTA(Road traffic accidents), etc. Patient should be admitted in casualty or emergency department for immediate treatment. Clients are admitted for investigations and planned treatment and surgeries. E.g. Patient with Diabetes, Hypertension, Jaundice, etc. Types of Admission

7. T herapeutic Diagnostic Therapeutic admission means Patient has already diagnosed With the medical condition and Now require medical care for the improvement. Admission when the patient has to undergo some procedure and require investigation like biopsy Types of admission

8. Long term admission Short term admission Long term admission is required when the patient is suffering from a chronic disease and needs more than 48 hours to recover from the disease condition. Eg- cancer Admission is called short term if patient is admitted for 24-48 hours in the hospital. Eg- Jaundice Types of admission

9. To receive the patient in ward for admission according to his/her condition. To provide comfort & safety to the patient. To provide immediate care. To be ready for any emergency. To obtain more information about patients. For Example: any allergies, disease history, etc. To establish a nurse-patient relationship. To assist proper discharge planning of care. Purpose of Admission

10. A dmission procedure Prepare the room, arrange all the items in place and adjust height of bed. Check patient’s identification and greet him\her and relatives, introduce yourself. Observe client’s signs and symptoms for laboratory tests, if required. Provide privacy. Give admission bath, if needed. Change to hospital clothes. Explain the use of bathroom and other equipments in the ward. Place call bell and locker in easy reach of the patient. Explain meal timings and visiting timings to client & relatives.

11. Unit is the place where the patient stays for treatment. The admission department notifies prior to the admission so that the unit is prepared before the arrival of the patient. Prepare the treatment table. Ensure all equipment are complete. Check Ventilation. Ensure patient’s privacy. Preparing the Unit for Admission

12. AFTER ADMISSION Things to do!

13. Welcome the patient and their family with a warm approach. Make the patient comfortable in bed and provide him with hospital clothes and ensure adequate privacy. Alleviate stress and fear. Identify Self This Photo by Unknown Author is licensed under CC BY

14. Location of nurses’ station Room Boundaries Clothes Storage Call Light Bed Controls Light Switches Telephone policy TV Controls Meal Timings Visiting Hours Diet Safety Measure-Side Rails and etc Time for doctor’s visit Scheduled Tests Orient Patient

15. Record all the basic information in the patient’s record. Clearly mention admission date, time, patient details, complaints of the clients, any allergies, patients’ mental status. Record in admission register, treatment book, report book, medical legal case(MLC) register, update ward census and nurses’ notes. Physical Assessment Patient’s Comfort Collect information for database. Perform initial admission assessment Obtain physician’s order for the lab, tests, medical activities, etc. Identify data Chief complaints Present history Past health history Review of body system Gather Information

16. What to look for in newly admitted patients? Anxiety Loneliness Increased Privacy/Isolation Loss of Identity Observation

17. Medico-Legal Case

18. It is a case of injury or ailment where an attending doctor after taking history and clinical examination of the patient thinks that some investigation by law-enforcing agencies is essential, so as to fix the responsibility regarding the case in accordance with the law. A doctor can receive a medico-legal case: Brought by the police for examination and reporting. Already registered MLC referred from other health care system for expert management/advice. After history taking and thorough examination, if the doctor suspects that the circumstances/ findings of the case are such that registration of the case as an MLC is warranted. What is a Medico-Legal Case?

19. 1.Cases of injury and burns, the circumstances which suggest a commission of an offence by somebody. 2. All kinds of vehicular, and industrial accidents or unnatural accidents especially when there is a likelihood of patient death. 3. Electrocution 4. Death due to snake/animal bite 5. Suspected or evidential criminal abortions 6. Unnatural unconsciousness 7. Suspected unnatural poisoning or intoxication 8. Cases referred by the court for age estimation 9. Cases brought dead with improper history creating suspicion of an offence. 10. Suicidal cases 11. Drowning 12. Unnatural death/injury in women including dowry deaths of a woman patient within 7 years of marriage. 13. Rape cases 14. Sexual offences Types of Medico Legal Cases

20. Registering a Medico-Legal Case Treatment (All legal formalities to be suspended till the patient is resuscitated) Identification (Whether the said case falls under Medico Legal Case or not) Intimation to Police (if it does fall in this category, then he must register the case as an MLC and/ or intimate the same to the nearest police station, either by telephone or in writing). Acknowledgement Reciept (From the police should be received for future reference). Procedure

21. Reporting a Medico-Legal Case Reports must be prepared in duplicate on proper pro-forma giving all necessary details. Avoid abbreviations, over writings. Correction, if any, should be initiated with date and time. Reports must be admitted to the authorities promptly. Medico-Legal documents should be stored under safe custody for 10 years. Age, sex, father’s name, complete address, date and time of reporting, time of incident, brought by whom. Identification marks and finger impressions. All MLC to be informed to the police for taking legal evidence If the patient is dying, inform the magistrate to record ‘dying declaration’. Procedure

22. Preparation of Medico-Legal Case Record While preparing a medico-legal case record a medical practitioner should necessarily include all the important details of the said medico-legal case in the following manner:- A medico-legal report (MLR) comprises three parts namely- Preamble- includes the date, time, and place of examination, name of the patient/ police official accompanying, FIR no.-, informed consent of the person being examined, two marks of identification. ii. Body (findings/observations) - includes a complete description of the injuries/any other findings present, any investigations/referrals, asked for. iii. Post-amble (opinion) - includes the: a) nature of the injury – whether simple or grievous b) Weapon/force used – whether blunt or sharp c) Duration of injuries – based on the characteristics of the external injuries All the medico-legal case reports are to be signed by the attending physician in capital letters with full name. Procedure

23. Possess Permanent Registration with MCI/SMC The doctor who has -First contact with patient should prepare an ML case report In rape victims by the examination and preparation of MLC is preferably done by female doctors. Documentation is done in duplicate in a set Proforma as per hospital policy. All columns are filled up carefully and by the same doctor who had examined the patient Each MLC is given a fresh MLC number sequentially or parallel series as per hospital policy After completion doctors sign and mention his/her name in full below it with designation with registration number . Police constable on duty informed in each case. After registration of a case as MLC, thereafter all documents  and requisition forms bear the same MLC number including the discharge slip. If death is inevitable, an arrangement to take the dying declaration is made. Procedure

24. All the materials such as vomit, gastric lavage sample, blood urine, etc. in poisoning cases, vaginal swab and pubic hair in sexual offences, foreign bodies found in the wounds, etc are collected. Samples are properly preserved, packed and sealed then handed over to the police. It must be remembered that a practitioner is protected against any harm done in good faith to a patient in an emergency situation ethically as well as legally as per Section 92 IPC.

25. There are some formalities that are taken care of when a medico-legal case is admitted or discharged: Whenever a medicolegal case is admitted or discharged or referred to some higher centre, the same should be intimated to the nearest police station. While referring or discharging the patient, a discharge card/referral letter should be provided with a complete summary of admission, the treatment given and the instructions to be followed after the discharge. Failure of which shall make the hospital liable for negligence and deficiency of service. Admission/Discharge of an MLC

26. When a patient in a medicolegal case is absconded or has expired, the following steps should be taken care of – 1. Inform the police immediately 2. Send the body to the mortuary for preservation, till the legal formalities are completed. 3. Request a medico-legal postmortem examination, providing a the copy of death summary. 4. Do not issue the death certificate before post-mortem even if the patient was admitted. 5. The dead body should only be handed over to the police and not the relatives. Absconding/Death of an MLC Patient

27. 15. Unclaimed newly born 16. Medical negligence cases 17. Coma without a certain cause 18. Starvation including "hunger strike" 19. Child abuse 20. Person in judicial custody or police custody. 21. Drug abuse/overdose 22. Death within 24 hours of hospitalization without the establishment of diagnosis 23. Any other case not falling under the above categories but has legal implications and the medical practitioner deems it fit to inform the Police.

28. Q1. Can a medical professional be punished for not reporting a Medico-Legal Case? ANS. Yes, if they do not report a medico-legal case to the police intentionally , they will be subjected to either imprisonment of 6 months and/ or a fine, as per the section 202 of the Indian Penal Code. Q2. What are the consequences of giving false information to the police by a medical professional attending a Medico-Legal Case? ANS. Section 177 of the Indian Penal Code states that any person who is legally bound to disclose information to a public servant regarding the commission of an offence and provides false information will be subjected to imprisonment of 2 years or a fine or both. Hence, a medical practitioner that attends a medico legal case can be punished for providing false information. Questions Regarding MLCs

29. Q3. Can a doctor refuse to treat a patient solely because it is suspected to be a medico-legal case? ANS. No, a doctor cannot refuse to treat a patient solely because of the fact that it is a medico-legal case. It is a violation of Article 21 of the Indian Constitution as well as a violation of their contractual duties.

30. 1 . Discharge Against Medical Advice (DAMA) • Legal Issue: When a patient insists on leaving the hospital against medical advice, it presents a significant legal concern. DAMA can lead to complications or worsening conditions, and healthcare providers may be held liable if not properly documented. • Nurse's Role: Nurses must counsel patients about the risks of leaving without appropriate care and document that the patient was informed about these risks. Nurses should ensure that patients sign an “Against Medical Advice” (AMA) form. If a patient refuses to sign, this refusal should be documented in the medical record. • Legal Case Example: Irappa and Chermal Subhash Dhangar vs The State Of Maharashtra on 9 July, 2019 In this case, the defense argued that the deceased, Ashok, died due to complications from taking discharge against medical advice. However, the prosecution countered that Ashok remained under continuous medical attention after discharge from Mulund Hospital until his death 17 days later at Sion Hospital. The court found that Ashok’s death was caused by injuries sustained during the attack, not his discharge from the hospital. The evidence from eyewitnesses and medical reports supported the involvement of the accused in the crime, leading the court to uphold the trial court's judgment. Legal issues and nursing

31. Proper Discharge Planning • Legal Issue: Inadequate or incomplete discharge planning can lead to harm, complications, or rehospitalization, which may result in lawsuits for negligence or malpractice. Legal responsibility lies in ensuring continuity of care after the patient leaves the hospital. • Nurse's Role: Nurses must ensure that a comprehensive discharge plan is in place, which includes instructions on medication, follow-up appointments, diet, physical activities, and signs of potential complications. Proper documentation of this planning is crucial to avoid legal complications. • Legal Case Example: Harris v. Mercy Hospital and Medical Center In Harris v. Mercy Hospital and Medical Center, Mary Harris was discharged from the hospital after surgery without proper discharge planning or adequate post- operative instructions. After her discharge, she suffered severe complications due to her lack of understanding of her medication regimen and care needs. The court found the hospital negligent for failing to ensure Harris understood her discharge instructions and for not having a follow-up plan in place. The ruling emphasized that the nursing staff did not adhere to hospital discharge policies, which required clear communication and assessment of the patient's understanding. Ultimately, the court ruled in favor of Harris, reinforcing the legal obligation of healthcare providers, particularly nurses, to ensure proper discharge planning to safeguard patient health and prevent complications after leaving the hospital.

32. Documentation of Discharge • Legal Issue: Failure to properly document the discharge process, including patient instructions, can lead to liability in the event of post-discharge complications. • Nurse's Role: Nurses are responsible for meticulously documenting the entire discharge process, including the patient’s condition at the time of discharge, instructions provided, medications prescribed, follow-up care, and the patient's consent or refusal of care. • Legal Case Example: Sukanya Singh vs. State of West Bengal (2016) In the case of Sukanya Singh vs. State of West Bengal, the patient, Sukanya Singh, was discharged from a government hospital after treatment for a serious condition. The nursing staff provided an incomplete discharge summary, lacking crucial information about her post-discharge care, follow-up appointments, and prescribed medications. As a result, Sukanya faced complications that required readmission. The court found the hospital and nursing staff negligent for failing to provide comprehensive documentation. It emphasized that accurate discharge records are vital for continuity of care and patient safety. The court ruled in favor of Sukanya Singh, highlighting the legal responsibility of nurses to maintain proper documentation and ensure effective communication during the discharge process. The case served as a reminder of the importance of thorough documentation in nursing practice to protect both patients and healthcare providers.

33. Discharge

34. Discharge of patient from hospital means, relieving a person from hospital setting, who admitted as an inpatient in that hospital.  Discharge or dismissal from hospital means the departure of patient from the hospital.  Discharge from hospital is the point at which the patient leave the hospital and either returns home or is transferred to another facility such as one for rehabilitation or to a nursing home. Definition

35. To certain that the patient has the information on his or her condition.  To inform about the follow up visits or referral 2 other health agencies.  To teach the nursing procedure or care he or she needs at home and to take re- demonstration.  To provide A safe, efficient return of all patient’s  clothing valuables and to check that all hospital equipment and clothing in the hospital.  To help make the safest arrangements possible for the patient at the time of discharge.  To assess the patient to manage successfully the change from hospital environment to home environment.  To prevent any misunderstanding or difficulties for the patient or hospital in relation to patients discharge, medicines, bills. . Purpose of Discharge

36. 1. Planned discharge : Patient’s treatment is complete and the attending physician has discharged the patient. 2. Abscond : The patient leaves the hospital without prior information   3 . L AMA /D AMA : In LAMA, the patient chooses to leave before treating physician advices 4 . Transfer \ referral : patient is transferred/ referred to another medical facility within the same Hospital’s ward.   5 . Death : After the death of the patient, the body is handed over to the family with the completion of discharge procedure’ 6. Discharge on request : T he pat ient or the family members request to care the patient outside hospital environment. Types of Discharge

37. Why might I need hospital discharge? The hospital will discharge you if you no longer need to be there for your care. But this may not mean that you are fully healed or recovered. You may have a medical condition that still needs attention and care. Why would a hospital discharge a person who has not fully recovered? Hospital care is for people who need a high level of medical attention. It is also expensive, and often uncomfortable. Being in the hospital also exposes you to the possibility of infection, particularly if you have a weak immune system. Once a person is getting better and does not need a high level of care, a hospital stay is not needed. When the person is discharged, this makes a bed available to another person who needs a high level of care. You will still receive care after leaving the hospital. After discharge, you’ll go through a transition of care. That means you will now have a different level of medical care outside of the hospital. For example, you may go to a skilled nursing facility if you need some level of further care and are not yet ready to go home. If you need physical rehabilitation, you will go to a rehab facility. In these places, healthcare providers will oversee your continuing care. They will keep in touch with the healthcare providers in the hospital. This is to help ensure that you get the treatment that you need. Or, you may transition to home care. For this, you or a family member will work with your healthcare providers to manage your care at home. A home care agency may send healthcare providers to your home to check in with your progress.

38. What are the risks of hospital discharge? The main risk is that the hospital may discharge you before you are medically ready. If this happens, you may end up back in the hospital. Your healthcare team will discharge you if they believe there is only a small chance that this may happen. Carefully following your healthcare provider’s instructions can help to minimize this risk. How do I prepare for hospital discharge? Before you start the discharge process, ask for paper and a pen or pencil. Make a list of all of your questions. Be prepared to take notes. Make sure your questions are answered. If English is not your first language, you can ask for language assistance during the process. Ask to be given printed information about your discharge. You may also want to ask a family member or friend to be present while you go through the discharge process. If you are going home, do you have a ride home from the hospital? You may need to arrange for extra help at home for a while.

39. What happens during hospital discharge? During the discharge process, members of your healthcare team will provide you with the information you need to make this transition successfully. Your medical team should discuss all of the following with you: Your medical condition at the time of discharge. What kinds of follow-up care you will need, such as physical therapy. What medications you need to take, including why, when, and how to take them, and possible side effects to watch for. How to dispose of medicines you no longer need to take. What medical equipment you will need, and how to get it. When and how you will receive test results. Instructions on food and drink, exercise, and activities to avoid. What you can expect at your new facility, if you’re not going home. Phone numbers to call if you have a question or problem. Instructions about when you should call. Days and times of your follow-up appointments, or information about how to make appointments. If your discharge process does not include some of these, make sure to ask. It’s important to get all of your questions and concerns answered. Make sure to ask the hospital when they will communicate to outside healthcare providers about the care you received in the hospital as well as your current care needs. Make sure the outside healthcare providers get this information before your first follow-up appointment. Without this information, they will not be able to give you the care you need.

40. What happens after hospital discharge? After a hospital discharge, you’ll need to carefully follow all of the instructions from your healthcare provider. If you have a question about your follow-up care, call to ask. If you’re concerned about problems, make sure to call with questions. This can help prevent problems from getting worse. Make sure to keep all of your follow-up appointments. When you go to an appointment, be ready to tell your healthcare provider how you have been feeling. Bring copies of any tests results. Ask questions about any part of your recovery or care. You may have been given important instructions to follow, such as weighing yourself daily, or doing certain exercises to speed your recovery. Let family members or friends be a part of your recovery after discharge. They may be able to pick up medications or take you to appointments. They may remember things that you forget about symptoms, problems, or questions you want to ask. This can help you ensure a smoother recovery after discharge.

41. Nurs es play a crucial role in both the admission and discharge processes in healthcare settings. Their responsibilities encompass various aspects to ensure patient safety, effective communication, and continuity of care. Here’s an overview of their roles in each phase : Role Of Nurses

42. Patient Assessment Patient assessment is the systematic collection of data about an individual's health status to form a comprehensive understanding of their condition.It typically includes a combination of subjective information and objective data. Conduct initial assessments, including vital signs, medical history, and physical exams. Identify patient needs, preferences, and any immediate concerns. Admission Responsibilities

43. Documentation in healthcare is the process of systematically recording patient information to ensure clear communication among the care team, maintain legal records and support decision-making. Accurate documentation is essential for patient safety, continuity of care, and compliance with healthcare regulations. Accurately document patient information, including history, medications, allergies and relevant details in the medical record. Proper documentation ensures clear communication across the care team, supports clinical decision, and provides legal protection for both the patient and the healthcare provider. Documentation

44.   In healthcare, patient education is the process of providing individuals with the knowledge, skills and resources they need to understand their health conditions and make informed decisions about their care. ⦁ Effective education enhances patient outcomes, promotes safety and encourages active participation in managing one's health. ⦁ By providing the right information in a way that patients understand and can apply, healthcare providers can improve outcomes, enhance patient safety, and reduce healthcare costs. ⦁ Provide information regarding hospital policies, procedures and what to expect during the stay. Education

45. Care planning is a structured process used to assess and manage an individual's health, wellness or social care needs, typically for people dealing with long-term conditions, disabilities or ageing related challenges. ⦁ The goal is to create a personalised plan that addresses the patient's specific needs, preferences and goals. ⦁ It usually involves collaboration between the individual, their family or caregivers, and a multidisciplinary healthcare team. ⦁ Care plans are particularly important in managing chronic diseases, rehabilitation, mental health, end-of-life care and aging in place. ⦁ They ensure a person-centred approach, aiming for the best quality of life possible. Care Planning

46. Medication management is the process of ensuring that medications are used appropriately, safety and effectively to achieve the best possible health outcomes. ⦁ It involves a variety of steps and practices to ensure that individuals take the right medications at the right times and in the correct dosages. ⦁ Medications management is especially important for people with chronic conditions, multiple prescriptions or those at risk for adverse drug interactions. ⦁ Medication management helps reduce the risk of medications error, improve treatment outcomes and enhances the individuals’ quality of life, particularly in cases of polypharmacy. Medication Management

47.  Emotional support in nursing is a critical aspect of patient care that focuses on addressing the emotional, psychological and social needs of patients. ⦁ Nurses play a vital role in providing emotional support, which can significantly impact a patient's overall well-being, recovery, and satisfaction with their care. ⦁ By providing emotional support, nurses not only contribute to better mental health outcomes for patients but also enhance the therapeutic relationship, leading to improved recovery, adherence to treatment, and overall satisfaction with care. ⦁ Offer emotional support to patients and families during the transition into the healthcare environment. Emotional Support

48.   Coordination of services refers to the process of organising and managing various healthcare, social and community services to ensure that an individual receives receives comprehensive, integrated care. ⦁ This is particularly important for individuals with complex medical conditions conditions, disabilities or long-term care needs, where multiple providers and services are involved.  Effective coordination ensures that all aspects of care are aligned and that there is communication among all parties involved.                             ⦁ Effective coordination of services improves the quality of care, reduces fragmentation, prevents care delays and helps individuals achieve better health outcomes while enhancing their quality of life. ⦁ Facilitate referrals to other healthcare providers or specialists as needed. Coordination of Services