The Effects of Incomplete or Incorrect Medical Documentation on Forensic Medical Evaluation

Abstract

Introduction: Complete and accurate medical records are critical not only for the continuity of clinical care but also for ensuring fair judicial decisions in forensic processes. Missing or incorrect documents negatively affect patient safety as well as the preparation of forensic reports.

Materials and Methods: In this retrospective-cross-sectional study, 47,500 case files referred to the 7th Specialization Board of the Council of Forensic Medicine between 2019 and 2025 were reviewed. A total of 1,000 files, in which forensic evaluation could not be completed due to medical record deficiencies, were included. Demographic characteristics, hospital type, clinical branch, missing document types, and the nature of the deficiencies were analyzed. Fisher’s exact and Mann-Whitney U tests were used for statistical evaluation.

Results: Of the cases, 63.6% were female and 36.4% male; the most common age group was 36-45 years. Deficiencies were more frequent in private healthcare institutions (68%) than in public hospitals (32%). The most frequently missing documents were discharge summaries (n=636), operative/procedure notes (n=404), and follow-up notes. The most common combinations were discharge+operative notes (n=88) and discharge+radiology records (n=76). The most frequent deficiency type was “absence” (63.2%), followed by “incompleteness” (33.2%). Multiple document deficiencies were detected in 34.7% of private hospitals and 15.0% of public hospitals (p<0.0001). By specialty, the highest rate was in dentistry (25.2%), and the lowest in pediatrics (7.4%).

Discussion: Deficiencies were mainly concentrated in discharge summaries and operative notes, with multiple deficiencies being more frequent in private hospitals. This may reflect institutional differences in templates and auditing processes. Such gaps limit forensic expert evaluations and increase reliance on judicial discretion.

Conclusion: Incomplete or incorrect medical documentation undermines both clinical quality and the reliability of forensic processes. Standardized templates for discharge summaries and operative notes, routine auditing-feedback systems, and secure electronic archiving are essential to ensure robust forensic evaluations.

Keywords

• medical records
• forensic medicine
• documentation
• hospital
• medical errors
• legal process

Eksik veya Hatalı Tıbbi Dokümantasyonun Adli Tıbbi Değerlendirmeye Etkileri

Abstract

Giriş: Tıbbi kayıtların tam ve doğru tutulması hem klinik hizmetin devamlılığı hem de adli süreçlerde hakkaniyetli kararların verilmesi için kritik öneme sahiptir. Eksik veya hatalı belgeler, hasta güvenliği yanında adli raporların hazırlanmasını da olumsuz etkileyebilir.

Materyal ve Metod: Bu retrospektif-kesitsel çalışmada, 2019-2025 yılları arasında 7. Adli Tıp İhtisas Kuruluna intikal eden 47.500 dava dosyası tarandı. Tıbbi kayıt eksiklikleri nedeniyle adli değerlendirmesi yapılamayan 1.000 dosya incelendi. Demografik özellikler, hastane türü, branş, eksik belge türü ve eksikliğin niteliği analiz edildi. İstatistiksel değerlendirmede Fisher’s exact ve Mann-Whitney U testleri kullanıldı.

Bulgular: Vakaların %63,6’sı kadın, %36,4’ü erkekti; en sık yaş grubu 36-45’ti. Eksikliklerin %68’i özel sağlık kuruluşlarından, %32’si kamu hastanelerinden kaynaklanıyordu. En çok eksik saptanan belgeler epikriz (n=636), ameliyat/işlem notu (n=404) ve takip notlarıydı. Kombinasyonlarda epikriz+ameliyat (n=88) ve epikriz+radyoloji (n=76) öne çıktı. Eksiklik niteliği en sık “yokluk” (%63,2), ardından “eksiklik” (%33,2) idi. İki veya daha fazla belge eksikliği, özel sağlık kuruluşlarında %34,7; kamu hastanelerinde %15,0 idi (p<0,0001). Branş bazında en yüksek oran Diş hekimliğinde (%25,2), en düşük Pediatri’de (%7,4) idi.

Tartışma: Bulgular, eksikliklerin özellikle epikriz ve ameliyat notları çevresinde yoğunlaştığını; özel hastanelerde daha sık çoklu belge eksikliğine rastlandığını göstermektedir. Bu durum, kurumlar arası şablon ve denetim farklılıkları ile açıklanabilir. Eksiklikler, bilirkişi değerlendirmesini sınırlamakta ve kararların hakimin takdirine daha çok dayanmasına yol açmaktadır.

Sonuç: Eksik veya hatalı tıbbi dokümantasyon, hem klinik kaliteyi hem de adli süreçlerin güvenilirliğini zedelemektedir. Epikriz ve operatif notlar için standart şablonlar, düzenli denetim-geri bildirim ve güvenli elektronik arşiv uygulamaları adli değerlendirmelerin sağlıklı yürütülmesi için öncelikli gerekliliklerdir.

Keywords

• tıbbi kayıtlar
• adli tıp
• dokümantasyon
• hastane
• tıbbi hata
• yargı süreci

References

1. 1. Ismawati NDS, Supriyanto S, Haksama S, Hadi C. The influence of knowledge and perceptions of doctors on the quality of medical records. J Public Health Res. 2021;10(2):2228. doi: 10.4081/jphr.2021.2228
2. Jeong H, Choi EY, Lee W, Jang SG, Pyo J, Ock M. Importance of Quality of Medical Record: Differences in Patient Safety Incident Inquiry Results According to Assessment for Quality of Medical Record. J Patient Saf. 2024;20(4):229-235. doi: 10.1097/PTS.0000000000001212
3. Mathioudakis A, Rousalova I, Gagnat AA, Saad N, Hardavella G. How to keep good clinical records. Breathe (Sheff). 2016;12(4):369-73. doi: 10.1183/20734735.018016
4. Demsash AW, Kassie SY, Dubale AT, Chereka AA, Nguise HS, Hunde MK, et al. Health professionals’ routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study. BMJ Health Care Inform. 2023;30(1):e100699. doi: 10.1136/bmjhci-2022-100699
5. Hammad EA, Wright DJ, Walton C, Nunney I, Bhattacharya D. Adherence to UK national guidance for discharge information: an audit in primary care. Br J Clin Pharmacol. 2014;78(6):1453-1464. doi: 10.1111/ bcp.12463
6. Awad MSA, Mohamednour MFA, Rafat FA, Altijani M, Elfatih A, Hamed FJM, et al. Documentation of Inpatient Medical Records: A Clinical Audit. Clinical Audit. 2024:16 9-17. doi: 10.2147/CA.S451630
7. Ayaz N, Meral O, Doğan M. The Importance of Radiology Consultation in Forensic Report Preparation: A Retrospective Study. Med Records. 2020;2(3):82-6. doi: 10.37990/medr.779193
8. Vahedi HS, Mirfakhrai M, Vahidi E, Saeedi M. Impact of an educational intervention on medical records documentation. World J Emerg Med. 2018;9(2):136-140. doi: 10.5847/wjem.j.1920-8642.2018.02.009

9. Elsayed AS, Mwaheb MA, Elsary AY, El Rashed K, Saleh AR. Awareness and perception of physicians about forgery and counterfeiting in the medical field in Egypt. Sci Rep. 2025;15(1):13549. doi: 10.1038/s41598-025-93729-4
10. Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D. Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review. PLoS Med. 2012;9(6):e1001244. doi: 10.1371/journal.pmed.1001244
11. Azzolini E, Furia G, Cambieri A, Ricciardi W, Volpe M, Poscia A. Quality improvement of medical records through internal auditing: a comparative analysis. J Prev Med Hyg. 2019;60(3):E250-E255. doi: 10.15167/2421-4248/jpmh2019.60.3.1203
12. Brown LF. Inadequate record keeping by dental practitioners. Aust Dent J. 2015;60(4):497-502. doi: 10.1111/adj.12258
13. Devadiga A. What’s the deal with dental records for practicing dentists? Importance in general and forensic dentistry. J Forensic Dent Sci. 2014;6(1):9-15. doi: 10.4103/0975-1475.127764
14. Gkiala A. Assessing the Correct Documentation of Time and Physician Information on Medical Records in the Emergency Department of Queen’s Hospital: An Audit and Re-audit. Cureus. 2022;14(12):e33000. doi: 10.7759/cureus.33000
15. Lorenzetti DL, Quan H, Lucyk K, Cunningham C, Hennesy D, Jiang J, Beck CA. Strategies for improving physician documentation in the emergency department: a systematic review. BMC Emerg Med. 2018;18(1):36. doi: 10.1186/s12873-018-0188-z
16. Qasem M, Qasem O, Skalidi N. Improving the Quality and Standardization of Operative Notes in a Tertiary Regional ENT Department: A Closed-Loop Audit. Cureus. 2024;16(6):e63398. doi: 10.7759/cureus.63398
17. Oladeji EO, Singh S, Kastos K. Improving Compliance With Operative Note Guidelines Through the Implementation of an Electronic Proforma. Cureus. 2022;14(12):e32222. doi: 10.7759/cureus.32222
18. Souliotis K, Golna C, Tountas Y, Siskou O, Kaitelidou D, Liaropoulos L. Informal payments in the Greek health sector amid the financial crisis: old habits die last. Eur J Health Econ. 2016;17(2):159-70. doi: 10.1007/ s10198-015-0666-0
19. Nobel JM, van Geel K, Robben SGF. Structured reporting in radiology: a systematic review to explore its potential. Eur Radiol. 2021;32(4):28372854. doi: 10.1007/s00330-021-08327-5
20. Toru HK, Aizaz M, Orakzai AA, Jan ZU, Khattak AA, Ahmad D. Improving the Quality of General Surgical Operation Notes According to the Royal College of Surgeons (RCS) Guidelines: A Closed-Loop Audit. Cureus. 2023;15(11):e48147. doi: 10.7759/cureus.48147
21. Goldszmidt M, Tung TH, Gob A, Dresser G, Moist L. Striking the right balance between accountability and quality improvement: a discharge summary timeliness tale. BMJ Open Qual. 2025;14(2):e003259. doi: 10.1136/bmjoq-2024-003259
22. Sharma R, Kostis WJ, Wilson AC, Cosgrove NM, Hassett AL, Moreyra AE, Delnevo CD, Kostis JB. Questionable hospital chart documentation practices by physicians, J Gen Intern Med. 2008;23(11):1865-70. doi: 10.1007/s11606-008-0750-6
23. Ngo E, Patel N, Chandrasekaran K, Tajik AJ, Paterick TE. The Importance of the Medical Record: A Critical Professional Responsibility. J Med Pract Manage. 2016;31(5):305-8
24. Hussein M, Pavlova M, Ghalwash M, Groot W. The impact of hospital accreditation on the quality of healthcare: a systematic literature review. BMC Health Serv Res. 2021;21:1057. doi: 10.1186/s12913-021-07097-6
25. Wurster F, Herrmann C, Beckmann M, Cecon-Stabel N, Dittmer K, Hansen T, et al. Differences in changes of data completeness after the implementation of an electronic medical record in three surgical departments of a German hospital-a longitudinal comparative document analysis. BMC Med Inform Decis Mak. 2024;24:258. doi: 10.1186/s12911-024-02667-0
26. Ataman G, Yarımoğlu EK. Hastane Türlerine Göre Hasta Memnuniyetini ve Hastane Seçimini Etkileyen Unsurlar. Hacettepe Sağlık İdaresi Dergisi, 2018; 21(2): 273-288 Bhatia M, Banerjee K, Dixit P, Dwivedi LK. Assessment of Variation in Cesarean Delivery Rates Between Public and Private Health Facilities in India From 2005 to 2016. JAMA Netw Open. 2020;3(8):e2015022. doi: 10.1001/jamanetworkopen.2020.15022
27. Mashoufi M, Ayatollahi H, Khorasani-Zavareh D, Boni TTA. Data quality assessment in emergency medical services: an objective approach. BMC Emerg Med. 2023;23:10. doi: 10.1186/s12873-023-00781-2