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

Öz

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.

Anahtar Kelimeler

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

Proje Numarası

yok

Eksik veya Hatalı Tıbbi Dokümantasyonun Adli Tıbbi Değerlendirmeye Etkileri

Öz

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.

Anahtar Kelimeler

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

Destekleyen Kurum

yok

Proje Numarası

yok

Etik Beyan

yok

Teşekkür

yok

Kaynakça

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