The Medical Report Beta Ahlam Gizela Bagian Ilmu Kedokteran Forensik dan Medikolegal FK UGM.

The Medical Report

Beta Ahlam GizelaBagian Ilmu Kedokteran Forensik dan Medikolegal FK UGM

The Medical Report

What is it ???

In every country in the world, there are crimes and its victims. In another side there are

tortures and ill treatments to the detainee who did a crime. To seek justice for both of cases above, it is needed medical proofing

The Medical Report

Documenting the medical consequences and the case history including the methods used for attack, ill treatment and torture

Expert Witness

Evidence

Cross matching

Judge Decision

To be continued to the next page

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Re-trial

Proof

Evidence Tool

Evidence (Court)

Forensic Science

Forensic science

Forensic medicine Dermatogliphy Forensic chemistry Forensic physics Forensic biology Ballistic etc

Medical Evidence

Human: living or dead Human remain: bone, teeth, body part Biological substances: blood, saliva, sperm,

epithelia, hair, other tissue

Medical Report Court

Judge need consideration for punishment. Judge ask about:

Is there a victim? How severe is the disease/injury? Is it related to the accused?

The Medical Report Can be used as a proof in the court

Projusticia Without projusticia

The Medical ReportUsing projusticia

Person being examined is an evidence tool

Request by the police/attorney/judge Called Visum et Repertum in Indonesia Doctor as a police doctor, only give

his/her report to the police/attorney/judge

The Medical ReportWithout projusticia

Person being examined is a patient who makes a contract of examination

Request by the patient Called Surat Keterangan Medis in Indonesia Doctor as a treaty doctor, only give his

report to the patient (medical confidentiality)

Late Request Letter

In some case, the request letter from the police/attorney/judge come later.

First contract come from the patient Law Criminal Procedure (KUHAP): the doctor

need Informed Consent from the patient to write the medical report for the police/attorney/judge

Medical Practice Act (Act no 29/2004): didn’t need Informed Consent

The Medical Reportof a living person1. Preamble (Projusticia, only for MR request by

police/attorney/judge)2. Introduction (Identity of requester, doctor,

person/patient, incident)3. Content (history, physic diagnostic, advance

examination, treatment)4. Conclusion (Identity, diagnosis: include

severity/qualification, whether or not there is any contradiction between the trauma/diagnosis and the history - possibility cause of trauma)

5. Closing (jurisdiction base, doctor’s signature)Adapted from Istanbul Protocol

INTRODUCTION

Personal data of client Circumstances of the report Phrasing of questions by requesting party Medical records / Relevant document Indicate to whom a copy of the report will be

sent

HISTORY

An important part of the case history is a description of the torture; this should be

detailed, as it is important for the interpretation of the findings during the medical examination. The recording of current symptomology should be painstakingly accurate and, if possible, its

relationship to the torture should be described.

PHYSICAL EXAMINATION and PSYCHIATRIC EXAMINATION

This section is therefore of great importance and will be examined in detail. It must be

accurate and easily understandable.

PHYSICAL EXAMINATION and PSYCHIATRIC EXAMINATION

The manner in which the wounds/scars are described is vital. The description should be

extensive and detailed. However it should only cover those abnormalities and symptoms that can be ascertained objectively. Constructing a report to include personal interpretations or subjective observations is to be avoided as it will undermine its own objectivity and directly

affect its credibility.

For example:

Do not write: “there is a perforation of the ear drum that was caused by a blow to the client’s ear” (own interpretation) but rather: “a perforation of the ear drum was found. An explanation of its cause could be a trauma, e.g. a blow to the ear, such as the client told me he had received”.

Summary, discussion and conclusion

This is the crux of the matter. You should concentrate on constructing a balanced and logical report, providing insight into the argument that lead to a conclusion that flows naturally from the preceding objective information. All that has been written on objectivity in earlier paragraphs is of course to be taken into consideration here.

CONCLUSION

In the Conclusion, a statement may be included underlining the probability of a connection between the torture suffered by the victim and the medical findings - if, of course, the medical findings support this objectively.

Warning !In practice it proves to be difficult for many people not to include personal interpretations and subjective descriptions in a report. The feelings, emotions and anger that people naturally feel when listening to these stories and on seeing the results of torture can have a profound influence. However it is important to remember the aim and the legal character of the report in order to understand the importance of the signs of torture.

The Autopsy Report

1. Preamble (Projusticia, only for MR request by police/attorney/judge)

2. Introduction (Identity of requester, doctor, corpse, incident)

3. Content (external examination, internal examination, advance examination)

4. Conclusion (Identity, cause of death, manner of death, time of death)

5. Closing (jurisdiction base, doctor’s signature)

Adapted from Minnesota Protocol

INTRODUCTION

Personal data of the victim Circumstances of the report Indicate to whom a copy of the report will be

sent Official Statement of the case

EXTERNAL EXAMINATION General: external abnormalities Specific: consequences of torture: + Scars: localization, size (in mm), shape,

limitation, colour, mutual arrangement, hypertrophy, include a diagram of the body and possibly photographs on which the scars are indicated

Describe the abnormality systematically, in detail, each part of the body.

INTERNAL EXAMINATION

Describe all the result internal examination in detail, each part of the body: Fracture Corpus alienum Haematoma Internal bleeding Organ damage or rupture Organ congestion or swelling Secretion, and any abnormalities found in

autopsy

LABORATORY EXAMINATION

Note the result of laboratory examination supporting an autopsy

SUMMARY AND DISCUSSION

Note summary of the examination, make a scientific explanation and interpretation to construct a conclusion.

CONCLUSION

Identity Cause of death Time of death Manner of death

Another Simply Medical Report

Death certificate Born certificate

Health certificate Immunization certificate

etc

References

Istanbul Protocol Minnesota Protocol David Owen, Hidden Evidence Indonesia Regulation