The Medical Report

Beta Ahlam Gizela dr., Sp.F, DFM

Blok Medikolegal, 8 Des 09 [04]

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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

Pembuktian Hukum
Barang Bukti
Forensic Science

Alat Bukti (Court)

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Forensic science

Forensic medicine Dermatogliphy Forensic chemistry Forensic physics Forensic biology Ballistic etc
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Barang bukti medis

Manusia: hidup atau mati Bagian tubuh manusia: kerangka, gigi, potongan tubuh Zat yang berasal dari tubuh manusia: darah, saliva, sperma, epitel yang terlepas, rambut
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The Medical Report

Can be used as a proof in the court
Projusticia
Without

projusticia

Dasar Hukum

Kitab Undang-Undang Hukum Acara Pidana (KUHAP):

Pasal 184, 187 alat bukti Pasal 179, 186 saksi ahli Pasal 170 rahasia medis

Undang-Undang Praktik Kedokteran:

Pasal 48 rahasia medis & penegakan hukum

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The Medical Report

Digunakan untuk kasus apa sajakah kedua macam laporan medis itu?

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The Medical Report Using 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
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The Medical Report Without 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)
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The Medical Report Requested by Patient (Surat Keterangan Medis)

The patient come to a doctor by himself He makes a contract to the doctor to examine and treat him (Informed Consent) There is a medical confidentiality The patient has a right to access all of the information about his disease The doctor has an obligation to tell the patient about his disease, orally and written if it is asked. 13

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): didnt need Informed Consent
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The Medical Report

of a living person
1. 2. 3. 4.

Preamble (Projusticia, only for MR request by

police/attorney/judge) Introduction (Identity of requester, doctor, person/patient, incident) Content (history, physic diagnostic, advance examination, treatment, resume & analyzes) 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, doctors signature)

Adapted from Istanbul Protocol 15

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

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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.
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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.

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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.

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For example:
Do not write: there is a perforation of the ear drum that was caused by a blow to the clients 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.
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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.
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Summary, discussion and conclusion

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.
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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.

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The Autopsy Report

1.

Preamble (Projusticia, only for MR request by

police/attorney/judge)
incident)

2.

Introduction (Identity of requester, doctor, corpse, Content (external examination, internal examination,
advance examination) death, time of death)

3.

4.

Conclusion (Identity, cause of death, manner of

5.

Closing (jurisdiction base, doctors signature)

Adapted from Minnesota Protocol

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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

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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.
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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
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LABORATORY EXAMINATION

Note the result of laboratory examination supporting an autopsy

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SUMMARY AND DISCUSSION

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

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CONCLUSION

Identity Cause of death Time of death Manner of death

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Another Simply Medical Report

Death certificate Born certificate Immunization certificate etc

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Anything need to be clarify, please contact: betaforensik@gmail.com or mobile phone: 08157927896

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