The Medical Report
Beta Ahlam Gizela
Bagian 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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Medical Evidence
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Human: living or dead
Human remain: bone, teeth, body part
Biological substances: blood, saliva, sperm, epithelia, hair,
other tissue
Medical Report  Court
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Judge need consideration for punishment.
Judge ask about:
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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 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
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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
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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 Report
of a living person
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5.
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)
Conclusion (Identity, diagnosis: include
severity/qualification, whether or not there is any
contradiction between the trauma/diagnosis and
the history - possibility cause of trauma)
Closing (jurisdiction base, doctor’s signature)
Adapted from Istanbul Protocol
INTRODUCTION
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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)
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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
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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
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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
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Note the result of laboratory examination supporting an
autopsy
SUMMARY AND DISCUSSION
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Note summary of the examination, make a scientific
explanation and interpretation to construct a conclusion.
CONCLUSION
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Identity
Cause of death
Time of death
Manner of death
Another Simply
Medical Report
Death certificate
 Born certificate
 Health certificate
Immunization certificate
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References
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Istanbul Protocol
Minnesota Protocol
David Owen, Hidden Evidence
Indonesia Regulation