The Medical Report

Beta Ahlam Gizela

dr., Sp.F, DFM
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 violence, ill treatment and torture
 Proof

Evidence Tool
Forensic Science

Evidence (Court)
Forensic science
 Forensic medicine
 Dermatogliphy
 Forensic chemistry
 Forensic physics
 Forensic biology
 Ballistic
 etc
 Medical Evidence
 Human: alive or death (corpse)
 Part of body: skeleton, tooth, mutilated
body
 Substance come from human: blood,
saliva, sperm, epithelia, hair
 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
 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)
 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.
 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 Report
of a living person
1. 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 violence/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
violence/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 violence/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 violence/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
violence/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 violence/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
 Anything need to be clarify, please
contact: betaforensik@gmail.com

 or mobile phone: 08157927896

Om, Tante,
Thank You for Your Attention
Don’t forget to prepare the examination!