off record
Shaukat Ali Jawaid

How to Write
Medico legal reports


Writing a Medico Legal report comes under the domain of Forensic Medicine which is both an Art and a Science. Forensic Medicine is a branch of medicine which deals with application of principles of medical knowledge for the purpose of law and for furthering Justice.

According to Prof. Naseeb R. Awan, an eminent expert in the field of Medical Jurisprudence who retired as Professor of Forensic Medicine from King Edward Medical College many years ago and later also served as Principal of two well known private medical colleges in Lahore, writing medico legal reports is a highly specialized job which should not be undertaken by some one who has no experience or training in Forensic Medicine.  In case of difficulty or inability to frame opinion, it is advisable to refer the matter to senior colleagues who are well trained for advice. Final opinion in the medico legal report should contain comments about nature of causative agent, estimation of time lapsed, gravity of damage inclusive of incapacity produced by trauma or intoxication.  The possibility of injury being self inflicted, homicidal or accidental should also be recorded. Working in the medico legal section of a healthcare facility is a very dangerous job and one must be careful of all these consequences which at times could be too harsh.

The practice of forensic medicine extends beyond the premises of hospitals into the courts of law in continuation of work which has already been done in the hospital to help further justice. A Medical Jurist has to present, authenticate, interpret and justify his work done in the hospital as factual and true. All this requires efficiency, precision, neatness and full concentration. Forensic Medicine work must reflect respect for human being victim or accused.

It is extremely difficult while dealing with dead bodies under putrefaction.  Besides legal, moral consideration, the job may become hazardous endangering safety of workers while they are medically examining the injured or dead. As such it requires recognition of risk and identification of hazards beforehand. Medico legal certification Prof. Naseeb R. Awan opines is highly technical hence it should not be allocated or attempted half heartedly.  Only trained, qualified forensic medicine examiners should perform and make their opinion reliable and creditable.

Despite the fact that examination of living and dead are similar but it differs in technical details and status of the examinee. Autopsy is more specific with additional objectives i.e. determining cause and manner of death, estimation of fatal and postmortem periods.  Medico legal examination requires purpose built centers supported with proper and specific implements in medico legal clinics for living and autopsy suits are required for the Dead.

Workload of forensic medicine includes physical and sexual assaults, intoxication resultant from self or criminal poisoning with drugs, accidental trauma on the road, rail, air and industry. Medical certificates may also be required for life insurance, police recruits, and drivers, age certification for schooling and fitness for job, marriage, election as well as capital punishment.

There are certain pre-exam formalities. In sexual assault, one has to determine whether the injury has produced any damage to private parts of the victim, injury resulted in damage or defect in private parts. Information about weapons used, number of persons involved, circumstances i.e. place of occurrence is also extremely important in case of physical and sexual assault cases. In case of road traffic accidents, industrial accidents it is important to listen to the victim carefully and record history of occurrence. Of course professional ethics demands that one has to take consent of the victim before starting the examination.

Physical examination of clothes has a special place in forensic medicine. They are preserved, searched to locate any foreign material present on them i.e.  Stain, hair, fiber, stains of blood, semen, vomitus, excreta, oil, its position, colour and distribution should all be recorded in the medico legal certificate. Details about smell, feel, shape and texture must also be recorded. One should use naked eye as well as magnifying lens. Any damage, cut in clothes is an important finding in forensic medicine. One should note its position and relationship to the injury. Examination should include physical exam, mental status examination, clinical systematic examination, local examination of the affected part. Local examination means exam of body parts or any portion with pathology, wound caused during assault or accident. Examination also includes exam of body opening violated during sexual assault. Wound margins, walls bed whether smooth, cleanly cut or lacerated needs to be carefully noted.

Body opening of vagina and anus if violated sexually must be examined. These openings are best examined in lithotomy and knee-elbow position respectively.  Adequate illumination is essential for good results. In Forensic Medicine, solely relying on victim’s statement could be hazardous. As regards documentation and certification, written record, drawn sketches, photographs must be prepared and preserved. Close up photographs of injuries, damage, staining of clothes, full view of injured or intoxicated are all very essential. Fractures should be recorded with X-rays. The certificate should include result of investigations, reports on collected material and all other relevant documents such as receipts and dispatches. In case the injured is admitted to the hospital, treatment notes, duration of stay, date of discharge should be obtained and incorporated in certification to help verify full facts of the case. It is worthwhile to note that medical opinion or conclusions should only be based on observed facts. Opinions should not go beyond knowledge of the medical examiner. Sentiments, sympathy, personal theory must not influence the formulation of opinion. It is also essential to record whether the findings are consistent with sexual intercourse or otherwise.

Note: This column is based on the presentation made by the author at the Second International Conference on Medical Writing held at Ajman UAE from March 5-7. 2015.

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