dr.vp singh- medrecon (final)

7/31/2019 Dr.vp Singh- Medrecon (FINAL)

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Forensic Documentation of Injuries

in a trauma case

Dr. Virendar Pal SinghMedico-legal Consultant &

Assoc. Prof., Forensic Medicine,

Dayanand Medical College & Hospital, Ludhiana.


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Medical records

Medical records are the documents made by

health-care practitioners during or after providing

health-care services. Medico-legal documents form an essential part

of the medical record.


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Medicolegal case

Any case of injury or ailment, whereinvolvement of law enforcementagencies is required.

It is a medical case with legal implicationsor

a legal case requiring medical expertise.


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Medicolegal case

Proper management is extremely importantto prevent litigation

First priority is to save the life.

Parmananda Katara V. Union of India (AIR 1989)

Documentation can be performed subsequently


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Forensic Documentation

If you have not documented,You have not done it

(good notes imply good practice)

In trauma cases, quality of medico-legal documents is poor


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Prepare diligently and with an understanding ofbasic legal principles.

Checklistand guidelines should be followedwhile documenting and interpreting the injuries.

Astructured format and objective opinion willenhance the reliability of the document.

Forensic Documentation


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Forensic Documents

Confidential

Should be properly stored to avoid tampering

Handed over to concerned authorities only


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Forensic documentation

Use appropriate forms

Prepare in duplicate

Informed Consent Police Information

Mention all necessary details


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Avoid abbreviations

Avoid technical terms

Avoid overwriting

Authenticate corrections with signatures


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Identification Marks

Scar mark

Mole

Thumb print


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Structure of the report


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Evidence to be preserved

ClothingsAny foreign material/ bullet etc

Properly sealed and signed


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1

2

3 4


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History

Essentials: By Whom ?

Incident in brief

Time of incident

Place of incident

Other relevant information


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General Physical Examination

Level of Consciousness

Orientation

BPPulse

Pupils


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Injuries

Essentials

Numbering

Type of Injury

Margins

DimensionsActual Site

Healing changes

Investigations

1. Lacerated Wound 4cm X o.75cm X o.5cm

obliquely placed over the back of head.

Margins are ragged.

Upper and lateral end is 12cm from left mastoid

process and 3cm from midline.

Lower and medial end is at the midline.

Bleeding not present.

Adv. Xray, CT Scan head


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Laceration

L X B X D cm

Actual Site

Margins

Base of the wound

- strands of tissue

- foreign material

Healing

Investigation


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Abrasion

(L X B cm)

Margins

Actual Site

Color

Scab

Adv. X ray


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Abrasion

2. Red abrasion 4 cm X 3 cmpresent over the back of leftforearm,

4cm below the elbow joint.Oozing of blood present.Adv. Xray.


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Scratch Mar


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Bruise

L X B cm

Actual Site

Color

Investigation

Re-examine after 24 hrs.


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Bruise

3. Bluish Red bruise 6 cm X 4 cmpresent over the lateral aspect of

right arm,starting 5cm below the tip of soulder.Tenderness present.

Adv. Xray.


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Different color shades of bruise


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Incised wound

L X B X D cm

Margins

Ends, tailing

Actual Site

Base of the wound

Healing changes

Investigation


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Injuries

4. Incised wound 7cm X 1 cm X 2.5 cm obliquely

placed over the front of right side of abdomen.

Upper and medial end is 6 cm right to midline

and 16cm below the level of right clavicle.

Lower and lateral end is 13 cm right to midline

and 20 cm below the level of right clavicle.Margins are clean cut.

Tailing of lower and lateral end present.

Bleeding present.


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Stab wound

L X B X D cm

Margins

Actual siteInvestigation


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Opinion

Nature of injury

Duration of injury

Kind of weapon used

Doctors opinion ondurationof injuries can

never be absolute.Ram Swarup V. State, AIR 2000


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Fresh Reddish in color, Oozing of blood.

12-24 hrs Reddish Scab

2-3 days Reddish Brown Scab

4-5 days Scab becomes darker

5-7 days Separation of Scab from periphery

Depigmented skin underneath

7-10 days Scab fallsNormal color of skin underneath

Duration of Abrasion


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Duration of Bruise

With in 12 hrs Red in color

12-24 hrs Bluish red

2-4 days Bluish black to Brown

5-7 days Greenish

7-10 days Yellowish10-14 days Normal color


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Duration of Laceration(in a Clean, asepticwound)

)

Within 12

Hrs

Margins red, swollen and tender

Bleeding or fresh clots are present

12-24 Hrs Margins red, swollen covered with dried

clots

3-5 Days Margins adherent with dried crust

6-7 Days Scab falls off or can be easily removed

1-2 weeks Scar forms


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Checklist

Use of standardized format

Informed consent

Police information History of the incident

Medical history

General Physical Examination


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Checklist

Examination of injury Numbering

Type of Injury

Margins

Dimensions

Actual Site

Healing changes

Investigations

Specimen obtained


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Guidelines

Describe each injury separately Multiple injuries

Use a measuring tape to record the dimensions.

Properly label the injuries on Body diagrams.

Signs of ageing of the wound (color of a bruise).

Ensure proper chain of custody


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Ability to write a good medico-legal report

is an art learnt over years.