Forensic Documentation of Injuries in a trauma case

Dr. Virendar Pal Singh

Medico-legal Consultant & Assoc. Prof., Forensic Medicine, Dayanand Medical College & Hospital, Ludhiana.

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.

Medicolegal case

Any case of injury or ailment, where involvement of law enforcement agencies is required.

It is a medical case with legal implications or a legal case requiring medical expertise.

Medicolegal case

Proper management is extremely important to prevent litigation

First priority is to save the life.

Parmananda Katara V. Union of India (AIR 1989)

Documentation can be performed subsequently

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

Forensic Documentation

Prepare diligently and with an understanding of basic legal principles. Checklist and guidelines should be followed while documenting and interpreting the injuries. A structured format and objective opinion will enhance the reliability of the document.

Forensic Documents

Confidential
Should be properly stored to avoid tampering Handed over to concerned authorities only

Forensic documentation

Use appropriate forms Prepare in duplicate Informed Consent

Police Information
Mention all necessary details

Forensic documentation

Avoid abbreviations
Avoid technical terms Avoid overwriting Authenticate corrections with signatures

Forensic documentation

Identification Marks

Scar mark Mole Thumb print

10

Structure of the report

Evidence to be preserved Clothings Any foreign material/ bullet etc Properly sealed and signed

2 3 4

History Essentials:
By Whom ? Incident in brief Time of incident Place of incident Other relevant information

General Physical Examination

Level of Consciousness Orientation BP Pulse Pupils

Injuries Essentials
Numbering Type of Injury Margins Dimensions Actual 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

Laceration
L X B X D cm Actual Site Margins Base of the wound - strands of tissue - foreign material Healing Investigation

Abrasion

(L X B cm) Margins Actual Site Color Scab Adv. X ray

Abrasion

2. Red abrasion 4 cm X 3 cm present over the back of left forearm, 4cm below the elbow joint. Oozing of blood present. Adv. Xray.

Scratch Marks

Bruise

L X B cm Actual Site Color Investigation Re-examine after 24 hrs.

Bruise
3. Bluish Red bruise 6 cm X 4 cm present over the lateral aspect of right arm, starting 5cm below the tip of soulder. Tenderness present. Adv. Xray.

Different color shades of bruise

Incised wound

L X B X D cm Margins Ends, tailing Actual Site Base of the wound Healing changes Investigation

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.

Stab wound
L X B X D cm Margins Actual site Investigation

Opinion

Nature of injury Duration of injury Kind of weapon used

Doctors opinion on duration of injuries can never be absolute.

Ram Swarup V. State, AIR 2000

Duration of Abrasion
Fresh 12-24 hrs 2-3 days 4-5 days 5-7 days 7-10 days Reddish in color, Oozing of blood. Reddish Scab Reddish Brown Scab Scab becomes darker Separation of Scab from periphery Depigmented skin underneath Scab falls Normal color of skin underneath

Duration of Bruise
With in 12 hrs Red in color 12-24 hrs 2-4 days 5-7 days 7-10 days 10-14 days Bluish red Bluish black to Brown Greenish Yellowish Normal color

Duration of Laceration
Within 12 Hrs 12-24 Hrs

(in a Clean, aseptic wound)

)

Margins red, swollen and tender Bleeding or fresh clots are present Margins red, swollen covered with dried clots

3-5 Days 6-7 Days 1-2 weeks

Margins adherent with dried crust Scab falls off or can be easily removed Scar forms

Checklist

Use of standardized format Informed consent Police information History of the incident Medical history General Physical Examination

Checklist

Examination of injury

Numbering Type of Injury Margins Dimensions Actual Site Healing changes Investigations

Specimen obtained

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

Ability to write a good medico-legal report is an art learnt over years.