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How to record medical evidence?

This video explores the importance of documentation of findings to enable independent review.
So let’s consider now some aspects of recording evidence and the findings in autopsy. Over the course of my professional life, the principle of reviewability, reviewability, has come to dominate the practice of forensic pathology. This principle can be described as follows, the minimum that can be expected of the forensic pathologist, is that what he’s seen is recorded in such a way that another pathologist at another time and place can be put in virtually the same position as a pathologist to come to his or her own view about the case. This includes records of normality as well as of abnormality. Coincidentally, it becomes a record the pathologist him or herself can refer to while coming to his or her own conclusions.
The rigors of undertaking the actual autopsy are sufficiently demanding for me, that I like to do a lot of my thinking afterwards. And the record, essentially, the photographs are an indispensable aid to this. Other records include one’s notes, diagrams, sketches, dictated descriptions which are subsequently typed out. Actual retained parts of organs or even parts of the body, and even videotapes. Samples were retained for review under the microscope are also obtained and form a valuable part of the record. The photographic record should be complete. All surfaces of the clothed body as a whole, then closer up properly done more photographs after the removal of each item of clothing.
Once all items of clothing are removed, the body is re-photographed front and back and each side. Then the top and bottom half of the body, front and back, the face, front and each side. Perhaps the neck alone, front and each side, the front of the chest, abdomen, thighs, lower legs, upper arms, forearms, each hand, front and back. The individual injuries in context and then as close up as possible. Then the body might be cleaned, washed and the whole routine gone through again. That serious with reviewability is taken.
Documentation of the external injuries. So this would be something in survivors be different and in case of deceased also would be different. In case of survivors, whatever photographs or video graphs you can only take after obtaining informed consent. In case of deceased, detailed photographs and videos are something which is a must. Obviously in the deceased, the consent issue doesn’t arise. But again, whenever these documents go to the courts, the necessary sensitivity in handling those has to be done by all the stakeholders, particularly when they are looking at genital photographs or looking at certain sensitive parts of the body. Wherever we don’t get consent for the photographs or video graphs in such situations, pictograms is something which has to be done.
So this is routinely being followed, even in the Ministry of Health and Family Welfare Guidelines. There are pictograms attached to the proforma, so these would be filled and marked, so that gives a complete picture of the documentation of not only the injuries, the lesions, the stains, wherever they are present. So a complete picture. So it would be a reconstruction. And essentially every proforma means it’s meant for documentation. So the written notes, whatever are there should also be. There cannot be any inconsistency between the written notes, the pictograms, the videos and the photographs. So care should be taken that all of them are in the same line or in sync with each other.

The importance of a well documented post mortem report is essential in any criminal case. Watch Dr Cordner and Dr Jagadeesh Narayanareddy explain the importance of detailed documentation during medical examination and how it is necessary for the reviewability of findings.

Look back at the post mortem reports which you have seen as part of your casework. Did you receive photographs with the report? Based on the description of the external and internal examination, and the other materials provided with the report (sketches, photographs etc.), do you think the findings of the post mortem are reviewable? Share your reflections in the comments below.

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Decoding Forensics for Legal Professionals

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