Transcript The issues to consider during report preparation and examination – 2

REPORTS
Associate Prof. Abdi ÖZASLAN
Istanbul University
Cerrahpasa Medical Faculty
Forensic Medicine Department
Aims
 The approach of the doctor to the forensic case
 The elements that should be included in the report
content
 Legal arrangements about reports
 Report types
 The sample reports and diagrams that should be
considered during report preparation
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Approach of Physician to the Person
that will be reported-1
1. The doctor must not forget that she/he should
approach to the person about whom a report to
be prepared as an ordinary patient. She/he must
take a detailed anamnesis, perform a full physical
examination and ensure required laboratory
analyses.
2. Within the scope of his/her training, in
accordance with modern requirements, to the
extent of the possibilities of the institution in
which she/he operates, the doctor should use
his/her experience only for the good of the
patient.
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Approach of Physician to the Person
that will be reported-2
3. She/he should be attentive to the
person for whom a report will be
prepared and to that person’s disease,
4. Like what should be done for an
ordinary patient, the doctor must keep
the secrets of these cases, too.
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Approach of Physician to the Person
that will be reported -3
5.The doctor should keep regular and proper
records about the person for whom the report will
be prepared, keep or ensure to be kept these
documents in a manner to be able to provide a
copy of these documents or at least to be able to
provide the information as a document.
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The elements that should be included
in the report content -I
 The institutions letterhead is a must
 Report number, date, hour must be written,
 The institution or person requesting that
report, and the subject must be indicated,
 The summary of the incident and the
complaints (body lesions related to the
incident) must be recorded exactly as the
patient tells,
 A full physical examination must be
performed and findings must be recorded,
 The diagnosis must be clear.
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The elements that should be included
in the report content -II
 Performed analyses, applied treatment
and suggestions must be included in the
forensic file, the results must definitely
be indicated in the reported,
 The report must be written in an
ordinary language as clear as possible to
be understood by people who are not
doctors as well,
 The reports must be legible.
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I- Legal arrangements about reports – 1
“False statements in the preparation of
official documents”
 Article 206. – (1) The person who
provides false statements to a civil
servant authorized to prepare an
official document shall be sentenced to
imprisonment from three months to two
years or judicial fine.
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I- Legal arrangements about reports – 2
 “Documents having the force of
official documents”
 Article 210. – (2) Doctors, dentists,
pharmacists, midwives, nurses or
other members of medical profession
who prepare documents contrary to
the facts shall be sentenced to
imprisonment from three months to
one year. …
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REPORT TYPES
I- Medical Reports
A- Health Reports (Committee or single doctor)
Reports the health conditions of the person (job
application, military service, driving license, etc)
B-Sickness Reports (Committee or single doctor)
 Resting Reports
 In order to determine required medications or
medical devices for the treatment of patients
and for preserving the most suitable health
conditions
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II. FORENSIC REPORTS
A- According to the purpose of use;
1. Laceration=Effective action
2. Alcohol
3. Sexual crimes
4. Criminal liability of juveniles
5. Juridical capacity
6. Determination of age
7. Criminal liability
8. Narcotic addiction
9. Poisoning (Intoxication)
10. Other
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II. FORENSIC REPORTS
B- According to results
Preliminary (Temporary) reports
1. If findings and the narrated story is not
compatible,
2. If facilities are inadequate,
3. If an expert opinion is needed,
4. If findings are not clear,
5. If laboratory analysis is needed,
6. If you do not feel safe and impersonal.
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II. FORENSIC REPORTS
B-According to results
Final (Decisive) report
1. If the aforementioned situations are
not the case and if the data are
complete
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II. FORENSIC REPORTS
B- According to results
Additional report
1. In some cases, a long process is necessary
for evaluation (Continuous functional
degradation of one of the sensory organs, a
permanent scar)
2. If the questions of the prosecutor, judge, or
court are not adequately answered or clear,
3. If new evidence or helpful information for
the clearing up of the case during the lawsuit
process, then additional report is requested.
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Besides treatment and preventive medical
services, the third duty of doctors – “Forensic
Medicine”
 1219 sayılı TŞSTİDK’nın 11. md.
 Sağ. Bak. Teşkilat Kanunu 31. md.
 Sağ. Hiz. Sosyalleştirilmesi Kanunu
10. md.
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The issues to consider during report
preparation and examination – 1
 If relevant authorities submit such a request, an
official letter of request must be provided.
 If the report class is not specified in the letter
of request, that must be determined by asking
to the law-enforcement forces.
 If there are no extraordinary conditions, the
patient must only be examined in the institution
in which the doctor operates.
 The examination environment must be
appropriate, in case there is a problem, the
authorities must definitely be informed with an
official letter.
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The issues to consider during report
preparation and examination – 2
 Security forces must never be present at the
examination room, if conditions are not
suitable, the person must be examined behind
a screen and security forces must stand on
the farthest point within the room.
 If conditions allow to do so, relatives of the
person to be examined should not be around.
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The issues to consider during report
preparation and examination – 3
 The person to be examined must never be
handcuffed.
 No material that might ignite the offensive
sensations of the person should neither be
carried nor kept within the examination room.
 If conditions allow to do so, the person should be
examined by two doctors; if not, an auxiliary
staff might accompany the doctor.
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The issues to consider during report
preparation and examination – 4
 Upon request, and under favorable
conditions, women might be examined by
female doctors,
(CMK 77 md.)
 No matter the crime committed by the
person, the doctor should regard and
approach to the person to be examined as an
ordinary patient.
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The issues to consider during report
preparation and examination – 5
 A detailed anamnesis must be taken
before the examination. The story of
the event and complaints of the patient
must be recorded at firsthand.
 Physical examination must be
performed systematically, the patient
undressed.
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The issues to consider during report
preparation and examination – 6
 As soon as the physical examination is
completed, the person must be accompanied
outside the room and delivered to the
security officer.
 If there are different lesions at separate
bodily locations, the characteristics and
localizations of these lesions must be noted in
detail, indicated on the body diagram,
photographed, and if necessary recorded on
video.
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The issues to consider during report
preparation and examination – 7
 Date, number, hour, the person to whom
it belongs to and the person determining
it must be noted on pictures and other
documents.
 After the report is written, the doctor
must stamp and sign the document; and
the document must be approved by
being affixed with the institution’s seal.
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The issues to consider during report
preparation and examination – 8
 Having closed the report in a manner to reveal
only the name, stamp and seal of the doctor,
the one to receive the report is summoned,
asked to write his/her name, surname, and
the institution in which s/he operates with
his/her own handwriting and to sign the
report.
 The copies of the report to be sent are
enveloped, closed tightly and handed to the
person so as to be delivered to the requesting
authority.
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19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.
The issues to consider during report
preparation and examination – 9
 Forensic Reports must be at least 3
copies
 Adli raporların gönderileceği makamlar
bir yönetmelikle belirlenmiştir.
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Muayene ve Rapor Düzenlemede Dikkat
Edilmesi Gerekenler -10
 Ceza Mahkemesinde Beden Muayenesi, Genetik
İncelemeler ve Fizik Kimliğin Tespiti Hakkında
Yönetmelik kapsamında bir suça ilişkin olarak şüpheli
veya sanık ile mağdur ve diğer kişilerin beden
muayenesi, bu kişilerin vücudundan örnek alınması ve
muayene sonucunda rapor tanzimi isteniyorsa; raporun
bir nüshası sağlık kuruluşunda kalacak, muayene
sonrasında hemen rapor tanzim edilmesi mümkün ise iki
nüshası kapalı ve mühürlü bir zarf içerisinde ilgili
hakimliğe, mahkemeye veya Cumhuriyet Başsavcılığı’na
iletilmek üzere getiren kolluk görevlisine teslim
edilecek, ileri tetkik ve benzeri nedenlerle hemen
rapor tanzimi mümkün değilse raporun iki nüshası
kapalı ve mühürlü bir zarf içinde sağlık kuruluşunca
ilgili adli makama en kısa sürede iletilecektir.
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Muayene ve Rapor Düzenlemede Dikkat
Edilmesi Gerekenler -11
 Yakalama, Gözaltına Alma ve İfade Alma
Yönetmeliği kapsamında kolluk kuvvetlerince
zor kullanılarak yakalanıp sağlık kontrolüne
getirilen kişilerin raporları;
- a.Yakalama ve nezarethaneye giriş durumu
söz konusu ise raporun bir nüshası sağlık
kuruluşunda kalacak, ikinci nüsha gözaltına
alınan kişiye, üçüncü nüsha ise soruşturma
dosyasına eklenmek üzere kolluk kuvvetine
verilecektir.
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Muayene ve Rapor Düzenlemede Dikkat
Edilmesi Gerekenler -12
- b. Gözaltı süresinin uzatılması, yer değişikliği
ya da nezarethaneden çıkış söz konusu ise
raporun bir nüshası sağlık kuruluşunda kalacak,
iki nüsha ise aynı şekilde kapalı zarf içerisinde
ilgili Cumhuriyet Savcılığı’na gönderilecektir.
Bu raporların gönderilme şekli ve sıklığı sağlık
kuruluşunun iş yükü, yerleşim biriminin
büyüklüğü ve ulaşım imkanları dikkate alınarak
yapılır. Sağlık kuruşunda görevli bir personel,
taahhütlü posta veya APS, imkanlar varsa
Elektronik İmza Kanunu uygulamasına göre
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Muayene ve Rapor Düzenlemede Dikkat
Edilmesi Gerekenler -13
 Raporların düzenlenmesinde ve adli makamlara
gönderilmesinde gizlilik kurallarına uyulacak ve
bu amaçla gerekli tedbirler alınacaktır.
 Sağlık kuruluşunda saklanması gereken rapor
nüshalarının korunması için ilgili mevzuata göre
gerekli tedbirler alınacaktır.
 ( Sağlık Bakanlığı’nın 22.09.2005 tarihli
B100TSH013003-13292 sayılı genelgesi )
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Muayene ve Rapor Düzenlemede Dikkat
Edilmesi Gerekenler -14
 Forensic cases are examined and only if
the institution working physician.
 The physician should not avoid forensic
medicine.
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Thanks…
[email protected]
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