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TheThe Medical Report Medical Report

Beta Ahlam GizelaBeta Ahlam Gizela

dr., Sp.F, DFMdr., Sp.F, DFM

Blok Medikolegal, 8 Des 09 [04]

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The Medical ReportThe Medical ReportWhat is it ???What is it ???

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In every country in the world, there In every country in the world, there are crimes and its victims. In another are crimes and its victims. In another

side there are tortures and ill side there are tortures and ill treatments to the detainee who did a treatments to the detainee who did a

crime. To seek justice for both of crime. To seek justice for both of cases above, it is needed medical cases above, it is needed medical

proofing proofing

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The Medical ReportThe Medical Report

Documenting Documenting the medical the medical consequencesconsequences and the case history and the case history including the methods used for attack, including the methods used for attack, ill treatment and tortureill treatment and torture

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Pembuktian HukumPembuktian Hukum

Barang Bukti

Alat Bukti (Court)

Forensic Science

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Forensic scienceForensic science

Forensic medicineForensic medicine DermatogliphyDermatogliphy Forensic chemistryForensic chemistry Forensic physicsForensic physics Forensic biologyForensic biology BallisticBallistic etcetc

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Barang bukti medisBarang bukti medis

Manusia: hidup atau matiManusia: hidup atau mati Bagian tubuh manusia: kerangka, Bagian tubuh manusia: kerangka,

gigi, potongan tubuhgigi, potongan tubuh Zat yang berasal dari tubuh manusia: Zat yang berasal dari tubuh manusia:

darah, saliva, sperma, epitel yang darah, saliva, sperma, epitel yang terlepas, rambutterlepas, rambut

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The Medical ReportThe Medical Report Can be used as a proof in the courtCan be used as a proof in the court

Projusticia Projusticia Without projusticiaWithout projusticia

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Dasar HukumDasar Hukum

Kitab Undang-Undang Hukum Acara Kitab Undang-Undang Hukum Acara Pidana (KUHAP):Pidana (KUHAP): Pasal 184, 187 Pasal 184, 187 alat bukti alat bukti Pasal 179, 186 Pasal 179, 186 saksi ahli saksi ahli Pasal 170 Pasal 170 rahasia medis rahasia medis

Undang-Undang Praktik Kedokteran:Undang-Undang Praktik Kedokteran: Pasal 48 Pasal 48 rahasia medis & penegakan rahasia medis & penegakan

hukumhukum

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The Medical ReportThe Medical Report

Digunakan untuk kasus apa sajakah Digunakan untuk kasus apa sajakah kedua macam laporan medis itu?kedua macam laporan medis itu?

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The Medical ReportThe Medical ReportUsing projusticiaUsing projusticia

Person being examined is an evidence Person being examined is an evidence tooltool

Request by the police/attorney/judgeRequest by the police/attorney/judge Called Called Visum et RepertumVisum et Repertum in Indonesia in Indonesia Doctor as a police doctor, only give Doctor as a police doctor, only give

his/her report to the his/her report to the police/attorney/judgepolice/attorney/judge

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Person being examined is a patient Person being examined is a patient who makes a contract of who makes a contract of examination examination

Request by the patientRequest by the patient Called Called Surat Keterangan MedisSurat Keterangan Medis in in

IndonesiaIndonesia Doctor as a treaty doctor, only give Doctor as a treaty doctor, only give

his report to the patient (medical his report to the patient (medical confidentiality)confidentiality)

The Medical ReportThe Medical ReportWithout projusticiaWithout projusticia

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The patient come to a doctor by The patient come to a doctor by himselfhimself

He makes a contract to the doctor to He makes a contract to the doctor to examine and treat him (Informed examine and treat him (Informed Consent)Consent)

There is a medical confidentialityThere is a medical confidentiality The patient has a right to access all The patient has a right to access all

of the information about his diseaseof the information about his disease The doctor has an obligation to tell The doctor has an obligation to tell

the patient about his disease, orally the patient about his disease, orally and written if it is asked.and written if it is asked.

The Medical Report Requested by The Medical Report Requested by Patient (Surat Keterangan Medis)Patient (Surat Keterangan Medis)

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Late Request LetterLate Request Letter

In some case, the request letter from In some case, the request letter from the police/attorney/judge come later.the police/attorney/judge come later.

First contract come from the patientFirst contract come from the patient Law Criminal Procedure (KUHAP): the Law Criminal Procedure (KUHAP): the

doctor need Informed Consent from doctor need Informed Consent from the patient to write the medical report the patient to write the medical report for the police/attorney/judgefor the police/attorney/judge

Medical Practice Act (Act no 29/2004): Medical Practice Act (Act no 29/2004): didn’t need Informed Consentdidn’t need Informed Consent

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The Medical ReportThe Medical Reportof a living personof a living person

1.1. PreamblePreamble (Projusticia, (Projusticia, only for MR request by only for MR request by police/attorney/judge)police/attorney/judge)

2.2. IntroductionIntroduction (Identity of requester, doctor, (Identity of requester, doctor, person/patient, incident)person/patient, incident)

3.3. ContentContent (history, physic diagnostic, advance (history, physic diagnostic, advance examination, treatmentexamination, treatment, resume & analyzes, resume & analyzes))

4.4. ConclusionConclusion (Identity, diagnosis: include (Identity, diagnosis: include severity/qualification, whether or not there is severity/qualification, whether or not there is any contradiction between the trauma/diagnosis any contradiction between the trauma/diagnosis and the history - possibility cause of trauma)and the history - possibility cause of trauma)

5.5. ClosingClosing (jurisdiction base, doctor’s signature)(jurisdiction base, doctor’s signature)Adapted from Istanbul ProtocolAdapted from Istanbul Protocol

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INTRODUCTIONINTRODUCTION Personal data of clientPersonal data of client Circumstances of the reportCircumstances of the report Phrasing of questions by requesting Phrasing of questions by requesting

partyparty Medical records / Relevant documentMedical records / Relevant document Indicate to whom a copy of the Indicate to whom a copy of the

report will be sentreport will be sent

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HISTORY HISTORY An important part of the case history is An important part of the case history is a description of the torture; this should a description of the torture; this should be detailed, as it is important for the be detailed, as it is important for the interpretation of the findings during interpretation of the findings during

the medical examination. The the medical examination. The recording of current symptomology recording of current symptomology

should be painstakingly accurate and, should be painstakingly accurate and, if possible, its relationship to the if possible, its relationship to the

torture should be described.torture should be described.

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PHYSICAL EXAMINATION and PHYSICAL EXAMINATION and PSYCHIATRIC EXAMINATION PSYCHIATRIC EXAMINATION

This section is therefore of great This section is therefore of great importance and will be examined in importance and will be examined in

detail. It must be accurate and easily detail. It must be accurate and easily understandable.understandable.

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PHYSICAL EXAMINATION and PHYSICAL EXAMINATION and PSYCHIATRIC EXAMINATION PSYCHIATRIC EXAMINATION

The manner in which the wounds/scars are The manner in which the wounds/scars are described is vital. The description should described is vital. The description should

be extensive and detailed. However it be extensive and detailed. However it should only cover those abnormalities and should only cover those abnormalities and

symptoms that can be ascertained symptoms that can be ascertained objectively. Constructing a report to objectively. Constructing a report to include personal interpretations or include personal interpretations or

subjective observations is to be avoided as subjective observations is to be avoided as it will undermine its own objectivity and it will undermine its own objectivity and

directly affect its credibility. directly affect its credibility.

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For example: For example:

Do not write: “there is a perforation of Do not write: “there is a perforation of the ear drum that was caused by a the ear drum that was caused by a blow to the client’s ear” (own blow to the client’s ear” (own interpretation) but rather: “a interpretation) but rather: “a perforation of the ear drum was found. perforation of the ear drum was found. An explanation of its cause could be a An explanation of its cause could be a trauma, e.g. a blow to the ear, such as trauma, e.g. a blow to the ear, such as the client told me he had received”. the client told me he had received”.

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Summary, discussion and Summary, discussion and conclusion conclusion

This is the crux of the matter. You This is the crux of the matter. You should concentrate on constructing a should concentrate on constructing a balanced and logical report, providing balanced and logical report, providing insight into the argument that lead to insight into the argument that lead to a conclusion that flows naturally from a conclusion that flows naturally from the preceding objective information. the preceding objective information. All that has been written on objectivity All that has been written on objectivity in earlier paragraphs is of course to be in earlier paragraphs is of course to be taken into consideration here.taken into consideration here.

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CONCLUSION CONCLUSION

In the Conclusion, a statement may be In the Conclusion, a statement may be included underlining the probability of included underlining the probability of a connection between the torture a connection between the torture suffered by the victim and the medical suffered by the victim and the medical findings - if, of course, the medical findings - if, of course, the medical findings support this objectively. findings support this objectively.

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Warning !Warning !In practice it proves to be difficult for many In practice it proves to be difficult for many people not to include personal interpretations people not to include personal interpretations and subjective descriptions in a report. The and subjective descriptions in a report. The feelings, emotions and anger that people feelings, emotions and anger that people naturally feel when listening to these stories naturally feel when listening to these stories and on seeing the results of torture can have and on seeing the results of torture can have a profound influence. However it is important a profound influence. However it is important to remember the aim and the legal character to remember the aim and the legal character of the report in order to understand the of the report in order to understand the importance of the signs of torture.importance of the signs of torture.

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The Autopsy ReportThe Autopsy Report1.1. PreamblePreamble (Projusticia, (Projusticia, only for MR request by only for MR request by

police/attorney/judge)police/attorney/judge)

2.2. IntroductionIntroduction (Identity of requester, doctor, (Identity of requester, doctor, corpse, incident)corpse, incident)

3.3. ContentContent (external examination, internal (external examination, internal examination, advance examination)examination, advance examination)

4.4. ConclusionConclusion (Identity, cause of death, manner (Identity, cause of death, manner of death, time of death)of death, time of death)

5.5. ClosingClosing (jurisdiction base, doctor’s signature)(jurisdiction base, doctor’s signature)

Adapted from Minnesota Protocol Adapted from Minnesota Protocol

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INTRODUCTIONINTRODUCTION

Personal data of the victimPersonal data of the victim Circumstances of the reportCircumstances of the report Indicate to whom a copy of the Indicate to whom a copy of the

report will be sent report will be sent Official Statement of the caseOfficial Statement of the case

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EXTERNAL EXAMINATIONEXTERNAL EXAMINATION

General:General: external abnormalities external abnormalities Specific:Specific: consequences of torture: consequences of torture: ++ Scars Scars: localization, size (in mm), : localization, size (in mm),

shape, limitation, colour, mutual shape, limitation, colour, mutual arrangement, hypertrophy, include a arrangement, hypertrophy, include a diagram of the body and possibly diagram of the body and possibly photographs on which the scars are photographs on which the scars are indicatedindicated

Describe the abnormality systematically, Describe the abnormality systematically, in detail, each part of the body.in detail, each part of the body.

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INTERNAL EXAMINATIONINTERNAL EXAMINATION

Describe all the result internal examination Describe all the result internal examination in detail, each part of the body: in detail, each part of the body:

FractureFracture Corpus alienumCorpus alienum Haematoma Haematoma Internal bleedingInternal bleeding Organ damage or ruptureOrgan damage or rupture Organ congestion or swellingOrgan congestion or swelling Secretion, and any abnormalities found in Secretion, and any abnormalities found in

autopsy autopsy

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LABORATORY EXAMINATIONLABORATORY EXAMINATION

Note the result of laboratory Note the result of laboratory examination supporting an autopsyexamination supporting an autopsy

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SUMMARY AND DISCUSSIONSUMMARY AND DISCUSSION

Note summary of the examination, Note summary of the examination, make a scientific explanation and make a scientific explanation and interpretation to construct a interpretation to construct a conclusion.conclusion.

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CONCLUSIONCONCLUSION

IdentityIdentity Cause of deathCause of death Time of deathTime of death Manner of death Manner of death

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Another Simply Another Simply Medical ReportMedical Report

Death certificateDeath certificate Born certificateBorn certificate

Immunization certificateImmunization certificate etcetc

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Anything need to be clarify, please Anything need to be clarify, please contact: contact: betaforensik@gmail.combetaforensik@gmail.com

or mobile phone: 08157927896or mobile phone: 08157927896