Structured format in MLR: Significance & Importance

Dr Gautam Biswas Prof. & Head Dept. of Forensic Medicine

Medico-legal case
A case of injury or ailment where the attending doctor after history taking and clinical examination considers that investigations by law enforcement agencies are warranted to ascertain circumstances of the causation of the said injury or ailment.

Medico-legal report (MLR)

A report on the condition of a patient, solicited for legal purposes which gives the medical experts findings, diagnosis, prognosis and opinion. It is a structured and formal mode of communication between the doctor and the legal system.

 The format should help the medical officer to give a comprehensive report that clearly separates the facts from the opinions, and provides a basis for the opinion stated.

An MLR comprises of three parts, namely:

Contents of MLR

Preamble

Body (Findings/Observations)

Post-amble (Opinion)

Guidelines
CMOs or any other RMP may be called upon to examine the injured person. Medico-legal injury cases should be examined without delay at any time of the day or night.

 All details of examination of the injured person, whether admitted into hospital or treated in OPD have to be entered in a Medico-legal Register. This register is a confidential record and should be in safe custody of the medical officer. It has to be produced in court of law, if asked for.

 The doctor is required to fill in the structured form of injury certificate, one copy of which is given to the I.O. in a sealed cover and the other retained for future reference.

 Serial number, admission number. Preliminary particulars: Name, age, sex, address, and fathers/husbands/guardians name. Name of the person who accompanied the injured person with address and relation. Date, time, and place of examination. Name and number of the accompanying police constable and police station to which he belongs. Consent of the person for examination. Two identification marks.

Particulars to be noted

Age It is to be noted as 'stated age as expressed by the patient/legal guardian or about.. years.

Brought and identified by

The identifying person will affix his signature with date (in case of police personnel - designation/No. and the name of the police station where he is attached is to noted).

Date & time of examination

Every medico-legal report must include the date & time of examination. It is prudent to include the time when the examination began and ended, as this may support the contention that the examination was a complete and thorough one.

 Moreover, the time and date of the start of examination may become important later when the appearance of any injuries observed, or the signs of intoxication by drink or drugs may suddenly be important in relation to the time between an incident and the examination.

CONSENT
Before starting of examination, informed consent from the patient or the legal guardian is to be taken in writing (preferably in presence of witness).

The statement is to be recorded as: I am willing for my medico-legal examination I have not been examined earlier I will show all my injuries on my person I have been explained that the result of the examination may go in my favor or against.

Signature / LTI with date of the person/guardian

Identification marks
It is better to note down at least 2 identification marks. If only one identification mark is recorded, there may be a chance of loss of one mark due to any reason scarification or amputation of that part; and during subsequent examination it may cause difficulty in identification.

The marks used for identification: Congenital marks - birth marks, moles, nevus, supernumerary teeth/fingers, cleft palate etc. Acquired marks - scar, tattoo, deformities, malunited fractures etc.

E.g.: White scar mark 1.2"xO.1" placed obliquely over anterior surface of left forearm, 8" below elbow joint and 9Y2" above wrist joint. Black mole of O.2"x0.1" size placed over right side of face, 1" in front of right antitragus, 3 "to the right of midline and 5.5"below vault of scalp.

 Alleged short history of the case as stated by the patient/by the persons accompanying the patient. If the patient is conscious and able to speak, history of the incidence is recorded from the patient. If the patient is unconscious, history of the incidence is then taken from the persons accompanying the patient.

History

 If the condition of the patient is serious, arrangement for dying declaration should be made.

 During examination of a female subject, a nurse/female attendant MUST BE PRESENT.

General physical examination

Consciousness, orientation, pulse, temperature, blood pressure, reaction of pupils to light Size of the victim i.e. stature, weight and development.

Type of injury
All injuries observed, even insignificant, should be noted. Nature of injuries i.e. abrasion, contusion, laceration, incised wound etc. should be noted. Multiple injuries can be grouped anatomically e.g. injuries of head, of the trunk or of limb.

 A lens should be used to get an accurate idea of the nature of edges, ends and floor of the wound. Presence of any foreign material in wound e.g. glass, hair or dirt should be noted.

Size of injury
All injuries should be measured with a tape and never guessed, and amount of blood extravasated should be measured and photographs or sketches showing the position and size of the wound are desirable.

Shape & direction of injury

Shape of the wound e.g. circular, oval or triangular should be noted and also the beveling of the edges. Direction of the wound i.e. horizontal, vertical or oblique should be noted with regard to anatomical position of the body.

Location of injury
Exact situation of wound with reference to some anatomical landmark e.g. midline, bony structure, umbilicus should be mentioned. Technical terms should be avoided as far as possible.

Management
It is appropriate to mention the investigations, procedures and management of the patient. If investigation or treatment is ongoing, a further (supplementary) report may be required.

Samples & specimens

Samples and specimens collected should be properly identified, sealed and labeled. They should be kept in safe custody and handed over to the I.O. of the case. Specimens once collected, loss/destruction of evidence is a punishable offence. Failure to collect, destruction or loss of such an exhibit is punishable under Sec. 201 of IPC.

 All evidence collected should be mentioned in MLR to establish the chain of custody in a court of law subsequently.

What was the type of weapon used?

In many cases, examination of the wound and clothing give fairly definite information about the kind of weapon. With stabs and incised wound there is not much difficulty.

What was the nature of the injury ?

Opinion is given as to whether the injuries were simple, grievous or dangerous in nature. Against each injury, it should be noted whether it is simple, grievous or dangerous.

Grievous hurt/injury
Sec. 320 IPC defines the grievous hurt and comprises of 8 clauses: 1. Emasculation 2. Permanent privation of sight of either eye 3. Permanent privation of hearing of either ear 4. Privation of any member or joint

5. Destruction or permanent impairment of the powers of any member or joint 6. Permanent disfigurement of the head or face 7. Fracture or dislocation of a bone or tooth 8. Any hurt which:
a. Endangers life b. Causes the victim to be in severe bodily pain for
20 days c. Unable to follow his ordinary pursuits for a period of 20 days

 Dangerous injuries are those which cause imminent danger to life without medical/surgical intervention either by involvement of important organs or structures, or an extensive area of the body.

 Injured person must be kept under observation, if nature of particular injury cannot be made out at the time of examination e.g. head injury or abdominal injury. In all injuries, when fracture of a bone is suspected, an X-ray should be done for confirmation.

 Whether an injury is simple, grievous or dangerous, is decided on the basis of status of injury at the time of infliction and not after medical/surgical intervention.

What is the time passed since infliction of the injury?

Opinion is based on the state of healing of the injuries as was recorded in the column of examination of the injuries.

Certification
All the particulars are entered in the injury report by the doctor in his own handwriting. After completion of the report, the doctor must sign along with his name, designation & registration no. at appropriate place.

Conclusion
The preparation of a MLR is an essential part of the service provided by hospital doctors. Task should be approached with a desire to accurately communicate the clinical situation encountered.