What© data should always be included in the injury report? It is a blunt injury caused by the teeth, it is due to a combined mechanism of pressure and traction. The lesions are arranged in two curved lines facing their concavity. ✅ Sports exercises and injuries caused by direct aggression. The practice of general medicine usually raises situations closely related to legal issues. A good GP response©saves them legal trouble, wasting©time and basically enormous security before possible legal proceedings or simply before the court is summoned to clarify a problem. The family doctor©is required to prepare the injury report if he suspects that a criminal offence has been committed. These include the presence of injuries of any kind, poisoning, suspicion of abortions that are not authorized by law, or any other situation that leads the physician©to believe that they may be derived from a criminal act. In summary, the following practical conclusions can be drawn in order to avoid, as far as possible, legal problems in medical practice: Classification: this is the exclusive criterion of the doctor, injuries©are described and determined to which class they correspond according to Article C. P., without mentioning the article number, only the legend. The general practitioner must keep in mind that the injury report is addressed to the judge, but it is also©a fundamental tool for the coroner. ©© For Criado2, the term “© injury” includes any anatomical or functional, physical or psychological change that is caused by violence and that ends with complete healing or sequelae. It is an important medico-legal document because it has evolved from documentation used to assess criteria for medical assistance to one containing medico-legal criteria.8©©© The contribution of medical history can be of great importance both for and against the physician©in professional liability proceedings. (1) Any person who, by means or procedure, inflicts on another person an injury which is bodily harming his physical integrity or to his physical or mental health shall, as a defendant in the crime of aggression, be punished by imprisonment from six months to three ± years, provided that the injury is objectively necessary for his health, in addition to the first medical assistance.
medical©or surgical treatment. Mere monitoring or optional follow-up of the course of the injury is not considered medical© treatment. Articles 262 and 355 of the Code of Criminal Procedure5 provide for the obligation to report violations. This does not mean that the physician©must inform the justice system of the injuries he is treating, but only of those that may constitute criminal behaviour. Among other things, this law regulates such important aspects as the use of clinical history, its retention, the patient`s right to information and the ownership of clinical history. The injury report should contain at least the following sections: parentage of the patient, date and time of arrival, pedigree of the attending physician© of the patient, description of the lesions, including their location, extent, morphology and possible damage to vital organs, possible harmful mechanism (depending on the patient), diagnostic judgment, prescribed treatment and prognosis quo ad vitam (i.e. danger to life due to injury or disease)6. The following practical findings are collected that can help the doctor©avoid legal problems. Since health-related data is particularly protected and subject to particularly strict rules©for its collection, storage and possible interruption, the use of clinical medical history for these purposes always requires specific legal authorization. Therefore, although the language used must of course be technical©, it must be accessible to a person who has no medical© knowledge, such as the judge. The style should be clear, simple and concise in order to be useful and understandable to the recipient and appropriate for its intended use. Legible handwriting prevents the physician©from further complaints as soon as the injury report reaches the courthouse.
If, in the course of his profession, the doctor suspects that an infringement has been committed, he must submit a report of damage to the Wachgericht. These are injuries caused by the action of hard, blunt bodies, that is, they do not have sharp edges acting on the organism by a more or less considerable force. How often does the physician©raise medico-legal©issues in his daily work as a nurse, who sometimes do not know how to resolve them. This work is part of a work in which she must address the main issues that can lead to a specific medico-legal©problem in the practice of general and family medicine, such as: the finding of injury, clinical history, consent and patient information. In this first part, the first two points are addressed, while the rest is covered in a second presentation. The medico-legal significance of this document is enormous, because in many cases the forensic©©examination takes place after some time since the appearance of the injuries and it may happen that at that time there is no objectivity. In this case, the coroner©may base his assessment only on the injury report or medical history, if any. Once this legal-medical©document has been completed, it will be sent as soon as possible to the on-call court of the judicial district concerned. The areas of law known as forensics, criminology, victimology and forensic science are extremely interesting.
If you are a student, a lawyer, or someone who wants to learn more about these topics, this article is ideal for you. The disorder or illegible handwriting gives a bad image when the medical history reaches the court for reasons of responsibility. It is therefore necessary to be careful in the elaboration of the classical history. The physician must never forget that, although it is a document of care, it has a fundamental legal©and medical significance. If the criminal act that motivates the formation of a case consists of injuries, the doctors© who care for the injured person are obliged to report their condition and progress during the periods ± to them, and immediately when any novelty that deserves to be brought to the attention of the investigating judge. The accident report is a medico-legal©document by which the doctor©informs the judicial authority of any violation that could constitute an error or a crime3. Urgent medical measures, refusal of treatment, abuse of a minor or suspicion of criminal intoxication are some situations that can lead to a medico-legal©©problem that the family doctor©must address. These are injuries in which the blunt agent creates a detachment of tissues or segments of the body. 3. The clinical history of aspects of direct patient care shall be the responsibility of the professionals concerned. In this article, we will discuss the definition of injuries, types of injuries, means of injury, location and injuries.
If you think that the content of this article might be important to your friends and classmates, feel free to share it, remember that Tareas Jurídicos is the largest legal community in Mexico. According to Gisbert Calabuig4, the objective pursued by this document is that the authority is aware of the fact and its consequences, in this case injuries, in order to be able to carry out the appropriate investigation and, if necessary, take appropriate measures with regard to the perpetrator. The injury report must be legible and must include the© patient`s first and last name, physician`s name (not just signature) with college number, description of injuries, location, diagnosis and©treatment. If points are created, the specified number of points must be specified. Lesions can be examined in several ways, which are listed below: But despite these problems, it is still necessary for the doctor to establish as complete a clinical history of each patient as possible, as this means not only a better quality of care, but also the basic legal©document of the doctor`s defence in court following a©possible claim for professional liability6. There are five 5 criteria that are examined on lesions for their classification: It is the basic tool of health care.