MLR + Death Certificate

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How to write Death Certificates and Reports of Medicolegal cases:

How to write Death Certificates and Reports of Medicolegal cases

Medical report of a Medicolegal case:

Medical report of a Medicolegal case

Definition:

Definition Report issued by a doctor for a medicolegal purpose such as court proceedings, worker’s compensation and insurance reports.

Precautions:

Precautions Know the purpose of the medicolegal report Use the medical records to prepare the report. Do not rely on your memory or the instructions from the patient or the requesting party. The report should be: Relevant to the request Well organized – headings should be used if the report is long Avoid the use of legal terminology Understandable to the audience e.g. ‘the patient had dysphagia (difficulty swallowing)’

Precautions:

Precautions Do not breach your patient’s confidentiality. If the report is to be sent to a person other than your patient, obtain the written authority of the patient to prepare and release the report to the third party. Do not act as an advocate for one party or the other. Do not provide an opinion beyond your expertise.

Precautions:

Precautions Do not alter your report at the request of your patient or a third party. If you receive further information or you have made a mistake, provide a supplementary report. Remember that you may be cross examined on your report – you should only write what you would be prepared to say under oath in court.

Components:

Components It is composed of 3 main parts: Introduction (pre-amble) Body (findings and observations) Opinion (post-amble)

Introduction (preamble):

Introduction (preamble) Purpose of Report : Refer to person or authority has asked you to address in the report.   Physician’s information and qualifications   Name Year of graduation, fellowships, specialties.   Person Examined Identity : (NASI) Name, age (date of birth), address, sex, ID Place and Date of Examination Person’s Consent : informed and written Papers (Documents) Reviewed List records and reports reviewed. Ensure you have all relevant medical records and review them.

Body (findings and observation):

Body (findings and observation) History Of Current Illness or Injury Patients version. Check against information in documents reviewed. Past History Previous conditions. Whether or not they impaired function. Whether they may affect disability/prognosis from current event.

Body (findings and observation):

Body (findings and observation) Patient Examination Details of examinations: Systemic examination: general examination (LOC, VD, skin), HEENT, neck, chest, abdomen, extremities, neurologic examination. Injury description: number, site, size, shape, edges, type, vital reaction, surgical interference. Comment on investigations related to complaint (i.e. EEG, MRI, CT etc.). N.B. Explain in terms a layman can understand.

Body (findings and observation):

Body (findings and observation) Diagnosis Cause Medical intervention

Body (findings and observation):

Body (findings and observation) Prognosis Recovery: Whether maximal medical recovery achieved. Probability of further recovery Expected duration for recovery Comment on future deterioration, future treatment including surgery. Disability: type and degree Death and its cause(s) N.B. There must be a real possibility and not mere speculation. Assign a percentage to the future risk if possible.

Opinion:

Opinion Traumatic conditions: Physician’s name Person’s name Injury description Instrument and force used Nature of injuries (simple, dangerous, fatal) Prognosis: current and expected Non-traumatic conditions: Physician’s name Person’s name Diagnosis Cause Severity Prognosis: current and expected

Opinion form: Trauma cases:

Opinion form: Trauma cases Upon the request of the Forensic Medicine Department of ASU, I (physician name) , fourth year student, examined and reviewed records of (person’s name) , (person's age) years old male/female patient and found that he had injury(ies) in the form of (complete description ) caused by (instrument description) . This injury requires more/less than 20 days for healing with/without leaving a permanent infirmity. The patient has recovered/in recovery/died . He was discharged/ is still hospitalized . This injury is simple/dangerous/fatal .

Opinion form: Non-trauma cases:

Opinion form: Non-trauma cases Upon the request of the Forensic Medicine Department of ASU, I (physician name) , fourth year student, examined and reviewed records of (person’s name) , (person's age) years old male/female patient and found that he had (chief sign ) caused by (disease or agent) . The patient has recovered/in recovery/died . He was discharged/ is still hospitalized . The case is mild/moderte/severe.

Write an opinion:

Write an opinion Fahmy El-Kazzaz is a 50 years old man who was presented to the ER two days ago after a hit-and-run accident by about 30 minutes. According to the patient, he was first hit in the thighs then thrown up on the front bonnet then fell to the ground. O/E a single irregular bruise (20x15 cm) was found on lateral aspect of the right thigh with edema and tenderness. An x-ray for that thigh was obtained and reveled two irregular fractures of the right femur. He was operated upon and a nail was inserted. He is still in the hospital.

Write an opinion:

Write an opinion Eman Farouk Naguib is 34 years old housewife referred to you from the police station to issue a medical report. She claimed that during an argument with her neighbor, she was hit by a stick on her left forearm 3 hours ago. O/E two wounds were observed on the lateral aspect of the left forearm about 7 and 10 cm long. Edges were regular with gaping and no bridging, bruises or abrasions. The wound was sterilized and sutured.

Write an opinion:

Write an opinion Atef Abdel Naeem is 59 years old diabetic hypertensive man with chronic renal failure who is doing regular sessions of hemodialysis. He was presented to the ER an hour after his colleague pushed him on the stairs in the workplace. O/E multiple abrasions and contusions (smallest 2x2 cm, largest 15x10 cm) were observed on both forearms, ankles and forehead. Skin of abdomen was normal, but abdominal US revealed abdominal fluid collection and ruptured left kidney for what it was surgically removed. Patient was discharged a week later.

Write an opinion:

Write an opinion Saly Ibrahim Salama is a 21 years old medical student. She was presented to Poison Control Center 6 hours after ingesting 40 Aspirin 325 mg tablets. She was presented by repeated vomiting, abdominal pain and air hunger. O/E she was obtunded, pale, hypotensive, tachypnic, tachycardic with moist skin. Chest auscultation showed bilateral fine basal crepitations. Epigastric tenderness was also found. Hyper-reflexia and muscle twitches were observed that rapidly progressed into seizures. ABG revealed metabolic acidosis with salicylate level of 85 mg/dL. She was admitted to the ICU where she is sedated, mechanically ventilated and kept on vasopressors and inotropics.

Death certificate:

Death certificate

Precautions:

Precautions Before issuing death certificate doctor must inspect the body to make sure that: Person is actually dead Death is natural. N.B. Unnatural death is suspected by: PMP of criminal aspect e.g. ligature mark PMP inconsistent with the alleged time of death

Precautions:

Precautions In natural deaths, the exact cause of death must be clarified. Vague terms must be avoided. In suspected unnatural deaths (e.g. violence, poisoning), doctor must: Not issue the death certificate ( or he will be accessory to a crime) Report to the police

Terminology:

Terminology Cause of death أحوال نشأ عنها السبب المباشر للوفاة Any injury or disease that produces a physiological derangement in the body that results in the death of the individual. Examples: a gunshot wound to the head, a stab wound to the chest, adenocarcinoma of the lung, and coronary atherosclerosis. Mechanism of death السبب المباشر للوفاة The physiologic derangement produced by the cause of death that results in death. Examples: hemorrhage, septicemia and cardiac arrhythmia

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عدد (_) تقرير طبي، وصفة طبية، تحاليل، أشعات طبيب الصحة

Write a death certificate:

Write a death certificate Osama Kamel El Bardisy lives in 35 El Laselky street, Maadi. He holds ID number 27704158800898 El-Maadi 3/2009. He notified that his neighbor, Seif Mahmoud Rashed, a 46 years old single engineer died 6:30 am this morning after developing acute chest pain. He was an ischemic heart patient known to be hypertensive and dyslipidemic.

Write a death certificate:

Write a death certificate Osama Kamel El Bardisy lives in 35 El Laselky street, Maadi. He holds ID number 27704158800898 El-Maadi 3/2009. He notified that his neighbor, Mina Nashed Abdo, a 58 years old married accountant, died 4:30 am this morning after developing coma 3 hours after peroration of a peptic ulcer. He was known diabetic patient.

Write a death certificate:

Write a death certificate Saeed El Sayed Ragab lives in 20 Shobra street. He holds ID number 2750415145145, 4/2005. He notified that his wife, Ekram Ali El Sheimy, a 28 years old housewife, died 4:30 pm this evening after developing coma 6 hours after ruptured tubal pregnancy. She was known to be anemic.

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Thank you for attention!

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