Introduction

The ability to appropriately assess, document, and interpret injuries that have been sustained is a key part of the work of any forensic physician or forensic pathologist. Crimes of violence are increasing throughout the world. Nonjudicial assault, such as torture, has also become more widely recognized (1). It has been suggested that the definition of physical injury in the forensic medical context should be "damage to any part of the body due to the deliberate or accidental application of mechanical or other traumatic agent" (2). This chapter specifically addresses the issues of physical assault and the assessment and documentation of wounds or injury.

The purpose of assessment and documentation is to assist in establishing how a wound or injury is caused, which may often be at issue in courts or tribunals of law. These two skills should be within the remit of any doctor, although they are rarely done fully and appropriately. The interpretation of the causes of wounds and injuries is probably best undertaken by those with forensic expertise, because there may be many factors involved in such interpretation. Because interpretation of wounds and injuries may be undertaken by review of documents, for example written descriptions, body chart mapping, or photographs, it is imperative that the descriptions are comprehensible to all. For

From: Clinical Forensic Medicine: A Physician's Guide, 2nd Edition Edited by: M. M. Stark © Humana Press Inc., Totowa, NJ

example, the term wound has specific meaning in certain jurisdictions, for example relating to whether the skin or mucosa is completely breached. It is more appropriate for those who are documenting injuries to ensure that they have documented them in detail and unambiguously so that the courts can then make the decision regarding the most appropriate judicial interpretation of the injury or injuries described and their relevance to the case.

In many cases, the initial examination and assessment may have been undertaken for purely therapeutic purposes, and the forensic significance of the injuries may not become apparent until several weeks or months later. Scrutiny of the doctor's notes at a later stage, possibly in court, may reveal serious deficiencies, which not only bring discredit on the individual practitioner and the profession as a whole but also can seriously prejudice the legal proceedings. Pediatricians and emergency medicine specialists are typical of those nonforensic practitioners who may encounter patients with injuries that may be contentious within court proceedings.

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