REPORTS Associate Prof. Abdi ÖZASLAN Istanbul University Cerrahpasa Medical Faculty Forensic Medicine Department

Aims The approach of the doctor to the forensic case The elements that should be included in the report content Legal arrangements about reports Report types The sample reports and diagrams that should be considered during report preparation Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI. 2

Approach of Physician to the Person that will be reported-1 1. The doctor must not forget that she/he should approach to the person about whom a report to be prepared as an ordinary patient. She/he must take a detailed anamnesis, perform a full physical examination and ensure required laboratory analyses. 2. Within the scope of his/her training, in accordance with modern requirements, to the extent of the possibilities of the institution in which she/he operates, the doctor should use his/her experience only for the good of the patient Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI. 3

Approach of Physician to the Person that will be reported-2 3. She/he should be attentive to the person for whom a report will be prepared and to that person’s disease, 4. Like what should be done for an ordinary patient, the doctor must keep the secrets of these cases, too Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI. 4

Approach of Physician to the Person that will be reported The doctor should keep regular and proper records about the person for whom the report will be prepared, keep or ensure to be kept these documents in a manner to be able to provide a copy of these documents or at least to be able to provide the information as a document Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

The elements that should be included in the report content -I The institutions letterhead is a must Report number, date, hour must be written, The institution or person requesting that report, and the subject must be indicated, The summary of the incident and the complaints (body lesions related to the incident) must be recorded exactly as the patient tells, A full physical examination must be performed and findings must be recorded, The diagnosis must be clear Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

The elements that should be included in the report content -II Performed analyses, applied treatment and suggestions must be included in the forensic file, the results must definitely be indicated in the reported, The report must be written in an ordinary language as clear as possible to be understood by people who are not doctors as well, The reports must be legible Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

I- Legal arrangements about reports – 1 “False statements in the preparation of official documents” Article 206. – (1) The person who provides false statements to a civil servant authorized to prepare an official document shall be sentenced to imprisonment from three months to two years or judicial fine Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

I- Legal arrangements about reports – 2 “Documents having the force of official documents” Article 210. – (2) Doctors, dentists, pharmacists, midwives, nurses or other members of medical profession who prepare documents contrary to the facts shall be sentenced to imprisonment from three months to one year. … Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

REPORT TYPES I- Medical Reports A- Health Reports (Committee or single doctor) Reports the health conditions of the person (job application, military service, driving license, etc) B-Sickness Reports (Committee or single doctor) Resting Reports In order to determine required medications or medical devices for the treatment of patients and for preserving the most suitable health conditions Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

II. FORENSIC REPORTS A- According to the purpose of use; 1. Laceration=Effective action 2. Alcohol 3. Sexual crimes 4. Criminal liability of juveniles 5. Juridical capacity 6. Determination of age 7. Criminal liability 8. Narcotic addiction 9. Poisoning (Intoxication) 10. Other Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

II. FORENSIC REPORTS B- According to results Preliminary (Temporary) reports 1. If findings and the narrated story is not compatible, 2. If facilities are inadequate, 3. If an expert opinion is needed, 4. If findings are not clear, 5. If laboratory analysis is needed, 6. If you do not feel safe and impersonal Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

II. FORENSIC REPORTS B-According to results Final (Decisive) report 1. If the aforementioned situations are not the case and if the data are complete Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

II. FORENSIC REPORTS B- According to results Additional report 1. In some cases, a long process is necessary for evaluation (Continuous functional degradation of one of the sensory organs, a permanent scar) 2. If the questions of the prosecutor, judge, or court are not adequately answered or clear, 3. If new evidence or helpful information for the clearing up of the case during the lawsuit process, then additional report is requested Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

Besides treatment and preventive medical services, the third duty of doctors – “Forensic Medicine” 1219 sayılı TŞSTİDK’nın 11. md. Sağ. Bak. Teşkilat Kanunu 31. md. Sağ. Hiz. Sosyalleştirilmesi Kanunu 10. md Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

The issues to consider during report preparation and examination – 1 If relevant authorities submit such a request, an official letter of request must be provided. If the report class is not specified in the letter of request, that must be determined by asking to the law-enforcement forces. If there are no extraordinary conditions, the patient must only be examined in the institution in which the doctor operates. The examination environment must be appropriate, in case there is a problem, the authorities must definitely be informed with an official letter Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

The issues to consider during report preparation and examination – 2 Security forces must never be present at the examination room, if conditions are not suitable, the person must be examined behind a screen and security forces must stand on the farthest point within the room. If conditions allow to do so, relatives of the person to be examined should not be around Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

The issues to consider during report preparation and examination – 3 The person to be examined must never be handcuffed. No material that might ignite the offensive sensations of the person should neither be carried nor kept within the examination room. If conditions allow to do so, the person should be examined by two doctors; if not, an auxiliary staff might accompany the doctor Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

The issues to consider during report preparation and examination – 4 Upon request, and under favorable conditions, women might be examined by female doctors, (CMK 77 md.) No matter the crime committed by the person, the doctor should regard and approach to the person to be examined as an ordinary patient Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

The issues to consider during report preparation and examination – 5 A detailed anamnesis must be taken before the examination. The story of the event and complaints of the patient must be recorded at firsthand. Physical examination must be performed systematically, the patient undressed Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

The issues to consider during report preparation and examination – 6 As soon as the physical examination is completed, the person must be accompanied outside the room and delivered to the security officer. If there are different lesions at separate bodily locations, the characteristics and localizations of these lesions must be noted in detail, indicated on the body diagram, photographed, and if necessary recorded on video Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

The issues to consider during report preparation and examination – 7 Date, number, hour, the person to whom it belongs to and the person determining it must be noted on pictures and other documents. After the report is written, the doctor must stamp and sign the document; and the document must be approved by being affixed with the institution’s seal Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

The issues to consider during report preparation and examination – 8 Having closed the report in a manner to reveal only the name, stamp and seal of the doctor, the one to receive the report is summoned, asked to write his/her name, surname, and the institution in which s/he operates with his/her own handwriting and to sign the report. The copies of the report to be sent are enveloped, closed tightly and handed to the person so as to be delivered to the requesting authority Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

The issues to consider during report preparation and examination – 9 Forensic Reports must be at least 3 copies Adli raporların gönderileceği makamlar bir yönetmelikle belirlenmiştir Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

Muayene ve Rapor Düzenlemede Dikkat Edilmesi Gerekenler -10 Ceza Mahkemesinde Beden Muayenesi, Genetik İncelemeler ve Fizik Kimliğin Tespiti Hakkında Yönetmelik kapsamında bir suça ilişkin olarak şüpheli veya sanık ile mağdur ve diğer kişilerin beden muayenesi, bu kişilerin vücudundan örnek alınması ve muayene sonucunda rapor tanzimi isteniyorsa; raporun bir nüshası sağlık kuruluşunda kalacak, muayene sonrasında hemen rapor tanzim edilmesi mümkün ise iki nüshası kapalı ve mühürlü bir zarf içerisinde ilgili hakimliğe, mahkemeye veya Cumhuriyet Başsavcılığı’na iletilmek üzere getiren kolluk görevlisine teslim edilecek, ileri tetkik ve benzeri nedenlerle hemen rapor tanzimi mümkün değilse raporun iki nüshası kapalı ve mühürlü bir zarf içinde sağlık kuruluşunca ilgili adli makama en kısa sürede iletilecektir Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

Muayene ve Rapor Düzenlemede Dikkat Edilmesi Gerekenler -11 Yakalama, Gözaltına Alma ve İfade Alma Yönetmeliği kapsamında kolluk kuvvetlerince zor kullanılarak yakalanıp sağlık kontrolüne getirilen kişilerin raporları; - a.Yakalama ve nezarethaneye giriş durumu söz konusu ise raporun bir nüshası sağlık kuruluşunda kalacak, ikinci nüsha gözaltına alınan kişiye, üçüncü nüsha ise soruşturma dosyasına eklenmek üzere kolluk kuvvetine verilecektir Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

Muayene ve Rapor Düzenlemede Dikkat Edilmesi Gerekenler b. Gözaltı süresinin uzatılması, yer değişikliği ya da nezarethaneden çıkış söz konusu ise raporun bir nüshası sağlık kuruluşunda kalacak, iki nüsha ise aynı şekilde kapalı zarf içerisinde ilgili Cumhuriyet Savcılığı’na gönderilecektir. Bu raporların gönderilme şekli ve sıklığı sağlık kuruluşunun iş yükü, yerleşim biriminin büyüklüğü ve ulaşım imkanları dikkate alınarak yapılır. Sağlık kuruşunda görevli bir personel, taahhütlü posta veya APS, imkanlar varsa Elektronik İmza Kanunu uygulamasına göre Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

Muayene ve Rapor Düzenlemede Dikkat Edilmesi Gerekenler -13 Raporların düzenlenmesinde ve adli makamlara gönderilmesinde gizlilik kurallarına uyulacak ve bu amaçla gerekli tedbirler alınacaktır. Sağlık kuruluşunda saklanması gereken rapor nüshalarının korunması için ilgili mevzuata göre gerekli tedbirler alınacaktır. ( Sağlık Bakanlığı’nın tarihli B100TSH sayılı genelgesi ) Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

Muayene ve Rapor Düzenlemede Dikkat Edilmesi Gerekenler -14 Forensic cases are examined and only if the institution working physician. The physician should not avoid forensic medicine Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

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