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THE MEDICAL CERTIFICATE
or the MEDICOLEGAL REPORT Atty. Antonio D. Rebosa,MD,BSCrim
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Medical certificates/medicolegal report/insurance forms/birth certificates/death certificates/SSS or GSIS forms, etc.
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The Medical Certificate
Personal circumstances Date I hereby certify that _____ was personally seen and examined by the undersigned last (…from)______ because of ____________. Clinical Impression is ____________.I have prescribed ______ and advised patient to rest for _________days/weeks. This medical certicate is issued for _______ purpose only and not intended for medicolegal/court use. (sgd)
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THE MEDICOLEGAL REPORT
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“… the patient is not your friend and the accused is not your enemy…”
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DOCUMENTATION MEDICAL CERIFICATE/MEDICO-LEGAL REPORT
Personal circumstances… name, age, civil status, sex, address, occupation Inpatient/outpatient/ER/clinic
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ALLEGED place, date, time of infliction Nature(?)
Date and time of examination ( important in the determination whether injuries are compatible/consistent with the date and time of infliction)
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GENERAL SURVEY Vital signs Level of consciousness and coherence
Degree of ambulation General appearance
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INJURIES NATURE SHAPE MEASUREMENT ANATOMICAL LOCATION
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NATURE OF INJURIES LACERATED/AVULSED WOUND
… caused by contact with BLUNT object e.g. fist blows, vehicle bumpers, baseball bat, lead pipes,etc.
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Lacerated wound
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Sutured lacerated wounds
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Self inflicted incised wounds
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PUNCTURED WOUND …caused by sharp-pointed instrument/object (e.g. needle, ice-pick, nail, pin etc.)
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STAB WOUND …caused by object/instrument with sharp point and sharp edge - single/double bladed
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Stab wound
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INCISED (SLICED/CUT) WOUND
…caused by sharp edged instrument or object (e.g. blade, knife, scalpel, etc.)
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HACKING WOUND …a large incised wound ( e.g. ax, bolo, samurai, etc)
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CONTUSION/BRUISE (pasa)
extravasation of blood into the surrounding tissues because of damage to blood vessels shape, color ( blue-brown-green-yellow) Ecchymosis, petechiae
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HEMATOMA (Blood Cyst/tumor/ bukol)
…extravasation of blood in a newly formed cavity Contusion hematoma, periorbital hematoma
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ABRASIONS …contact with rough surface, friction, graze, scratch -linear -multi linear -confluent
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GUNSHOT WOUNDS Point of entry vs. point of exit Products of combustion
tattooing/smudging/singeeing Contusion collar
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CONCLUSION Barring any complications or injuries not clinically apparent at the time of examination, patient’s injuries shall require medical attendance or shall incapacitate the patient from performing his habitual work for a period of not less than _______ days but not more than ________ days.
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REMARKS Pertinent and relevant findings and results of the diagnostic tests done Therapeutic/ surgical procedures performed
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KNOWINGLY ISSUING A FALSE MEDICAL CERTIFICATE IS A CRIME!!!
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Falsification of public/private documents
Fraud Perjury Simulation of Birth
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MARAMING SALAMAT PO!!! Atty. Antonio D. Rebosa,MD,BSCrim
Castro Rebosa Rebosa Law Office
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