Forensic pathology regards the diagnosis of when a lesion occurred and how it occurred. All physicians will have to deal with violence and trauma at some point. It is important you can describe a lesion well and accurately as your report may be used as evidence in a court case. You should be able as a doctor to diagnose a lesion, age it, describe it and know what to do to preserve evidence.
Forensic pathology starts with a physical exam. You need to assess the whole body (you also need to listen to the patient, don’t forget!). If you don’t document a lesion or ‘crime’ and the victim doesn’t talk, then any evidence of the ‘crime’ will disappear. No sign of a crime will remain if there is no documentation. You need to have a keen eye to spot scars or bruises on darker skin.
Description of lesions needs to be metric and repeatable, there is no reason to not take a photo of a difficult to describe lesion. (although now there are issues with tampering of photos with programmes such as photoshop). If you take a picture, place a ruler in the periphery of the lesion at the same level of the lesion and consider putting a coin in the photo to help spot distortion or modification of the image later (make sure you take the picture perpendicular to the skin surface and the macro function on the camera will help). Remember you may need to share this information later with someone who didn't attend the visit, so they need to understand the lesion exactly as if they were there just from your description.
"...which criminal matters and medical negligence are key examples. In both cases the medical practitioner’s records will be scrutinized by a number of lay persons and medical and legal professionals, and failure to have kept appropriate records can lead to criticism of a practitioner’s competence, or fitness to practice. It is therefore in the interest of every medical professional to take great care in the contemporaneous documenting and recording of notes." Encyclopedia of Forensic Medicine 2005
How do you describe a lesion?
Need to record:
