Report writing in Postmortem Examination & cause of Death – The report should be prepared on printed Performa from rough notes immediately after completing the physical examination/specimen collection and reconstruction of the body for disposal purposes.

The report should be written carefully, it should be legible with no cutting, erasing, or overwriting.

No column should be left blank. Clearly indicate the name or police station, police officials escorting the body & identifiers who had identified the dead body in the presence of the Medical Examiner.

 

The report should bear the book number, MLC number, and stamp of the examining doctor, place of work, date and time of postmortem examination.

 

If the body is unidentified, Record data pertaining to subsequent identification (e.g.  age, sex, stature, dental data, scars, deformities, tattoo, complexion, the color of hair, eyes, presence of beard, mustaches, etc.) Including details of the clothes worn and the other personal effects.

 

Details of external & internal examination should be written.

 

 

In case of physical injury, give detail of the trauma. E.g. sharp. size, depth, characters, etc.

 

Clearly indicate any specimens taken for further investigations, where sent, and to whom handed over. Take a written receipt on the postmortem register.

 

On internal dissection, if organs are intact and healthy on gross examination, the word HEALTHY should be written.

 

In pathological conditions, write morbid findings externally and on the cut surface, the histological examination should be assigned to Bacteriologist to Government of Punjab.

 

Any collection of body fluid (blood, pus, effusions) should be measured and recorded.

 

While formulating the opinion, cause, manner, mode of death should be indicated clearly.

CAUSES OF DEATH:

Report writing in Postmortem Examination & cause of Death
Report writing in postmortem examination

Report writing in Postmortem Examination

The main objective of the medico-legal autopsy is to furnish a cause of death. 

  Antemortem injuries (external or Internal) are usually cause of death which can be verified on gross examination by the examining doctor.

Natural disease or pathology of various Organs, viscera or system may be a cause of death, i e. infective/degenerative diseases (e.g. meningitis I hepatitis, Milliary TB, Chronic Nephritis, Atherosclerotic vascular diseases, etc.), histopathological examination of appropriate organs Viscera/tissues may be required to certify the cause of death from disease.

 

Poisoning (by inhalation, ingestion, or through dermal contact) may cause death. To certify causation of death from poison chemical analysis of appropriate biological material (body fluid or viscera) is required.

 

Mode of death should be indicated e.g. hemorrhage, hypovolemia, shock. asphyxia, broncho or hypostatic pneumonia, brain death, renal, hepatic or heart failure, etc.

 

Manner of death should be commented about the trauma or injuries whether homicidal, accidental, or suicidal. Similarly in case of death due to poisoning, the manner of causation of death is important.

Postmortem Examination | Protocol & Procedure

REPORT WRITING IN EXHUMATION

I have conduction exhumation of male body at graveyard of __________(address of graveyard) as per court orders of ___________(name of judge) dated _________ .

Exhumation was started at 12:15pm in presence of ASI ______________ (Name 0f ASI / SHO) & Mr ____________ (Name of judge / magistrate)

Grave was identified by _________ (Names with ID cards / mobile numbers of two persons)

Grave was present approximately 20 feet away on east side from entrance gate of graveyard. On east side of grave, there was the grave of his mother ________ (name of person) and west side of, there was grave of his cousin _______(name of person) on head end, there was grave of his uncle _______(name of person) and on foot end, there was empty space at that time.

After identification of grave, digging started process started at 12:45pm by order of judge / magistrate, removal of dome of grave done, there were 04 concrete slabs removed, it was Kachii grave ( کچی قبر) from inside with presence of dead body covered in white shroud, there was no wooden casket. Dead body was brought outside of grave, muddy / blood stained shroud removed & post-mortem examination started, ……………

Report writing in Exhumation Postmortem Examination

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