Clinical Records for Police Surgeons
It is absolutely vital that FMEs keep a permanent record of their clinical findings in any work done
in the forensic field.
This chapter is divided into sections. These sections will indicate:-
—The chronometry of the record ''WHEN"
—The method of keeping "HOW"
—The content of the record "WHAT" and
—The storage of the record "WHERE"
When
If your clinical note is going to be used in court then the record should be made at the time of the
examination.
During or immediately after the contact is equally acceptable. Any delay could cast doubt on the
accuracy of the record. The acceptability of a record and its contemporaneity is dealt with in more
detail in chapter 4 dealing with Statements and Court.
If the record is found to be incomplete or incorrect, hours, days or even much later, and your
memory of the omission or mistake is absolutely clear, then any amendment made to the record
should be in a form which clearly distinguishes it from the original and from which it should be
physically separate, such as on another sheet of paper. The timing of the amendment should be
clearly recorded. Any additional information justifying or qualifying the changes should also be
added. If a statement or report has already been submitted, or copies of the notes disclosed before
the amendment is considered, then the additional material should be forwarded to the appropriate
party under a fresh statement heading see Chapter 4 for statement writing.
The record should be kept for at least the natural life of the FME.
Even if the doctor has given up forensic work, it is possible that the content of
the record may be called upon through the courts many years later. The recent history of
miscarriages of justice (eg Kisco, Judith Ward) would indicate the necessity for the preservation of
any record for at least decades. The FME has an ethical duty to the patient and the authorities who
requested the examination, to preserve that record for all time.
The NHS Executive has recently issued guidance 1 on the subject of General Practice Medical
Records and has recommended an increase in preservation time of the records which in broad
summary is now 10 years after the patient's death. Though this directive does not relate directly to
FME's records it indicates the importance placed on the long term availability of clinical records.
How
The written record is still the most common form of hard copy for clinical records in forensic
medicine. In today's practice there are numerous other options available. Audiotape, video tape,
computer discs using the various memory options available, are examples. Whatever method is used
it must be remembered that the original recording is the contemporaneous note, and not a transcript!
For example a hand held micro cassette recorder produces a micro-cassette of electromagnetic tape
as the original record. It is that which comprises the record which must be preserved and to which
one could refer in court. However, any valid document can be referred to before going into court,
but contemporaneity confers the special benefit of being able to be used whilst giving evidence.
Computerised records are acceptable in civil cases2 if that was the best form of the record and it was
recorded at the time. Though a laptop computer would readily lend itself to methods of recording
data, written and diagrammatic, and with the advent of digital photography, pictures as well, the
system would have to be a comprehensive one to replace the standard written record. Paper free
computerised records should probably only be used when the FME has such a comprehensive
system.
At the moment written records are to be recommended.
They should be legible at least to the author but preferably to others as well. If medical "shorthand"
is used, a legend explaining the text should be to hand, when you and the record arrive at court.
It is far better and looks more professional to use either a hard backed book or pre-prepared
individual sheets.
A hard backed book is easier to store than many individual sheets of paper, and could demonstrate
the contemporaneous nature of the notes by a single record's position in the book. However it is not
easy or tidy to store additional material and copies of other documents, such as drug database forms
or consent forms, in a hard backed book. The very nature of a bound book containing numerous
records makes it difficult to preserve the confidentiality of other cases if your record is taken in as
an exhibit, a circumstance which has happened to contemporaneous clinical records in the past.
Though bound books are acceptable, the recommendation is for the use of individual sheets of
paper. The use of aides-memoir in the form of pre-printed sheets can be extremely helpful, though
the use of comprehensive multipage booklets for every case is not advocated, when often only a
small percentage of the document will be used in an individual situation. Examples of these booklets
have been produced by some constabulary forces. This may raise the question as to who owns the
record. The Police Surgeon who examines the patient and makes the record has proprietorial
rights of that record, and responsibility for it.
There is no place for using torn pieces of scrap paper, or the back of constabulary stationary. It is
acceptable to make additional notes on the back of copies of constabulary forms used specifically
for a case, such as HO/RT/5 (see Chapter 12) in a case of blood sampling for a drink/driving
offence, but in preference it is recommended that individually prepared sheets are used. These can
also contain a consent form (see Chapter 2). One example of such a sheet is shown in Appendix 1a
and 1b. This form has administration details on the front and standard medical history format on the
back. These forms are just examples; it is advisable for individual clinicians to design a form with
which they are comfortable and which can contain the appropriate information. A non specific form,
similar to the ones mentioned above, is available from GMP for their Police Surgeons and is shown
at Appendix 1d & 1e, however this form is not to be considered proscriptive. In addition body charts
are a useful tool. Examples are shown in Appendix 1c, Charts 1-6. There are six charts in this set
and all are A3 in size. The copyright belongs to the Association of Police Surgeons (APS) and they
are available, to members, from the Association of Police Surgeons Office in Harrogate. FMEs may
then make working photocopies from these sets.
Other similar charts are in common use, and as long as the chart is clear and simple any such
pictogram could be used.
For supplies of the APS charts from which photocopies can be made write to:-
Mrs Christine Houseman
Association of Police Surgeons
18a Mount Parade
Harrogate
North Yorks
HG1 1BX
Added to the clinical notes and diagrams should be copies (photo or carbonated) of any form issued
if the clinical notes are going to be complete. Thus copies of HO/RT/5, form 717 (Appendix 3c and
see also Chapter 3 Disclosure), and
prescriptions that are issued to prisoners or detained persons should form part of the clinical record
of the patient. Though it is perfectly acceptable just to keep a record of prescriptions issued, there is
nothing as accurate as a copy of the original. Self-carbonated pads with the clinician's name and
professional address would be one example of fulfilling this function. The pads could also then be
used for casualty referral letters or any other communication to a third party. However any
letterhead with carbon paper would serve the same ends.
What
The Police Surgeon's record should contain the following
• Who was seen.
• The time, date, duration and place of examination.
• At whose request the examination was made and/or the officer responsible if appropriate.
• Anyone else present at the time of examination.
• Why the examination was performed.
• The consent form for the examination.
• A history of the relevant medical condition or incident such that a professional judgement and
interpretation of the clinical findings can be made.
• The clinical examination findings.
• A record/list of any samples that may have been taken.
• A record of any procedures (eg referral to Casualty/X-ray) that may have been instituted including
a copy of the referral letter.
• A copy of any instructions issued to the patient or custody officer.
• A copy of any document given in connection with the examination (eg HO/RT/5) or any
prescription issued.
• Copies of any subsequent correspondence or reports connected with the case.
• If the police surgeon has been involved with another individual or scene connected with the
current case, the risk of contamination (Locard's principle) should be declared and the measures
taken to avoid that risk should be listed. (If such contamination could be a threat to the integrity of
evidence gathering, different police surgeons should be used wherever possible).
Where
The storage must be secure, as for any medical record containing confidential information.
It must remain in the care of the Police Surgeon who made the record.
It must be easily retrievable, for later reference for statement construction or use in court.
Code C of the Police and Criminal Evidence Act Codes of Practice under paragraph 9C of the notes
for guidance (page 49 of the latest codes [10 April 1995]) states that the custody record must
indicate where the medical practitioner has recorded his findings if they are not on the custody
record.
Reference should also be made to Chapter 4 on statement and report writing.
It is absolutely vital that FMEs keep a permanent record of their clinical findings in any work done
in the forensic field.
This chapter is divided into sections. These sections will indicate:-
—The chronometry of the record ''WHEN"
—The method of keeping "HOW"
—The content of the record "WHAT" and
—The storage of the record "WHERE"
When
If your clinical note is going to be used in court then the record should be made at the time of the
examination.
During or immediately after the contact is equally acceptable. Any delay could cast doubt on the
accuracy of the record. The acceptability of a record and its contemporaneity is dealt with in more
detail in chapter 4 dealing with Statements and Court.
If the record is found to be incomplete or incorrect, hours, days or even much later, and your
memory of the omission or mistake is absolutely clear, then any amendment made to the record
should be in a form which clearly distinguishes it from the original and from which it should be
physically separate, such as on another sheet of paper. The timing of the amendment should be
clearly recorded. Any additional information justifying or qualifying the changes should also be
added. If a statement or report has already been submitted, or copies of the notes disclosed before
the amendment is considered, then the additional material should be forwarded to the appropriate
party under a fresh statement heading see Chapter 4 for statement writing.
The record should be kept for at least the natural life of the FME.
Even if the doctor has given up forensic work, it is possible that the content of
the record may be called upon through the courts many years later. The recent history of
miscarriages of justice (eg Kisco, Judith Ward) would indicate the necessity for the preservation of
any record for at least decades. The FME has an ethical duty to the patient and the authorities who
requested the examination, to preserve that record for all time.
The NHS Executive has recently issued guidance 1 on the subject of General Practice Medical
Records and has recommended an increase in preservation time of the records which in broad
summary is now 10 years after the patient's death. Though this directive does not relate directly to
FME's records it indicates the importance placed on the long term availability of clinical records.
How
The written record is still the most common form of hard copy for clinical records in forensic
medicine. In today's practice there are numerous other options available. Audiotape, video tape,
computer discs using the various memory options available, are examples. Whatever method is used
it must be remembered that the original recording is the contemporaneous note, and not a transcript!
For example a hand held micro cassette recorder produces a micro-cassette of electromagnetic tape
as the original record. It is that which comprises the record which must be preserved and to which
one could refer in court. However, any valid document can be referred to before going into court,
but contemporaneity confers the special benefit of being able to be used whilst giving evidence.
Computerised records are acceptable in civil cases2 if that was the best form of the record and it was
recorded at the time. Though a laptop computer would readily lend itself to methods of recording
data, written and diagrammatic, and with the advent of digital photography, pictures as well, the
system would have to be a comprehensive one to replace the standard written record. Paper free
computerised records should probably only be used when the FME has such a comprehensive
system.
At the moment written records are to be recommended.
They should be legible at least to the author but preferably to others as well. If medical "shorthand"
is used, a legend explaining the text should be to hand, when you and the record arrive at court.
It is far better and looks more professional to use either a hard backed book or pre-prepared
individual sheets.
A hard backed book is easier to store than many individual sheets of paper, and could demonstrate
the contemporaneous nature of the notes by a single record's position in the book. However it is not
easy or tidy to store additional material and copies of other documents, such as drug database forms
or consent forms, in a hard backed book. The very nature of a bound book containing numerous
records makes it difficult to preserve the confidentiality of other cases if your record is taken in as
an exhibit, a circumstance which has happened to contemporaneous clinical records in the past.
Though bound books are acceptable, the recommendation is for the use of individual sheets of
paper. The use of aides-memoir in the form of pre-printed sheets can be extremely helpful, though
the use of comprehensive multipage booklets for every case is not advocated, when often only a
small percentage of the document will be used in an individual situation. Examples of these booklets
have been produced by some constabulary forces. This may raise the question as to who owns the
record. The Police Surgeon who examines the patient and makes the record has proprietorial
rights of that record, and responsibility for it.
There is no place for using torn pieces of scrap paper, or the back of constabulary stationary. It is
acceptable to make additional notes on the back of copies of constabulary forms used specifically
for a case, such as HO/RT/5 (see Chapter 12) in a case of blood sampling for a drink/driving
offence, but in preference it is recommended that individually prepared sheets are used. These can
also contain a consent form (see Chapter 2). One example of such a sheet is shown in Appendix 1a
and 1b. This form has administration details on the front and standard medical history format on the
back. These forms are just examples; it is advisable for individual clinicians to design a form with
which they are comfortable and which can contain the appropriate information. A non specific form,
similar to the ones mentioned above, is available from GMP for their Police Surgeons and is shown
at Appendix 1d & 1e, however this form is not to be considered proscriptive. In addition body charts
are a useful tool. Examples are shown in Appendix 1c, Charts 1-6. There are six charts in this set
and all are A3 in size. The copyright belongs to the Association of Police Surgeons (APS) and they
are available, to members, from the Association of Police Surgeons Office in Harrogate. FMEs may
then make working photocopies from these sets.
Other similar charts are in common use, and as long as the chart is clear and simple any such
pictogram could be used.
For supplies of the APS charts from which photocopies can be made write to:-
Mrs Christine Houseman
Association of Police Surgeons
18a Mount Parade
Harrogate
North Yorks
HG1 1BX
Added to the clinical notes and diagrams should be copies (photo or carbonated) of any form issued
if the clinical notes are going to be complete. Thus copies of HO/RT/5, form 717 (Appendix 3c and
see also Chapter 3 Disclosure), and
prescriptions that are issued to prisoners or detained persons should form part of the clinical record
of the patient. Though it is perfectly acceptable just to keep a record of prescriptions issued, there is
nothing as accurate as a copy of the original. Self-carbonated pads with the clinician's name and
professional address would be one example of fulfilling this function. The pads could also then be
used for casualty referral letters or any other communication to a third party. However any
letterhead with carbon paper would serve the same ends.
What
The Police Surgeon's record should contain the following
• Who was seen.
• The time, date, duration and place of examination.
• At whose request the examination was made and/or the officer responsible if appropriate.
• Anyone else present at the time of examination.
• Why the examination was performed.
• The consent form for the examination.
• A history of the relevant medical condition or incident such that a professional judgement and
interpretation of the clinical findings can be made.
• The clinical examination findings.
• A record/list of any samples that may have been taken.
• A record of any procedures (eg referral to Casualty/X-ray) that may have been instituted including
a copy of the referral letter.
• A copy of any instructions issued to the patient or custody officer.
• A copy of any document given in connection with the examination (eg HO/RT/5) or any
prescription issued.
• Copies of any subsequent correspondence or reports connected with the case.
• If the police surgeon has been involved with another individual or scene connected with the
current case, the risk of contamination (Locard's principle) should be declared and the measures
taken to avoid that risk should be listed. (If such contamination could be a threat to the integrity of
evidence gathering, different police surgeons should be used wherever possible).
Where
The storage must be secure, as for any medical record containing confidential information.
It must remain in the care of the Police Surgeon who made the record.
It must be easily retrievable, for later reference for statement construction or use in court.
Code C of the Police and Criminal Evidence Act Codes of Practice under paragraph 9C of the notes
for guidance (page 49 of the latest codes [10 April 1995]) states that the custody record must
indicate where the medical practitioner has recorded his findings if they are not on the custody
record.
Reference should also be made to Chapter 4 on statement and report writing.
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