Verification of initial forensic certificates through requisitions: a descriptive serial case

Abstract

Context and objective. The medical characterization of injuries from a physical assault is provided through the initial descriptive medical certificate and judicially by the determination of work disability, which is a fundamental factor in assessing the severity of the injuries. The objective of the study is to define appropriate drafting criteria for initial medical certificates, while examining discrepancies between established medical certificates and those submitted for expertise through requisitions. Methods. This was an observational study conducted from 2017 to 2020, based on the analysis of 137 initial medical certificates (IMCs) verified as part of a requisition at the Forensic Institute of the Ibn Rochd University Hospital in Casablanca. After the description of the characteristics of the study population, a bivariate analysis was performed to determine relationships between variables, based on chi-square tests. Results. Victims were predominantly male (82.48%), with the most affected age group being 26 to 40 years old. Road traffic accidents accounted for the majority of cases (91.24%), with an average time to obtain the IMC of 8 days. Approximately 49.64% of victims were hospitalized, and 41.61% underwent surgery. Pre-printed paper was most commonly used for drafting certificates (75.91%). However, deficiencies were observed, including illegible words in 40.87% of IMCs and absence of mention of accompanying minors (86.96%). Results of additional examinations were reported in 78.83% of cases. The verified duration of work disability was consistent with that established in most cases (81.75%), but discrepancies were noted in some cases (16.06% lower, 2.19% higher). Conclusion. The present study identifies criteria for quality drafting of initial medical certificates and assesses the associated duration of work disability. The results highlight the importance of ensuring the quality of IMCs and suggest potential improvements in their drafting and evaluation to ensure proper care for victims in the studied context.

Received: January 16^th, 2024

Accepted: October 24^th, 2024

https://dx.doi.org/10.4314/aamed.v18i1.8