Page 14 of 20

FM14.{1,9} | Medico-legal Examination & Reporting of Injuries — SDL Guide (Part 2)

Writing the Medico-legal Certificate: Structure and Language

The medico-legal certificate for an injured person has a standard structure that is required by law and custom in Indian medical practice. Deviating from this structure — for example, by omitting the opinion section or failing to number injuries — reduces the document's utility and legal reliability.

The required sections of the MLC are:

Header: hospital/institution name; MLC reference number; date, time, and place of examination; name and designation of the examining doctor.

Patient identification: full name, age, sex, address, occupation. Method of identification (brought by police/self/relative — describe the identifier).

Alleged history: recorded from the police version and separately from the patient's version where they differ. Use quotation marks or clearly attributed phrasing. This section records what is alleged, not what the doctor has verified.

General examination: vital signs (BP, pulse, temperature, respiratory rate), level of consciousness (GCS), nutritional/build status, any intoxication (alcohol smell, behaviour), relevant comorbidities if disclosed.

Injuries (numbered list): each injury is described separately with the SSSMD format:
- Site: exact anatomical location with distance from landmarks
- Size: length × width in centimetres (depth for stab wounds)
- Shape: geometric description (linear, oval, stellate, triangular)
- Surroundings: bruising, abrasion collar, soiling, clothing tear at injury site
- Margins and base: character of wound edges, presence/absence of tissue bridges, wound depth, base characteristics, and vital reaction (ante-mortem status)

Opinion: the medico-legal opinion section connects the findings to statutory and circumstantial categories. It should state: (a) nature of each injury (wound type); (b) BNS category (simple hurt, grievous hurt — specifying the sub-category); (c) weapon class consistent with the injuries; (d) whether the injuries are consistent with the alleged mechanism; (e) any finding of ante-mortem/post-mortem significance; (f) prognosis if relevant to BNS Category 8 certification.

Signature, designation, and date/time: the examining physician must sign the MLC personally. Countersignature or senior endorsement may be required by some institutions but does not transfer responsibility to the countersigner — the examining doctor retains primary liability for the content.

Provided image

Applied MLC Practice: Integrating Findings into a Complete Report

In simulated or supervised clinical environments, the medico-legal examination skill requires integrating all prior knowledge into a coherent clinical document. Consider the following worked case, which integrates findings from the opening scenario:

Case: Female, 19 years, brought by police at 02:15 hours. Police version: alleged assault by partner at home with hands and a wooden stick.

General examination: conscious, oriented, GCS 15/15, BP 110/70, pulse 88/min, no alcohol smell, visibly distressed.

Injuries found on systematic head-to-toe examination:

1. Laceration, right eyebrow: site — right eyebrow, lateral third, 0.5 cm from lateral canthus. Size — 2 cm × 0.3 cm × 0.2 cm depth. Shape — linear. Surroundings — bruising extending 1.5 cm around wound. Margins — irregular, tissue bridges present at wound base. Ante-mortem: active bleeding, vital reaction present.

1. Abrasion, left cheek: site — left cheek, 3 cm below the left orbit. Size — 2 cm × 1 cm. Shape — irregular. Surroundings — mild surrounding redness. Margins — surface skin disruption, no gap, no deep haemorrhage. Ante-mortem: vital reaction present.

1. Contusion, right forearm: site — right forearm, posterior aspect, 8 cm above the right wrist. Size — 3 cm × 2 cm. Shape — oval. Surroundings — nil. Skin intact, subcutaneous haemorrhage, purplish discolouration. Ante-mortem.

1. Contusion, left forearm: site — left forearm, posterior aspect, 6 cm above the left wrist. Size — 4 cm × 2 cm. Shape — oval. Ante-mortem.

Opinion: 1. Laceration right eyebrow — blunt force injury, simple hurt (BNS S115); consistent with blunt cylindrical weapon. 2. Abrasion left cheek — blunt force/friction injury, simple hurt (BNS S115). 3 & 4. Bilateral posterior forearm contusions — blunt force injuries; the bilateral posterior forearm location is consistent with defence wounds sustained while raising both forearms to ward off blows with a blunt weapon. This pattern is consistent with the alleged homicidal assault.

This integrated opinion demonstrates the application of wound type classification, BNS categorisation, and circumstantial injury pattern interpretation in a single MLC document. The defence wound finding is a significant additional observation that corroborates the victim's account and informs the police investigation.