Part 2: Medico-legal documentation - Practical completion of pages 1 and 4 of the J88 form

Abstract

This is Part 2 of a three-part series on medico-legal documentation. Part 1 addressed the knowledge and skills necessary to complete a legal J88 document. The aim of Part 2 is to give practical guidance on completion of the J88 form in the case of assault. Part 3 will address the sexual assault section of the J88 form. As a legal document, the J88 form must be completed accurately with regard to demographic information, including the time and date of examination, to assist with interpretation of the findings. The full names of the person examined appear on the SAPS 308 form, and must be confirmed by the patient and an identification document, if available. The name of the healthcare provider must be identifiable and contact details must be stated to assist with tracing, if necessary. A complete history is important because a differential diagnosis needs be considered, and the clinical findings must be consistent with the description of the incident in terms of time, mechanism of the injury and the place at which the incident took place, as these all add to the probability that the incident occurred as disclosed. The health worker has a dual responsibility with regard to both the health and medico-legal aspects pertaining to the patient and must record these in the clinical notes. Only medico-legal aspects are recorded on the J88 form. A top-to-toe, back-to-front examination must be performed methodically, since the person may be unaware of certain injuries. The healthcare worker must write a conclusion in the space provided. Support of the history with the clinical picture is the basis for the conclusion.