•
All information provided by the prisoner necessary for medical examination (including his own description of heath state and all claims about ill-treatment);
•
Full description of objective medical conclusions based on medical examination;
•
Views of the doctor about the above issues, including reflections about correspondence of the claims of the person with objective medical conclusions.
Medical records should include information about all additional tests, conclusions made
and medical aid provided. There should be special forms for documenting bodily injuries
allowing anatomical illustration of injuries. It would be desirable to obtain photos of
injuries.19
Istanbul Protocol, the Manual on the Effective Investigation and Documentation of Torture and Inhuman or Degrading Treatment and Punishment emphasizes the need for
taking photographs of bodily injuries, in order to secure prevention of torture.20
The doctor that examines a detainee should be able to establish probability of infliction
of injuries through violence, even if the patient does not report about it. He/she should
be able to document physical and psychological evidence of violence and establish the
degree of correspondence of the applicant’s report about ill-treatment and the results
of examination
.21 The doctor
can use the following formulations: “does not correspond” “corresponds” “corresponds
with high probability” “is characteristic (typical)”.22 The doctor should use a standard
medical report for documentation.23
At the time of admission of prisoners to penitentiary establishments, a doctor meets
them immediately to examine their health state. At the time of meeting, the doctor
documents bodily injuries, if any. After injuries are detected, medical documentation is
filled in and included in the medical history of the prisoner. Besides, there is ‘a trauma
register for accused persons and convicts’ where bodily injuries of prisoners are registered by medical personnel. It is necessary to include the name and last name of the
prisoner, time of detecting the injury, location and character of the injury, origin of the
injury, the signature of the doctor and the signature of the patient. They describe the
injury and specify its origin: “self-injury” “injury inflicted by another person”, „everyday
life injury“. The doctor does not evaluate correspondence of the character of the injury
with the information provided by the patient about its origin.
The documentation of bodily injuries of prisoners at penitentiary establishments con19
20
21
22
23
26
Ibid., para. 74.
Istanbul Protocol, para 105.
Ibid, para 122.
Ibid, para. 187.
Ibid, para. 125.
NATIONAL PREVENTIVE MECHANISM (NPM), 2015
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