Standardizing the forensic medical reports for enhancing the credibility of forensic science / 中国法医学杂志

The decreasing reliability of forensic medical reports led to the inadequate credibility of forensic science.Therefore,we can improve the credibility of forensic science by improving the reliability of forensic medical reports.The reliability assessment of the forensic medical examination is presented by the final reports.Standardized production of forensic medical reports can not only reflect the reliability of the related forensic service,but also improve such forensic activities by reversing supervision.The standardized preparation of forensic medical reports is the final positive step when improving the reliability of justice.Therefore,it is necessary to improve the standardization of forensic medical reports from the micro perspective,in order to help enhance the credibility of forensic science,which will finally lead to the enhancement of the credibility of the judicial activities.

Análise de uma amostra de processos de Curatela de idosos com síndromes demenciais da Comarca de Belo Horizonte e proposta de um modelo de relatórios médico / Analysis of a sample of Guardianship processes for elderly people with dementia syndromes in the District of Belo Horizonte and proposal of a medical reporting model

Introdução: as síndromes demenciais são condições crônicas de saúde que levam a importante declínio cognitivo e prejuízo funcional, especialmente para as atividades de vida diárias e atos da vida civil. O relatório médico visa nortear e auxiliar a decisão judicial e pode identificar a extensão, a gravidade e a eventual reversibilidade da incapacidade do indivíduo a ser interditado. A incapacidade é obtida por meio do processo de interdição. Objetivos: descrever e analisar as informações contidas nos relatórios médicos juntados aos processos de pessoas curateladas com síndromes demenciais; realizar entrevistas com seis magistrados das respectivas varas de família da comarca de Belo Horizonte analisadas; e após as análises dos dados, propor um modelo de relatório a ser confeccionado por médicos assistentes. Métodos: estudo transversal com dois braços, sendo um descritivo, transversal e retrospectivo de pesquisa documental de processos judiciais eletrônicos de curatela, de indivíduos acima de 18 anos portadores de diagnóstico de demência, nas 2a, 3a, 4a, 5a, 9a e 11a varas de família do Tribunal de Justiça de Minas Gerais (TJMG). O outro braço do estudo é descritivo por meio de entrevista semiestruturada com os juízes de varas de família da comarca de Belo Horizonte, com abordagens quantitativas e qualitativas. Resultados: a amostra foi formada na sua maior parte por mulheres idosas, de alta escolaridade e viúvas. A curatela foi solicitada por filhos em 76,4% dos processos analisados. Houve predomínio do sexo feminino com a nomeação do curador, na sua maioria de filhas. Geriatria e Medicina de Família e comunidade se destacaram como especialidades que mais emitiram o relatório médico inicial (54,1%). A amostra apresentou predomínio da descrição do diagnóstico etiológico por demência de Alzheimer (61,1%) com prevalência do sexo feminino em portadores dessa etiologia (45,8%). Foi realizada a concordância do laudo médico pericial e o relatório médico. A avaliação de referência foi o laudo médico pericial. Na descrição da doença, 61,1% com diagnóstico de demência de Alzheimer; e no laudo pericial, 52,8%. Houve sensibilidade de 89,47% e especificidade de 70,59% do relatório médico perante o laudo pericial. O coeficiente de Kappa foi 0,6063, indicando concordância moderada. A análise descritiva de códigos da Classificação Internacional de Doenças (CID) no relatório médico esteve presente em 66,7% e 94,4% dos laudos periciais. O tempo de tramitação do processo (em meses) apresentou mediana de 20 meses. As varas de família B e D relataram resultado estatisticamente significativo, as medianas foram, respectivamente, 13,5 e 29 meses, referente ao período de tramitação desses processos (p=0,022). Conclusões: o relatório médico no contexto do processo judicial de curatela mostrou significativa importância para o portador de uma síndrome demencial, contribuindo para o esclarecimento de quais direitos e exercícios de atos da vida civil ainda poderão ser por ele praticados. O presente trabalho apurou a necessidade de treinamento da equipe multiprofissional da rede de atenção primária à saúde, para acolher devidamente o paciente e orientar as famílias/cuidadores de forma a resguardar e preservar os direitos do curatelado.

Introduction: Dementia syndromes are chronic health conditions that lead to significant cognitive decline and functional impairment, especially in daily life activities and acts of civil life. The medical report aims to guide and assist the judicial decision and can identify the extent, severity and possible reversibility of the incapacity of the individual to be interdicted. Disability is obtained through the interdiction process. Objectives: To describe and analyze the information contained in the medical reports attached to the processes of people under care with dementia syndromes. Conduct interviews with 6 magistrates from the respective family courts of the analyzed Belo Horizonte district. After analyzing the data, propose a report model to be prepared by assistant physicians. Methods: A cross-sectional study with two arms, one of which is descriptive, cross-sectional and retrospective of documentary research on electronic judicial processes of guardianship, of individuals over 18 years of age with a diagnosis of dementia, in the 2nd, 3rd, 4th, 5th, 9th and 11th courts of family of the Court of Justice of Minas Gerais (TJMG). The other arm of the study is descriptive through semi-structured interviews with judges from family courts in the district of Belo Horizonte with quantitative and qualitative approaches. Results: The sample consisted mostly of elderly women with high education and widows. The guardianship was requested by sons in 76.4% of the processes analyzed, there was a predominance of females with the appointment of the guardian, mostly daughters. Geriatrics and Family and Community Medicine stood out as the specialties that issued the most initial medical reports (54.1%). The sample showed a predominance of the description of the etiological diagnosis of Alzheimer's dementia (61.1%) with a predominance of females in patients with this etiology (45.8%). The expert medical report and the medical report were agreed. The reference assessment was the expert medical report. In the description of the pathology, 61.1% diagnosed with Alzheimer's Dementia and in the expert report 52.8%. There was a sensitivity of 89.47% and specificity of 70.59% of the medical report compared to the expert report. The Kappa coefficient was 0.6063, indicating moderate agreement. The descriptive analysis of ICD codes in the medical report was present in 66.7% and 94.4% of the expert reports. The processing time of the process (in months) presented a median of 20 months. Family courts B and D showed a statistically significant result, the medians were respectively 13.5 and 29 months, referring to the processing period of these processes (p=0.022). Conclusions: The medical report in the context of the judicial guardianship process is of significant importance for the person with dementia syndrome, contributing to the clarification of which rights and exercises of acts of civil life can still be practiced by him. The present work pointed out the need for training of the multidisciplinary team of the primary health care network, to properly welcome the patient and guide the families/caregivers in order to safeguard and preserve the rights of the guardianship.

Laudo médico e a sua utilização em ações judiciais de fornecimento de medicamentos / The use of medical reports in lawsuits for the supply of medicines

O artigo discutiu os requisitos ínsitos do laudo médico e receituário decorrentes do julgamento do Recurso Especial n. 1.657.156/RJ, no qual o Superior Tribunal de Justiça fixou as bases de observância obrigatória por todos os juízes brasileiros para determinação de fornecimento de fármacos não constantes das listas oficiais do Sistema Único de Saúde. Foi feita pesquisa bibliográfica e documental, com abordagem qualitativa e exploratória, a partir do acórdão disponibilizado pelo portal do Superior Tribunal de Justiça; seguiu-se, então, para consultas às demais fontes bibliográficas, dentre as quais Google Scholar, Biblioteca Virtual em Saúde, Scientific Electronic Library Online e Biblioteca Digital Brasileira de Teses e Dissertações do Instituto Brasileiro de Informação em Ciência e Tecnologia. Por fim, passou-se à análise dos achados e, com embasamento teórico e empírico, buscou-se compreender e justificar as exigências relativas a laudo médico utilizado em ações judiciais, em uma tentativa de contribuir para a gestão da política sanitária e dos próprios processos judiciais, bem como para a popularização do precedente. Concluiu-se que o precedente do Superior Tribunal de Justiça levara à exigência de laudos médicos com mais informações, demandando nova atuação dos médicos, e à expectativa de priorização dos protocolos clínicos, das diretrizes terapêuticas e dos medicamentos constantes das listas oficiais do Sistema Único de Saúde.

The article discussed the requirements of medical reports and prescriptions resulting from the judgement of Special Appeal nº 1.657.156/RJ, in which the High Court of Justice established the compulsory adoption measures that all Brazilian judges must follow to decide on the supply of drugs that are not listed in the official Brazilian Unified Health System. This is a bibliographic and documentary research, with a qualitative and exploratory approach, based on the electronic document availability of the judgement trough the High Court of Justice portal. This research followed a critical approach, and entailed searches in various bibliographic sources, including: Google Scholar, Virtual Health Library, Scientific Electronic Library Online and the Brazilian Digital Library of Dissertations and Theses of the Brazilian Institute of Information in Science and Technology. Finally, we proceeded to the analysis of the findings, and, with a theoretical and empirical basis, we sought to understand and justify the requirements related to the medical report used in the lawsuits. This had the purpose of contributing to both the management of the health policy and the legal processes themselves, and the popularization of the requirements. It is concluded that these requirements will conduct to having medical reports with more information, doctors aware of important actions, and prioritization of clinical protocols, therapeutic guidelines and medications included in the official lists of Brazilian Unified Health System.

HEDEA: A Python Tool for Extracting and Analysing Semi-structured Information from Medical Records / 대한의료정보학회지

OBJECTIVES: One of the most important functions for a medical practitioner while treating a patient is to study the patient's complete medical history by going through all records, from test results to doctor's notes. With the increasing use of technology in medicine, these records are mostly digital, alleviating the problem of looking through a stack of papers, which are easily misplaced, but some of these are in an unstructured form. Large parts of clinical reports are in written text form and are tedious to use directly without appropriate pre-processing. In medical research, such health records may be a good, convenient source of medical data; however, lack of structure means that the data is unfit for statistical evaluation. In this paper, we introduce a system to extract, store, retrieve, and analyse information from health records, with a focus on the Indian healthcare scene. METHODS: A Python-based tool, Healthcare Data Extraction and Analysis (HEDEA), has been designed to extract structured information from various medical records using a regular expression-based approach. RESULTS: The HEDEA system is working, covering a large set of formats, to extract and analyse health information. CONCLUSIONS: This tool can be used to generate analysis report and charts using the central database. This information is only provided after prior approval has been received from the patient for medical research purposes.

La reunión de alta al egreso hospitalario como doble vínculo entre la docencia y la atención primaria de salud / The discharge meeting to the hospital discharge as a double link between teaching and primary health care

La educación en el trabajo es la forma fundamental de la organización del proceso docente educativo en los años de estudios superiores de las carreras de la Educación Médica Superior. El pase de visita docente asistencial es la modalidad por excelencia de educación en el trabajo, que por lo general culmina con la reunión de alta convocada para los pacientes cuyo egreso hospitalario se ha decidido con vistas a su seguimiento a través del nivel primario de atención sanitaria. Esta actividad es importante en la evaluación de la calidad de la asistencia brindada a los enfermos y su grado de satisfacción,por lo que se considera un doble vínculo entre la asistencia y la docencia y entre los niveles primario y secundario de atención, sobre la base bidireccional de la relación médico paciente y los principios éticos que la sustentan y en la cual el médico cumple su papel de educador, de ahí la necesidad de profundizar en los diferentes aspectos cognoscitivos sobre el tema a fin de incrementar la ejecución adecuada de esta imprescindible actividad docente asistencial(AU)

Education at work is the fundamental form of the organization of educational process in the years of higher education of the career of Higher Education. The teaching assistance pass is the most important form of education at work, which usually culminates with the high-level meeting convened for patients in which the hospital discharge has been decided with a view to follow-up through the primary level of education health care. This activity is important in assessing the quality of care provided to patients and their level of satisfaction, so a double link between care and teaching and between the primary and secondary levels of care is considered, based on Bidirectional relationship of the patient medical relationship and the ethical principles that underpin it and in which the physician fulfills his role as educator, hence the need to deepen the different cognitive aspects on the subject in order to increase the adequate execution of this essential activity Teaching assistant(AU)

Legal medicine: assessing mental capacity and writing medical reports for deputy applications

Medical reports are required to support court applications to appoint a deputy to make decisions on behalf of a person who has lost mental capacity. The doctor writing such a medical report needs to be able to systematically assess the mental capacity of the person in question, in order to gather the necessary evidence for the court to make a decision. If the medical report is not adequate, the application will be rejected and the appointment of the deputy delayed. This article sets out best practices for performing the assessment and writing the medical report, common errors, and issues of concern.

El informe médico, un dilema asistencial / Medical report, medical assistance dilemma

El informe médico a pacientes y familiares es una práctica a la que nos enfrentamos los profesionales de la salud cada día, y en la cual, con frecuencia, se cometen errores éticos, que son percibidos por la familia o el paciente. Esto se debe, en gran medida, a factores subjetivos, dependientes del personal de salud y a determinadas virtudes de los seres humanos que deben ser respetados y explotados a la hora de informar a un paciente o familiar, como son: confianza, compasión, integridad, justicia y humanidad, entre otras. Se trata el tema de forma integral en cuanto a aspectos primordiales de comunicación en momentos difíciles de la vida de las personas, cuando se informa a pacientes y familiares, ya sea para obtener un consentimiento informado, en nuestro desempeño diario en consultas, o a la cabecera de pacientes y familiares.

The medical report for patients and families is a practice that we follow every day as health professionals, in which ethical errors are frequently made and perceived by the family or by the patient. This is due to a great extent to subjective factors depending on the health personnel and to certain virtues of the human beings that should be respected and exploited at the moment of providing information to a patient or to a relative such as confidence, compassion, integrity, justice and humanity. This topic was addressed in an integrated way in terms of primary aspects of communication at difficult times in personal life, when patients and families are given information for informed consent, in our daily work at the medical services or at the patient's bedside.

Antônio Gonçalves Gomide: uma semiologia das doenças nervosas no Brasil / Antônio Gonçalves Gomide: a semiotics of nervous illnesses in Brazil

Analisa o parecer médico de Antônio Gonçalves Gomide, publicado em 1814. Trata-se de análise crítica realizada pelo médico, a fim de compreender as manifestações de uma beata, Germana Maria da Purificação, que viveu em Minas Gerais, entre os séculos XVIII e XIX. No texto o médico se contrapõe a um exame realizado por dois cirurgiões que declararam o estado da beata como sobrenatural. A intenção é analisar o parecer situando a concepção da patologia da beata para destacar a importância do documento na compreensão da constituição dos saberes médicos no Brasil. Procura-se ressaltar o fato de o texto ter sido um dos primeiros publicados sobre a medicina mental, podendo ser considerado um dos escritos fundadores dessa medicina que se inaugurava no Brasil no século XIX.

Prontuário médico e suas implicações médico-legais na rotina do colo-proctologista / Medical record and his medical-legal involvement in daily procedures of colon and rectal surgeon

As normas do Conselho Federal de Medicina preceituam que o médico não poderá deixar de preencher corretamente o prontuário médico. Essa observância é fundamental, pois sendo o atendimento prestado ao paciente uma ação multidisciplinar, todos os envolvidos ficarão informados sobre as condições clínicas, evolução, resultados de exames e procedimentos realizados nos pacientes. Sob o ponto de vista legal é um precioso instrumento, talvez o mais importante, em demandas judiciais, pois é a partir de sua análise que os peritos e julgadores colhem subsídios para a decisão judicial. Sob o ponto de vista de saúde pública, são nos prontuários médicos que residem os dados, permitindo os dados de prevalências e de incidências de determinadas doenças, permitindo assim, ações de prevenção e medidas de tratamento mais eficazes. Este trabalho tem como objetivo enfatizar a importância do cumprimento das normas e do correto preenchimento do prontuário médico, ressaltando suas implicações médico-legais, principalmente na prática da cirurgia colo-retal. Tais práticas não só representam a qualidade do trabalho profissional, mas permitem aos médicos dispor de um importante instrumento de defesa nas ações judiciais.

The norms of Federal Council of Medicine set down that the doctor cannot stop filling out the medical handbook correctly. That observance is fundamental, because being the service rendered the patient an action to multi-discipline, all involved they will be them informed about the clinical conditions, evolution, results of exams and procedures accomplished in the patients. Under the legal point of view it is a precious instrument, maybe the most important, in judicial demands, because it is starting from his/her analysis that the experts and judges pick subsidies for the judicial decision. Under the point of view of public health they are in the medical handbooks that the data live, al1owing the data of prevalences and of incidences certain diseases, allowing like this, prevention actions and more effective treatment measures. This work has as objective emphasizes the importance of the execution of the norms and of the correct completion of the medical handbook, emphasizing their forensic implications, main in the colon rectal surgery practice. Such practices not only they represent the quality of the professional work, but they allow to the doctors disposal of an important defense instrument in the lawsuits.