Soft Tissue Injuries in Hungarian and Austrian Clinical Diagnostic Reports

Abstract

Introduction: In addition to providing first aid, primary treating doctors are required to describe and register injuries acquired in accidents and assaults. They should do this with the highest possible accuracy, as this official document is often the only documentary evidence of soft tissue injuries in case a lawsuit is filed later. Characteristics of injuries may disappear faster with the healing process of the soft tissue, making it impossible for forensic experts to deduce the weapon involved. Consequently, terminological accuracy is a prerequisite for the appropriate reconstruction of the type and severity of injuries. This study aims at analysing reports on soft tissue injuries in Hungary and Austria from the terminological point of view. It is meant to reveal inaccuracies in the use of noun phrases impairing objective and accurate forensic assessment.Material and method: A corpus-based analysis was conducted on 200 Medical Diagnostic Reports (MDRs) from Hungary and Austria (100 from each country) with the linguistic software WordSmith 5.0. Results were processed in Microsoft Excel and demonstrated in graphs.Results: The analysis showed that terminology describing soft tissue injuries is not consistent. Comparatively few characteristics of injuries were recorded in both sub-corpuses. Due to inconsistent use of terms and missing characteristics, 17 % of the Hungarian and 18% of the Austrian MDRs were not completely assessable by forensic experts.Conclusions: Describing injuries for legal purposes needs standardisation.

Accident or child abuse? Terminological requirements for clinical documentation of child injuries

“…In the Nagy-Törő book the term 'roncsolt' (crushed) was used with the latin term 'vulnus lacerocontusion' (meaning lacerated-contused wounds 'zúzott seb'), however, the definition did mention that the wound was a mixture of a ruptured and contused wound so it was only the Hungarian term that was inconsistent as it differed from terminology found in previous studies (i.e. ruptured and contused wound is 'zúzott seb' or 'repesztett seb' (Fogarasi, 2012). Laceration in the Sótonyi book is also called 'ruptured injury' i.e.…”

“…The short and long-term effects and the importance of recording the diagnosis and documentation are demonstrated in Figure 1 (Törő, 2006:35). However, the lack of focus on the terminological aspects of medical documentation has created many ambiguous records meaning that almost 15 % of the analyzed Hungarian medical reports could be only partly assessed by forensic experts (Fogarasi, 2012) although medical terminology should accurately reflect the medical diagnosis" (Christian et al, 2009(Christian et al, :1410.…”

“…By this time, key characteristics of soft tissue injuries such as hematomas and wounds may have changedespecially in childrenor, in the case of open wounds, wound characteristics such as margins, edges and walls may no longer be visible due to surgical wound care (Fogarasi, 2012). A prior investigation showed that even in German and Austrian forensic institutions, where there is the facility to carry out an almost immediate forensic examination, the forensic assessment of already closed wounds could not be carried out completely (Fogarasi, 2012). Consequently, in cases of inadequate clinical documentation, important evidence can be lost forever (Schneider, 2017).…”