Lesson on writing medical report and why I think doctors should avoid using the word SODOMY

My first reaction was sh*t. Someone had sent me a Private & Confidential medical document: Saiful Bukhari's medical examination notes prior to the police report. I need to destroy it and pretend I never read it.

Then later, as a matter of blog reading routine, I went to Raja Petra's site. He had disseminated the same information I received earlier, to the great blogosphere masses!

Of course. The medical document sent to me as e-mail attachment was in fact a copy & paste job from Raja Petra's blog. My nerves settled; the initial panic of receiving a document pertaining to one of Malaysia's hottest cases slowly turned to a quiet sense of triumph, for the country most outspoken politician.


I tried to decipher the doctor's writing. If it was difficult for a fellow trained doc like myself to read it, I say it is near impossible for the lay-person to make heads and tails of the scribble. Someone had kindly unscrambled the medical report for us mortals (I got it from Susan Loone's Saiful was never sodomised by Anwar entry):

The conclusion was simple: NOTHING WAS FOUND ON THE DOCTOR'S EXAMINATION TO SUPPORT THE ALLEGED ACTIVITY.

But I really didn't see why the doctor must use the word SODOMY in his report when alleged sexual assault (or alternatively, alleged anal penetration without consent) will do the job nicely, and also sounds more clinically appropriate.

Personally, I would not have used the word SODOMY, I will let the lawyers argue about that later. As a doctor, I would be happy sticking to more familiar general terms such as alleged sexual assault, alleged forced anal penetration and the likes. Unless of course, I have been reading novels with plenty of SODOMY words in them and subconsciously flooded my head with that word, or perhaps someone had whispered the word to me over and over (and over) again. I would not have used the word SODOMY in my report because they are so many better alternatives. Professionally, for me, the word sodomy sounds too street and fit for lawyers, not doctors (wikipedia the word sodomy if you don't believe).

Anyway, on to something more purposeful...

I had written a few medical reports for the police in my short medical career. And let me impart some of my experience to budding doctors on handling assault cases and writing medical report for assault claims:-

(1) Every hospital should have a protocol for examination on raped/anally raped victim! Read them and familiarise yourselves with the law before touching the patient (in UK, rape victims go straight to the Police Doctor). Get a senior help if in doubt. If you are a very junior doc, you should never be involved in those cases in the first place. Take the advice of your medico-legal representative (every doctor should have one!) to clarify on the law if your senior on duty cannot be relied upon.

(2) In assault cases, you are expected to carry out a head to toe examination and document every little abnormality down. Never assume birth scars and never try to guess the age of injury. Write as observed. Do not form any assumptions during your initial examination.

(3) Do not put yourself in unnecessary legal predicament through poor choice of words. Use generalised descriptions such as ALLEGED ASSAULT; INJURY FROM CONTACT WITH OBJECT; PATIENT REPORTS DISCOMFORT IN _____ (anatomical location); etc. You get the drift. Try to avoid using specific adjectives in your report unless they are vital and necessary as part of life-saving measures; otherwise wait till the court demand for more specific answers later. You don't have to jump the gun.

(4) Do not hurry your job even if harassed by the Police. Your priority is your patient and his/hers confidentiality. The police cannot demand to see the medical report without consent from the patient; unless they have specific instruction from the court. Be firm with the Police. No one is above the law.

(5) If you can describe an event or injury clearly in few words, do it. No extra marks are given for lengthy prose.

Hope that helps.