Comparative terminological analysis of injury descriptions created by clinicians and by forensic experts based on...

In Germany, injuries are often assessed by forensic experts who refer to clinical documentation without meeting the injured individual in person. However, forensic assessment of clinical injury documentation is often hindered by insufficient descriptions and inconsistent terminology. Soft tissue injuries heal quickly, yet their exact description can provide important information for assessing the underlying mechanisms and the weapon involved. This study examines the extent to which clinical photographic documentation contributes positively to forensic assessment. We collected 141 clinical injury reports with and without photographs that had been provided to the Institute of Forensic Medicine of the Johannes Gutenberg University of Mainz in Germany for the purpose of forensic assessment during a criminal procedure. Our corpus included 259 injuries documented in writing by clinicians, and 585 injuries described by forensic experts solely based on clinical photographic documentation. Statistical analysis was performed to compare the level of detail and the terminology used to describe soft tissue and other injuries. Factors contributing to limited forensic interpretability of injuries based on photography and clinical injury descriptions were also identified. In 18.6% of cases, the forensic expert opinion explicitly indicated that the clinical photographs provided limited information for the interpretation of the injuries. Establishing standards for both written and photographic clinical injury documentation could enhance the quality of photographs and improve the level of detail and terminological consistency in clinical descriptions.