The forensic odontology report
Quality assurance
From
IOFOS with advice from:
Drs. Vermylen (Belgium), Prieels (Belgium), Gunst (Belgium), Grundmann (Germany), Mitsea (Greece), Sejrsen, Denmark, Dawidson (Sweden), Kvaal (Norway) and Johannessen (Norway)
If you follow the
procedures:
1.
Black indicates required steps
2.
Blue indicates recommended steps (may be omitted or changed without further
explanation)
General
1. The forensic odontology report is a legal document and must fulfil requirements as such
a. general requirements
b. national requirements to comply with national laws
2. The report should be systematic and always end in a conclusion
3. It should be written in terms understandable to the lay person
4.
A worksheet should be kept to compliment the report, documenting different
stages of the investigation
The request
1.
A request for odontology casework should be in writing, containing:
a.
information relevant to the case
b.
questions to be answered
2.
Oral requests may be accepted, but should preferably be followed by a written
request
The report
1. Should be on official paper (institution, your name, address, telephone, e-mail etc)
2. Should be dated, and should contain the date of the request
3. Should be an answer to the person or institution who made the request
4. Should include the reference numbers and/or relevant background information
5.
Background information should be sufficient so that the report is able to stand
alone and be understood without reading other documents
6. Should detail the material examined
a. when and
how the material was obtained
b. what the
material consisted of
c. how it
was store
d. was the
material marked in any way
e. was the
material returned or retained by the odontologist
7. When examining a living individual
a. confirm
the identity of the person
b.
obtain informed consent to the examination or alternatively view (and retain a
copy of) a court order
Methods used
1. Describe the methods used
2. If utilising a published method, cite reference(s)
Results
1. State the findings of the examination
2. State negative findings if relevant
3. Make sure your address the questions given
4. Give results from supplementary investigations
5. Give results from calculations etc
6.
State findings outside the request if judged important for the case
Discussion
1.
Discuss the nature and quality of the material
2.
Discuss the methods used
3. Discuss the interpretation of the findings and results
a.
the implication in relation
to the problem
b.the
uncertainties and limitations (probabilities, possibilities)
c.
questions which could not be
answered
Conclusions
1. Must be clear
2. Must not lead to misunderstanding
3. The conclusion is your honest opinion in the case - start with "according to my/our opinion----"
4. Answer the questions given in the request
5.
State the certainty of your opinion and limitations
6.
State conclusions outside the request only if of great importance
Material
and documentation
1. Record where relevant material is stored
2. Keep a copy of your report
Signature
1. Date of the report
2. Full name
3. Handwritten signature
4.
Qualifications/position
5.
State that you have done the work and interpretations to the best of you ability
6.
Countersigned by a second colleague who has read the report and agreed to the
conclusion
7.
Present qualifications of the second colleague
8.
State that you adhere to the IOFOS recommendations for quality assurance
9. State where copies of the report are sent
Edit 12/02/2008