Since the first steps of the Istanbul Protocol implementation projects in Georgia, gaps and weak points were noticed and analyzed in forensic medical documentation practice in civil and parallel healthcare systems. As similar projects were implemented in many post-Soviet countries, the comparison of general patterns, regulations, and practices in all of them show huge similarities, and most of the topics could be considered characteristic of all post-Soviet countries.2
 

Challenges in legal regulations

These challenges were mainly related to the criminal codes and health legislation. Among the most significant changes must be the rules about the forms of forensic evaluations and documentation; adding the alternative or so-called "independent" forensic examination option in the Criminal Procedural Code made a huge step forward in introducing forensic medical documentation practice in parallel healthcare systems, like police and prison healthcare systems. 

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The new definition of the Expert in the same document made it possible to use the expert opinion of different medical professionals and not only licensed forensic physicians in the court; this dramatically increased the pool of experts and made a practice of professional competition among them, which in its turn stimulated quality of forensic medical evaluations and reporting.3 The regulations for confidentiality and consent were updated in health laws, and a new Law on Patients' Rights appeared in 2000, considering all aspects of international standards of the field and medical ethics.4

 

Challenges in medical practice and documentation

These challenges were commonly related to weaknesses in legal norms but rarely associated with existing practices. Many of them remain as current challenges that the police healthcare system is facing. Among many others, must be mentioned the comprehensiveness of physical examination during medical evaluations represents one of the main principles of the Istanbul Protocol and allows the effectiveness of the entire process of documentation and investigation;1 if the physical examination is limited, almost only by just dermatological evaluations and does not include examination of all body systems and parts, it cannot be informative enough. This will lead to the missing medical evidence. The medical evaluations must be prompt, especially in detention places, and not delayed for many days and weeks when many of the physical findings are changed or almost entirely vanished; the timing of medical evaluations in many ways depends on the effectiveness of the investigation process, but sometimes it can suffer from weaknesses of the police medical system itself too. Having clear conclusions is an essential part of the forensic report, but it should not be so dry that is not show the expert opinion of the professional; clear interpretation and forming of forensic medical opinion must be a crucial part of the report, which can be extremely helpful for investigation and finally for the judge to understand common picture of the case.3

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Introducing a new form for medical documentation for police detention isolators in Georgia

As part of the IP implementation activities in Georgia, a unique documentation form for police detention isolators was introduced. The drafts of the short documentation forms according to the Istanbul Protocol were provided by Physicians for Human Rights and used as templates to create the Georgian Form for the police healthcare system. The Form reflects all IP principles of the effectiveness of medical documentation. It follows the structure of Annex IV of IP, including general information about the case, relevant medical history, allegations of abuse, physical symptoms and/or disabilities related to the alleged abuse, psychological symptoms related to the alleged abuse, examination of physical evidence, assessment and conclusion on degrees of consistency. There are several topics of particular interest, as follows:

• The Form starts with a short reminder about the methodology and international standards;

• The referral pathways for the patient and information are particularly emphasized;

• Informed consent is specially addressed as there may be challenges to obtaining informed consent in police detention isolators, especially the permission for photographing injuries or examination and documentation of the injuries related to genitalia;

• The content of informed consent is structured in detail, including information about referrals and essential procedural safeguards for the patient;

• Special permission must be obtained to photograph the injuries;

• The reason for requesting medical evaluation is underlined as, besides routine medical checking at the admission of the detainee, other possible reasons may exist, like medical complaints, accidents, alleged abuse, etc.;

• The prompt medical examinations will reveal the moments of new injury development and help investigators relate them to human rights violations.

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A unique table was developed to describe and mark injuries on the body diagrams (Tab.1). The detailed criteria for injury description are placed in the table, together with the alleged method of infliction. The requirements for description include location, Form, size, direction, color, surface, surrounding tissues, and others. Each physical finding related to the alleged method of injury must be assessed with degrees of consistency according to the Istanbul Protocol standards. The overall conclusion must be made using the same principles of the degrees of consistency.

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TABLE 1. The table for description of injuries and marking on the body diagram