Injury Certificate: A Step-by-Step Guide to Writing in Bangladesh

An injury certificate is a crucial medico-legal document issued by a registered medical practitioner. It serves as evidence of injuries sustained by a person, often in cases of accidents, assaults, or workplace injuries. In Bangladesh, this document plays a vital role in legal proceedings, insurance claims, and police investigations. This guide will provide a step-by-step approach to writing an injury certificate with examples and explanations.

1. Essential Components of an Injury Certificate

A well-structured injury certificate must include the following key details:

1.1. Header

• Name of the hospital/clinic: Mention the institution issuing the certificate.
• Address: Complete location details.
• Date and Time of Examination: When the doctor assessed the patient.
• Reference Number: If applicable, mention the hospital or police reference number.

Example:
XYZ Medical College & Hospital
Dhaka, Bangladesh
Date: 01 March 2025
Reference No: 12345

1.2. Patient Information

• Full Name: As per official documents.
• Age and Gender: Crucial for identification.
• Father’s/Husband’s Name: For further verification.
• Address: Permanent and present address.
• Occupation: Optional but helpful.

Example:
Name: Md. Rahim Islam
Age: 35 years, Male
Father’s Name: Abdul Karim
Address: 15/A, Bashundhara, Dhaka

1.3. History of Incident

• Source of Information: Whether from the patient, police, or eyewitness.
• Date, Time, and Place of Incident: When and where it occurred.
• Cause of Injury: Assault, accident, fall, etc.

Example:
“The patient states that he was assaulted by an unknown individual with a sharp weapon on 28 February 2025 at around 10:00 PM near his residence.”

2. Examination Findings

A detailed physical examination is necessary to document injuries accurately. This section should include:

2.1. General Condition

• Consciousness Level: Alert, drowsy, or unconscious.
• Vital Signs: Blood pressure, pulse, temperature.
• Mental Status: Oriented, confused, or intoxicated.

Example:
“The patient is conscious, oriented to time, place, and person. Blood pressure: 120/80 mmHg, Pulse: 80 bpm.”

2.2. Description of Injuries

Each injury should be described in detail:

• Type of Wound: Abrasion, laceration, contusion, incised wound, or gunshot.
• Size and Shape: Length, width, and depth.
• Location: Body part affected.
• Margins and Edges: Regular or irregular.
• Surrounding Tissue Condition: Swelling, bruising, bleeding.

Example:

1. Lacerated wound: 3 cm x 1 cm x muscle deep on the right forearm, irregular margins, fresh bleeding noted.
2. Abrasion: 2 cm x 2 cm on the left forehead, reddish-brown in color.
3. Contusion: 5 cm x 4 cm swelling over the left thigh, bluish discoloration present.

2.3. Nature of Injury

• Simple or Grievous: As per legal classification under the Penal Code of Bangladesh.
• Possible Weapon Used: Blunt, sharp, firearm.
• Healing Time Estimate: Approximate duration required for recovery.

Example:
“The injuries are simple in nature, caused by a blunt object, and will likely heal within two weeks.”

3. Opinion and Conclusion

This section summarizes findings and the medical expert’s opinion.

3.1. Whether the Injury is Recent or Old

Mention if the injury is fresh (within 24 hours) or older.

Example:
“The injury appears fresh, sustained within the last 6–12 hours.”

3.2. Probable Cause of Injury

• Accidental, Homicidal, or Self-inflicted: Based on findings.
• Consistency with History Provided: If the injury matches the reported cause.

Example:
“The injury is consistent with a sharp weapon assault as per the history given.”

3.3. Need for Further Investigation

• X-ray, CT Scan, or Surgery Recommendation: If needed.
• Advising Police for Forensic Analysis: In medico-legal cases.

Example:
“An X-ray of the left thigh is advised to rule out underlying bone injury.”

4. Certification and Authentication

The certificate should end with:

• Doctor’s Full Name and Designation.
• Registration Number.
• Signature and Official Seal.

Example:
Dr. Hasan Ahmed
Medical Officer, XYZ Hospital
BMDC Reg. No: 45678
(Signature and Seal)

Frequently Asked Questions (FAQs)

1. Who can issue an injury certificate in Bangladesh?

A registered medical practitioner working in a government or private hospital.

2. Is an injury certificate legally binding?

Yes, it can be used as evidence in court and police investigations.

3. What is the difference between simple and grievous injury?

• Simple injury: Minor wounds that heal quickly.
• Grievous injury: Severe injuries, including fractures, deep cuts, and life-threatening wounds.

4. Can a patient get multiple injury certificates?

No, only one certificate should be issued. Duplicates may be provided with authorization.

5. How long is an injury certificate valid?

There is no expiration date, but it remains legally relevant for court cases.

Conclusion

Writing an injury certificate requires precision, objectivity, and adherence to medico-legal guidelines. A properly written certificate ensures justice and fair legal proceedings. Doctors must be cautious while drafting the document to maintain authenticity and prevent misuse.

For further information on medico-legal documentation, refer to the Bangladesh Medical & Dental Council (BMDC) guidelines.