Quality of initial medical certificates in a Tunisian traumatology unit: A five-year retrospective audit

Background The initial medical certificate (CMI) is the primary medico-legal document issued during the first assessment of a trauma victim. Because it may influence compensation claims and judicial proceedings, its preparation should comply with forensic standards. Data on CMI quality in North African healthcare settings remain limited. This study evaluated the quality of CMI redaction at a major Tunisian traumatology center. Methods A retrospective audit was conducted at the Department of General Surgery, Ben Arous Traumatology Center, Tunisia. Eighty-seven CMIs issued between January 2017 and June 2021 were independently assessed by two reviewers using a 12-item checklist based on Haute Autorité de Santé (HAS) recommendations. Compliance rates with 95% Wilson confidence intervals were calculated, and co-occurring deficiencies were analyzed. Results Documentation of the certificate issuance date and temporary total incapacity (ITT) duration achieved 100% compliance. Most deficiencies involved redaction quality. Handwriting was difficult to decipher in 22.9% (95% CI: 14.7–33.2%) of certificates, and non-standard abbreviations were identified in 31.0% (95% CI: 21.7–41.8%). Adequate anatomical injury description was documented in 72.4% (95% CI: 62.0–81.3%) of cases. ITT duration was considered disproportionate to reported injuries in 11.5% of certificates and was frequently associated with incomplete injury descriptions. Among non-compliant CMIs, 73.9% exhibited at least two concurrent deficiencies. Overall compliance reached 73.6% (95% CI: 63.1–82.5%). Conclusions CMI quality was generally satisfactory but showed recurrent documentation deficiencies with potential forensic implications. Standardized templates, targeted training, and regular audits may improve practice and should be evaluated in multicenter studies.