What documents are issued to a serviceman after injury

The Ministry of Defense of Ukraine explained which documents are issued to a serviceman after injury.

Why documents after injury are not a formality

An injured serviceman is not obliged to personally control what and how documents are processed for him in the medical institution. However, the correctness of document processing directly affects:

• the passage of the Military Medical Commission (VLC) and establishing the causal link of the injury (wound, concussion, mutilation) or disease;
• the appointment of additional rewards during prolonged treatment in inpatient conditions or leave for treatment;
• the assessment of daily functioning to determine the disability group;
• obtaining the status of a person with a disability due to war;
• the appointment of a one-time monetary assistance (OMA) in case of disability establishment.

Errors in documents are not grounds for denial of rights – but they force the return of document packages for revision, which delays the process by months.

For questions regarding document processing, referral and passage of the VLC, as well as the implementation of social guarantees, a serviceman can contact specialists of the support service of his military unit, healthcare institution, or the territorial recruitment and social support center (TRSSC). The tasks of support services include assisting the wounded in passing the VLC and processing documents for obtaining status and payments.

Primary medical card: the first medical document

The primary medical card (PMC) is the primary accounting document used during pre-hospital medical care. It is filled out in case of injury (wound), illness, or damage and confirms the fact of medical care at the pre-hospital stage.

The card is one of the sources of information for issuing a certificate about the circumstances of the injury (wound, concussion, mutilation).

Discharge summary from inpatient medical record: what to check

The discharge summary from the outpatient (inpatient) medical record is issued by the healthcare institution after treatment. It certifies diagnoses, the patient's condition at discharge, and the duration of treatment.

Two points are important to check in the discharge summary:

• completeness of diagnoses – all established injuries must be recorded. Bone fractures, for example, are not always detected during pre-hospital care – they are recorded after detailed examination;
• the date of injury in the medical history – for example, the wording "consequences of traumatic brain injury received on 01.05.2024" can be compared with the PMC data and the certificate about the circumstances of the injury.

Inaccurate data may negatively affect the establishment of the causal link during the VLC or the cause of disability during the assessment of daily functioning. Discharge summaries must be kept and provided during each subsequent medical examination.

Certificate about the circumstances of the injury: key document

The certificate about the circumstances of the injury (wound, concussion, mutilation) is Appendix 5 to the Regulation on Military Medical Expertise in the Armed Forces of Ukraine, approved by the Ministry of Defense of Ukraine order dated August 14, 2008, No. 402 (with amendments).

This document is mandatory for:

• establishing the causal link of the injury during the VLC;
• appointment of payments, including OMA upon disability establishment;
• confirming the right to additional rewards and assistance from territorial communities;
• appealing VLC decisions regarding the established causal link.

What to pay attention to during processing

The certificate is checked for:

• correctness of personal data;
• dates of injury (wound, concussion, or mutilation);
• completeness of injury description and circumstances of their occurrence – all types and locations of injuries must be reflected;
• the wording of circumstances must correspond to reality and be consistent with other documents (combat log, PMC, service investigation data, etc.).

The Ministry of Defense emphasizes the necessity of using formulations in the certificate about circumstances in accordance with the descriptions of causal links of injuries (wounds, concussions, mutilations) in paragraph 21.5 of chapter 21, section II of the Regulation on Military Medical Expertise in the Armed Forces of Ukraine.

Important. The certificate must contain a direct indication that the injury is not related to committing a criminal or administrative offense, is not a consequence of actions under the influence of alcohol, drugs, or toxic substances, and is not a deliberate self-inflicted bodily injury. Without this wording, the document package for OMA is returned for revision.

Who and how establishes the causal link

The causal link between the injury and military service is established exclusively by the VLC – according to the first paragraph of point 1.2 of chapter 1, section I of the Regulation on VLC in the Armed Forces of Ukraine. Neither the commander, nor the head of the medical service of the military unit, nor the personnel service can do this. The commander only processes the certificate about the circumstances of the injury – the document on the basis of which the VLC makes a decision.

The procedure for processing the certificate depends on the circumstances of the event:

• Injury from enemy actions – no official investigation is conducted.

Available data are collected (primary medical card, combat log, orders on participation in combat, etc.), a report is prepared for the command to issue a commander's order, based on which the certificate about the circumstances of the injury is processed in the electronic document management system (EDMS) and sent to the VLC office or healthcare institution. The serviceman is issued a paper copy of the electronic document.

• Event without enemy influence – a mandatory official investigation is conducted according to the Ministry of Defense Instruction No. 332 dated 27.10.2021, investigation and accident reports are drawn up. Then the same procedure follows: report, order, certificate about the circumstances of the injury in EDMS, copy issued.

Certificate of direct participation in combat actions

The certificate of direct participation of a person in activities necessary to ensure the defense of Ukraine is issued according to the form of Appendix 6 to the Procedure approved by the Cabinet of Ministers of Ukraine Resolution dated August 20, 2014, No. 413 (with amendments).

This document is necessary for:

• obtaining the status of a combatant participant (UCP);
• establishing the connection of disease with the defense of the Fatherland during the VLC.

The certificate is issued by the military unit. If the commander does not submit the necessary documents to the commission, the serviceman has the right to initiate this process independently according to the requirements of Procedure No. 413.

How to store documents and what to do if errors are found

All medical and administrative documents received during treatment should be stored in originals and copies should be made in advance. The list of documents needed later includes:

• military registration document;
• primary medical card;
• discharge summaries from medical records for each inpatient treatment period;
• certificate about the circumstances of the injury (Appendix 5 to Ministry of Defense Order No. 402);
• certificate of direct participation in combat actions (Appendix 6 to Cabinet of Ministers Resolution No. 413);
• extract from accounting documentation (Form 12).

If an error is found in the documents (incorrect date, incomplete diagnosis, incorrect wording of circumstances), it is corrected through the medical institution, military unit, or TRSSC before submitting the document package to the VLC, the Expert Commission on Assessment of Daily Functioning (ECADF), or for payment appointment. Corrections after submission are possible but require more time.

If at the time of establishing the causal link of the injury (wound, concussion, mutilation) or disease the necessary documents were absent but appeared later, an application can be submitted to the regular VLC with a request to re-establish the link, attaching the relevant documents.

Appealing the VLC decision

If a serviceman disagrees with the VLC decision – including the established causal link – he has the right to appeal it to a higher-level VLC or in court.

The appeal period is 30 days from the date of the decision.

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