Medical-Legal Report: The Basics

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Medical-Legal Report: The Basics

What is a Medical-Legal Report, and when would you need it?

A medico-legal (sometimes written as medical-legal) report is a document composed by a medical professional, such as an orthopaedic or a psychologist, which contains the results of physical, medical and psychological assessments. It comprises information about your medical condition, history, the possible treatment plan, and how long it might take to recover to everyday life before the incident occurred. If you are an unrepresented claimant, the report details are provided to your solicitor or to you. It is a report that can be used in legal matters, whether in civil or criminal cases or personal injury claims such as:

  • Civil Cases/Family Law
    • Family assessments
    • Child protection matters
    • Separation or Divorce
  • Criminal Cases
    • Assault
    • Possession
    • Driving charges (drunk driving, speeding etc.)
  • Personal Injury Claims
    • Work-related injury
    • Motor vehicle accidents
    • Post Traumatic Stress Disorder

What is a Medical-Legal Report, and who can write this report?

The basis for the report is the medical expert’s informed medical opinion on the case, which was generated based on existing evidence and their years of experience and knowledge in their respective field. However, it should report the medical-legal document in a way that is written, so anyone reading it does not require additional research or explanation. The report should have the following: 

  • Title page with all the required information of the claimant
  • Date of the report submission
  • Date of examination
  • Client’s full name and date of birth
  • Identity of the involved parties
  • Nature of the report
  • Expert’s details include name, current post, registration number, licence, and area of expertise.
  • Should have a detailed summary of the evidence
  • Include the source of information for authenticity
  • It must also have an explanation of technical terms

Medical Experts Viewpoint

Medical experts should evolve their viewpoint beyond the medical area of expertise. For these experts to write a medical-legal report, they need to develop what Giles Eyre. Who co-authored Writing Medico-Legal Reports in Civil Claims-an essential guide and authored Clinical Practice and the Law-a legal primer, calls  the “medico-legal mind,” which is capable of and can:

  • Understand the duties of an expert witness and the specific requirements of expert evidence within the litigation process;
  • Adopt an appropriate methodology to provide reliable evidence dealing with the medico-legal issues in dispute;
  • Identify the factual matters relevant to a dispute, share that identification in their report, and apply medical expertise to these facts in a logical and medically supportable way;
  • Address all relevant medical issues that arise by providing opinions and conclusions that a lawyer can understand and engage with;
  • Understand and apply, in every case, the civil standard of proof and the appropriate legal tests to the evidence;
  • Understand how to assess and report on the consequences of an injury;
  • Recognise that the fundamental purpose of expert medical evidence is to help the court to assess the validity of a compensation claim and the level of damages to be awarded.

Tips on how to write a Medical-Legal report?

An accurate, unambiguous, and transparent medical-legal report written by a qualified expert medical professional should follow the following tips:

  • Read Part 35 of the Civil Procedure Rules and the accompanying Practise Direction
  • Read the Civil Justice Council’s 2014 advice
  • Read the current Academy of Medical Royal Colleges report in conjunction with the Academy for Healthcare Science. The British Dental Association, the Royal College of Midwives, the Royal College of Nursing and others, with confirmation from the General Dental Council, General Medical Council, and the Nursing and Midwifery Council.
  • Make sure the claim is authentic.
  • Ensure you are the right medical expert for the claim.
  • Ensure you have the knowledge, training, and experience needed to be the expert witness for the claim.
  • Ensure you have all the relevant medical records before commencing the report.
  • Ensure there is no conflict of interest.
  • Ask the claimant all the relevant questions so you won’t have to waste time revisiting the report.
  • Make sure to act following all the deadlines.
  • If can’t reach a prognosis, request to see the claimant again for a follow-up.
  • Use tailored questionnaires to record all pertinent information.
  • Make sure your expert medical opinion is correct because will scrutinise it.

The medical opinion of an expert witness provides considerable power to a claimant’s case. The medical experts’ years of clinical practice, knowledge and skill provide evidence that their opinion documented in the medical-legal report is empirical and admissible in court.

Let us help you

Since these reports are so crucial, whether for a solicitor or an independent unrepresented claimant if you need an expert witness medical-legal report for your case, Idox services will guide you through the process from the receipt of the instruction to the final report and even towards physical and psychological rehabilitation. Our administrative staff is rightly equipped and knowledgeable in assisting you in finding the right medical expert witness for your case with a fast and thorough turnaround. Connect with us today and learn more about the different services we provide at Idox and how we can guide you back to recovery.

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