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/or psychological assessments. It is made up of information that talks about your medical condition, your medical history, what the possible treatment plan is, and how long it might take to recover back to the normal life before the incident occurred. The details of the report are provided to your solicitor or to you, if you are an unrepresented claimant. 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 in 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, the medical legal document should be reported in a way that it is clearly 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 such as name, current post, registration number, licence, and area of expertise. 
  • Sould have a detailed summary of the evidence
  • Include source of the information for authenticity
  • It must also have explanation of technical terms

Medical experts should evolve their viewpoint that goes further, 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, and 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 medical expert 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

  1. Read Part 35 of the Civil Procedure Rules and the accompanying Practise Direction 
  2. Read the Civil Justice Council’s 2014 advice 
  3. Read the current Academy of Medical Royal Colleges report, which was written 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.
  4. Make sure the claim is authentic.
  5. Ensure you are the right medical expert for the claim.
  6. Make sure you have the knowledge, training, and experience needed to be the expert witness for the claim. 
  7. Make certain you have all the relevant medical records before commencing the report writing.
  8. Ensure there is no conflict of interest.
  9. Ask the claimant all the relevant questions so you won’t have to waste time revisiting the report.
  10. Make certain to act in accordance with all the deadlines.
  11. If a prognosis can’t be reached, request to see the claimant again for a follow up.
  12. Use tailored questionnaires to record all pertinent information.
  13. Make sure your expert medical opinion is correct because it will be scrutinised.

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 the evidence that his or her opinion documented in the medical legal report is empirical and admissible in the court. 

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 to find 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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