Medical Docu Clinical Practice Guidelines

8/3/2019 Medical Docu Clinical Practice Guidelines

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Clinical Practice Guidelines

RCH > Medicine >General Medicine >Clinical Practice Guidelines

Writing a good medical reportSelected text from:

The Medico-Legal Report in Emergency Medicine

Simon Young and David Wells

Emergency Medicine 1995:7;233.

Abstract

The preparation of a medico-legal report is an exercise in communication between the

doctors and the legal system. A proper request and informed consent are essential prior to

commencing report preparation. A structured format incorporating elements of background

information, medical history, physical examination, specimens obtained, treatment provided

and opinion is suggested.

Introduction

The medico-legal report is a structured and formal vehicle for communication between the

doctors and the legal system. Requests for medico-legal reports are common and originate

from a variety of sources such as police, lawyers, government tribunals, insurance companies

or the patients themselves. Once prepared they may be used in criminal or civil proceedings

with consequences for the patient, the doctor, third parties and the judicial system In view of

these potential implications they must be prepared with accuracy, diligence and an

understanding of basic legal principles. Although usually prepared for a specific person, the

report may become a public document and be used by a diverse non-medical audience.

Clarity of communication and economy of scale are vital to maximise its effectiveness.

The request

The circumstances surrounding many emergency department attendances especially thoseinvolving violence considerably increase the likelihood of a request for a medico-legal report.

The request should be directed specifically to the most senior doctor who was involved with

the clinical management of the patient. Whilst it is possible to direct the request to any person

involved or to someone who may only compile a report from the medical notes, this is less

satisfactory. If the latter occurs there will always be uncertainty as to why the senior treating

doctor was not asked, implying them may be something to conceal.

The request should specifically state:

1. Who should write the report,

2. The name and preferably the date of birth of the patient concerned;3. The time and date of any incident;
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4. The purpose of the report;

5. Any specific issues that need to be addressed. The request should be accompanied by

a signed statement of consent completed by the patient or legal guardian, allowing

release of medical information.

Consent

Consent for the release of medical information to a third party must be obtained prior to a

medico-legal report being dispatched. It is recommended that consent is obtained prior to a

report being prepared to prevent inadvertent release without consent.

The following criteria must be met for consent to be valid:

1. The subject (or their legal guardian) must be competent to provide it;

2. It must be informed. That is, the subject must have a clear understanding of the

implications of the release of the information;

3. It must be specific;

4. It must be freely given. Release of privileged medical information in a medico-legal

report without valid consent is unethical and may be illegal. In situations where a

medico-legal report is requested but consent is withheld, the requesting agency may

apply for a court order for release of the material.

Format

Them are many formats for a medico-legal report. Style may be directed either by the

personal preference of the author or by the requirements of the legal process or the requesting

agency.

Within these boundaries them are some common features which include:

1. The date on which the report was prepared;

2. The name of the person to whom the report is directed;

3. The full name, date of birth and hospital unit record number of the subject. The

subject's address should not usually be included as the document may become public.

This has the potential to cause problems for the subject.

4. Identification of the author: This should include the practitioner's full name, practising

address, current employment and qualifications. It may also be appropriate to include

details of precious relevant employment, appointments, publications andmemberships.

5. Jurat This is a certification of the veracity and authorship of the report. Different

formats are required in different jurisdictions. It has to be sworn or the statement

witnessed before an authorised officer.

Factual content

The report must primarily be prepared from the original notes. There should be no factual

information that is unsupported by data contained in these notes. Clearly this places an onus

on the doctor to create precise and comprehensive notes during or immediately after the


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initial examination. Ideally, reports should be prepared as soon as possible after the

examination The terminology used should be appropriate to the potential audience. Medical

terms not in common usage should be avoided or alternatively should be adequately

explained. For example nose bleed is preferable to epistaxis and pin point bruising preferable

to petechiae. The use of the words 'victim' or 'offender' or 'rape' presuppose that an offence

has occurred and should not be used. Ideally, assaults and other offences should be referred toas "alleged offences". The content of each report will vary as it is dependent upon the exact

circumstances concerning each case. Whilst a degree of flexibility is necessary to encompass

all the relevant points, a structured framework is strongly recommended. Such a framework

provides a useful aide memoir for the author and will also assist legal practitioners to locate

particular points for subsequent commentary or questioning.

A suggested structure is:

Background

Data such as the time, date and place, and the reason for the examination. Detail the nature

and extent of your involvement in the case. A brief account of the alleged offence and the

sources of that information should also be included. It is often useful to quote verbatim the

subject's account of critical issues. A specific comment should be made concerning the

provision of consent.

Medical History

A brief account of any relevant medical conditions is appropriate.

Examination

Comments on the general presentation of the subject should be included. Emotional,

psychiatric and intellectual state and the effects of alcohol or other drugs should be described.

Specific attention should be given to sites of particular interest in the case; for instance the

genito-anal examination in a rape case. Relevant negative findings should also be recorded. If

there are any difficulties or limitations encountered during the examination (for example

limited co-operation by the subject or a withdrawal of consent to examine certain areas), this

should be noted.

Specimens

It is uncommon for hospital staff to be required to take forensic specimens. Details of all

specimens obtained should appear in the medico-legal report There should be clear notation

as to the site from which the specimens derived, the way they were labelled, details of

handling and the reason for obtaining that specimen (for example bacteriology for

comparison purposes). Comments should also be made regarding the time and date of transfer

of specimens to the care of another person. This ensures that continuity of evidence can be

proven later in court. The report should refer to any photographs taken and the text should

clearly identify each photograph.

Management


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It may be appropriate to comment on investigations, procedures and management of the

patient. Occasionally, if investigation or treatment is ongoing, a further (supplementary)

report may be required.

Opinion

It is advisable to distinguish if possible between fact and opinion. The facts being what was

seen or done and the opinion being what was inferred or assumed. In practice this may be

difficult. Opinion evidence will often come under particular scrutiny by the reader of the

report, and may be publicly tested in court. The authors experience and expertise are

fundamental to the weight given by the court to their opinion. Some opinions sought may be

beyond the expertise of the author. It is perfectly reasonable to decline to provide a statement

in this situation. Under these circumstances, the requesting agency may seek a, opinion from

another more experienced practitioner based upon the earlier report. If other persons'

statements or scientific articles are used the source must be disclosed. When formulating an

opinion it is essential to maintain impartiality and objectivity. Resist fitting opinions to the

allegation and acknowledge and weigh alternative conclusions. Only say what you would beprepared to repeat under oath in court.

Putting it all together

Draft reports should be prepared and the contents compared with the original notes. On

completion of a final report all draft reports should be destroyed. This prevents any confusion

at a court hearing as to what was draft and what was final report. A copy of the final report

should be held either with the patient's records, or by the author. On no account should any of

the original notes be destroyed and, if they are rewritten, the second version should be

acknowledged and kept with the original. Requests to edit reports to remove unfavourable

material should never be accepted. The report should provide a balanced and complete

account of the consultation. All reports should be typed without alterations.

Finally, whenever possible, ask a colleague to review and comment upon the report before it

is sent. It is difficult to alter a report once it has been issued. Constructive criticism at this

time is preferable to cross-examination in the witness box. Review of the notes, reports,

diagrams and photos should occur before the start of court proceedings. If, at this stage, any

mistakes are noted in the report, these should be acknowledged openly in court.

Conclusion

The preparation of a medico-legal report is an essential part of the service provided by

hospital doctors. It is a task that should be approached with a desire to accurately

communicate the clinical situation encountered. A structured format and objective opinion

will enhance both the readability and accuracy of the report.

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