Report Writing Skills Tips for TestifyingAnne Smith

Medical Director, VFPMS, November 2015

Proformas are available for use. The VFPMS proformas are available on the VFPMS website. Use them. Diagrams – There are diagrams for three sizes of children; infants, children and adolescents. Print off relevant pages to document the injuries using body diagrams.

Detail your description of injuries according to :-• site (reference body landmarks, standard anatomical position of the body, cm from a

joint)• size (use one measurement – either cm or mm and remain constant)• shape• surrounds• surface • edge (margins) • colour• contour• contents• pattern• swelling• blanch / stretch/ movement• tenderness / pain on movement• discharge / fluid / debris

Description: skin • Information re lighting and position• Fitzpatrick scale skin type - pigmentation• Reference to the body in the standard anatomical position • Reference to body landmarks

• Have a system!• Head (face and scalp) + ears + neck• Torso – front + back + genitals• R arm + L arm• R leg + L leg

• Use consistent measurement scale (cm vs mm)• Use same style

• Location + classification +size + colour + shape….

Number the injuries for ease of reference later…

1. Head and neck• 1a) on the left side of X’s forehead, just below the hairline of his L

temple, was a yellow-green discolouration with features of a bruise measuring 3cm (vertical) x 2.2cm (horiz)

• 1b) on the left cheek approx 1 cm lateral to the left alar cartilage of his nose was a horizontally oriented, firmly adher dry black-brown scab measuring 0.2cm x 1.6cm. The surrounding skin was slightly reddened extending 0.1-0.2 cm from the scab in all directions.

• 1c) on the tip of the outer helix of the R ear was a red-purple non-blanching discolouration with features of a bruise. Within this 0.4cm x 2.1cm bruise were 4 small red pinpoint sized bruises (petechiae). This area was subjectively tender.

• …..• eg• Left leg - below the knee over the anterior and lateral shin were

approximately 10 to 15 small scattered bruises of varying sizes and colours ranging from pale grey-blue to brown.

None of the bruises were green or yellow.

REPORT WRITING – reminder FORENSIC OPINION SECTION

The key question to address is, “Has this child been assaulted/abused?”.

The opinion section should enable the reader to clearly understand your thoughts about this, even if your answer is “maybe”, “the cause is undetermined” or “I don’t know”.

Comments about probability are appropriate.

Comments about someone’s guilt or lack of guilt are entirely inappropriate.

NOTE

The opinion section should answer the following questions:-

• What is the story?

• Is the child injured?

• What are the injuries?

• What else (physical damage) might be injured? Harmed?

• How did it happen? (Mechanism)

• What forces were/might have been involved?

• When did it happen? (Timing of all injuries?)

• What consequences might result?

• How do the findings and the story “match up”?

• What are ALL the possible differential diagnoses, and how are they weighted?

• Overall probability of assault versus accident versus

other cause for findings.(if you can)

When writing medico-legal report

Ask yourself

What is the purpose?

How should it be structured?

What information must be in it

What information might be in it?

How should it be worded?

What are the important “do”sand “don’t”s?

Types of medico-legal reports

Child Abuse

• (perhaps not?) Letter to colleague

• Child Protection - for information

• Child Protection – Court Report

• Criminal justice system (for criminal court)

• Victims of Crime Compensation

• Expert Opinion

It is all about

PREPARATION

FIRST prepare

a good medical

report

THEN provide

testimony in

court

http://www.worth1000.com/cache/contest/

contestcache.asp?contest_id=2455&start

=51&end=60&display=photoshop#entries

Ensure that the Medical Report

(a) is clearly expressed and not argumentative in tone;

(b) is centrally concerned to express an opinion, upon a clearly defined question or questions, based on the expert’s specialised knowledge;

(c) identifies with precision the factual premises upon which the opinion is based;

(d) explains the process of reasoning by which the expert reached the opinion expressed in the report;

(e) is confined to the area or areas of the experts specialised knowledge; and

(f) identifies any pre-existing relationship between the author of the report, or his or her company etc, and a party to the litigation (eg a treating medical practitioner).

guidelines from the Federal Court of Australia

Separate the following:

Facts• Those things that are

known to be true

Circumstantial evidence• Those things that might

influence opinion about the likelihood that a proposition is true

Speculation• Imagine a scenario

(Probably best avoided)

Opinion• Evaluation of likelihood

that a proposition is true

References • evidence base

Writing a medical report

For whom?

How will it be used?

Who owns it?

What qualifiers and protection is required?

Differing format for

1. Criminal justice

(police report)

2 . Expert opinion

3. Child Protection

4. Victims of Crime Comp

5. Family Court

6. Coroners Court

7. Medical Board hearing

Smithtown Family Clinic1 Parkside WaySmithtown 3006Ph 9684 4480Fax 9684 4481

3rd February 2004

Detective Senior Constable PloddSmithtown Criminal Investigation Unit122 Smith’s RoadSmithtown 3006

Re: Mr John Smith DOB: 13th January 1970I, Mary Nicole Brown of the Smithtown Family Clinic, 1 Parkside Way

SmithtownHereby state that:I am a medical practitioner registered in the state of Victoria.I hold the qualifications of Bachelor of Medicine and Bachelor of Surgery

conferred in 1988, and Fellowship of the Royal Australian College of General Practitioners conferred in 1996. I have worked in the capacity of a general practitioner in both rural and metropolitan practice since 1992.

Reprinted from Australian Family Physician Vol. 33, No.

11, November 2004

Helen Louise Parker. Writing a Police Statement

Smithtown Family Clinic1 Parkside WaySmithtown 3006Ph 9684 4480Fax 9684 4481

3rd February 2004

Detective Senior Constable PloddSmithtown Criminal Investigation Unit122 Smith’s RoadSmithtown 3006

Re: Mr John Smith DOB: 13th January 1970I, Mary Nicole Brown of the Smithtown Family Clinic, 1 Parkside Way

SmithtownHereby state that:I am a medical practitioner registered in the state of Victoria.I hold the qualifications of Bachelor of Medicine and Bachelor of Surgery

conferred in 1988, and Fellowship of the Royal Australian College of General Practitioners conferred in 1996. I have worked in the capacity of a general practitioner in both rural and metropolitan practice since 1992.

Reprinted from Australian Family Physician Vol. 33, No.

11, November 2004

Helen Louise Parker. Writing a Police Statement

Smithtown Family Clinic1 Parkside WaySmithtown 3006Ph 9684 4480Fax 9684 4481

3rd February 2004

Detective Senior Constable PloddSmithtown Criminal Investigation Unit122 Smith’s RoadSmithtown 3006

Re: Mr John Smith DOB: 13th January 1970I, Mary Nicole Brown of the Smithtown Family Clinic, 1 Parkside Way

SmithtownHereby state that:I am a medical practitioner registered in the state of Victoria.I hold the qualifications of Bachelor of Medicine and Bachelor of Surgery

conferred in 1988, and Fellowship of the Royal Australian College of General Practitioners conferred in 1996. I have worked in the capacity of a general practitioner in both rural and metropolitan practice since 1992.

Reprinted from Australian Family Physician Vol. 33, No.

11, November 2004

Helen Louise Parker. Writing a Police Statement

Smithtown Family Clinic1 Parkside WaySmithtown 3006Ph 9684 4480Fax 9684 4481

3rd February 2004

Detective Senior Constable PloddSmithtown Criminal Investigation Unit122 Smith’s RoadSmithtown 3006

Re: Mr John Smith DOB: 13th January 1970I, Mary Nicole Brown of the Smithtown Family Clinic, 1 Parkside Way

SmithtownHereby state that:I am a medical practitioner registered in the state of Victoria.I hold the qualifications of Bachelor of Medicine and Bachelor of Surgery

conferred in 1988, and Fellowship of the Royal Australian College of General Practitioners conferred in 1996. I have worked in the capacity of a general practitioner in both rural and metropolitan practice since 1992.

Reprinted from Australian Family Physician Vol. 33, No.

11, November 2004

Helen Louise Parker. Writing a Police Statement

Background

I have received a request from Detective Plodd to detail the injuries received by Mr Smith as a result of an alleged assault on him on Saturday 12th January 2004. In particular he has asked whether Mr Smith’s head wound could have ‘resulted from being struck with a baseball bat or could have occurred when he fell to the pavement’. I examined Mr Smith at this clinic on Tuesday 15th January 2004, 3 days after he was allegedly assaulted, and again on Monday 21st January 2004 to remove his sutures. I have been provided with a signed consent form from Mr Smith for the release of this report to police.

This report has been prepared from:

• my clinical notes made at the time of the examination

• a letter from the Smithtown Hospital Emergency Department.

Background

I have received a request from Detective Plodd to detail the injuries received by Mr Smith as a result of an alleged assault on him on Saturday 12th January 2004. In particular he has asked whether Mr Smith’s head wound could have ‘resulted from being struck with a baseball bat or could have occurred when he fell to the pavement’. I examined Mr Smith at this clinic on Tuesday 15th January 2004, 3 days after he was allegedly assaulted, and again on Monday 21st January 2004 to remove his sutures. I have been provided with a signed consent form from Mr Smith for the release of this report to police.

This report has been prepared from:

• my clinical notes made at the time of the examination

• a letter from the Smithtown Hospital Emergency Department.

HistoryMr Smith told me that he had been assaulted on the previous

Saturday night (ie. 3 days before the consultation). He said he was unable to recall much of what had occurred as he had consumed a considerable amount of alcohol. He stated the following to me:

• he was in a queue outside a nightclub and was shoved from behind

• he turned around and verbally abused the male standing behind him and that male punched him in the face

• he recalled being on the ground and thinks he was struck on the head with a baseball bat

• he was taken to hospital by ambulance.The letter from the hospital indicated a wound on his scalp was

sutured.Mr Smith attended here requesting review and documentation of

his injuries, and a medical certificate for work.There is no past medical history of relevance to this allegation.

Symptoms of recent injuryMr Smith complained of headaches and indicated his injuries to

me.

OpinionIn summary, Mr Smith is a 34 year old man whom I examined

3 days following an incident in which he was allegedly punched to the face and possibly struck with a baseball bat. He had evidence of a black eye and a sutured wound on the back of his scalp. With respect to the findings I am of the opinion that:

1. The bruise around the eye is the result of blunt trauma:• blunt trauma may result from a blow or forceful contact

with an object• it is impossible to accurately age a bruise, however that

observed could have occurred within the time frame of the alleged incident

• it is not possible to state more precisely the cause of this bruising around the eye. It may have resulted from a punch, however other mechanisms are possible

• this injury should fully resolve leaving no permanent sequelae, however, a blow to the eye has the potential to result in permanent serious visual impairment.

Opinion

2. The sutured wound had the appearance of a laceration, due to the application of blunt trauma to the region causing the skin to split:

• it had the appearance of a relatively recent wound and could have occurred within the time frame of the incident

• it is not possible to state more precisely the exact cause of this wound, and in particular I am unable to differentiate between a fall onto the pavement versus a blow with a baseball bat as the cause. The doctor who initially treated Mr Smith and sutured his wound may be able to assist you further with this inquiry

• this wound should heal, leaving a scar that will be barely visible under the hair.

Dr Mary Nicole Brown

MBBS, FRACGP

I hereby acknowledge that this statement is true and correct and I make it in the belief that a person making a false statement in the circumstances is liable to the penalties of perjury.

Mary N Brown

Acknowledgement taken and signature witnessed by me at 3 pm,

On 6th February 2004 at Smithtown

Signature P Plodd _____________________________________

Name Peter Plodd______________________________________

Rank/No D/S/C 31268 ________________________________

Medical Report - Children

Who said what• Verbatim**

• New paragraph per person

• Allegations

Headings optional

Number paragraphs optional

Content• Allegation 1st

• Concerning features• Delay in presentation

• History changes over time

• Differing histories by individuals

• Paediatric medical history

Allegations• What?

• Who?

• Where?

• When?

History• Specific

• related to allegation

• chronology

• Nonspecific • past medical and

developmental concerns

• child care practices

• genogram

Medical Report - Children

Examination - general

• Demeanour, affect

• Cooperation

• Clothing

• Measurements and percentiles

• Skin

• Orifices• Mouth, ears, eyes

• Systems

• Pattern recognition

Examination -specific• Injuries

• Obvious

• Search

• Documentation• Site

• Size

• Shape

• Surrounds

• Colour

• Contour

• Contents

• Edge

• (pain, discharge, movement)

Medical Report - Children

Investigations

• What?

• When?

• Who interpreted findings?

• Implication(s) of findings?

• +/- sensitivity and specificity of the test (rarely)

Consultations: Quote

• Who ?

• What opinion ?

Medical Report - Children

Opinion – clear heading

Summarise allegations

Summarise examination findings

How the 2 relate to each other

What you believe is the most likely cause for the child’s condition WHY?

Other conditions to consider • Why they are or are not likely to be the cause of the child’s condition• References

Medical Report - Children

Limitations of your opinion

Qualifiers

Jurat

Evidence on which your opinion is based• References

Limit / permit the use or distribution of the report?

(court documents = public records)

CHECK IT for• Typing errors• Grammatical errors, sloppy

language, imprecise language, misleading language

• Errors of fact• Errors of judgement• Opinion = accurate and

completeSign itSend it (cc to all the relevant

professionals)Record in child’s record when

report sent to whom

Revision:Opinion in medico-legal reportShould address matters related to • Cause of injury

• Accident or assault ……& neglect• Mechanism (nature of insult & forces) • Certainty / probability / likelihood

• Timing of injury• Circumstances surrounding injury• Evidence base for your conclusions• Confidence in diagnosis /probability /likelihood• Treatment required• Outcomes (note if potentially life-threatening)

Cause of injury – words to use

Possible phrases to use• Indicative of.. Indicates that… Has been caused by …• Suggestive of… suggests that…

• Is likely to have been caused by… • Probably has…

• Raises concern about …• Could have been caused by .. It is possible that..• Not able to determine the cause based on the appearance alone• Is unlikely to have been caused by…• Is highly unlikely to have been caused by …• Almost certainly has not been caused by…• Cannot have been caused by…

Time of injury – words to use

• Minutes to hours

• Hours to days

• Days to weeks

• Weeks to months

• Months to years

Unpopular phrases (not wrong)

• Consistent with…

• Is in keeping with …

• As she alleged….

• Within the alleged time frame….

• Could have been caused by A.. or B.. or C..

• Nonspecific (both an accidental cause and assault is possible )

Lawyer: "What happened then?" Witness: "He told me, he says, 'I have to kill you because you can identify me.'" Lawyer: "Did he kill you?" Witness: "No."

http://rinkworks.com/said/courtroom.shtml

Courtroom Quotes

Lawyer: "How far apart

were the vehicles at the

time of the collision?"

Lawyer: "Now, Mrs. Johnson, how

was your first marriage

terminated?"

Witness: "By death."

Lawyer: "And by whose death was it terminated?"

Lawyer: "I show you Exhibit 3

and ask you if you recognize

that picture."

Witness: "That's me."

Lawyer: "Were you present

when that picture was taken?"

COURT TESTIMONY

Effectiveness depends on CREDIBILITY

Credibility depends on

Preparation

Impartiality

Honesty

Keeping within the confines of your expertise

Credibility

Influenced by appearance, demeanour, voice and language (oath = 1st impression), eye contact, nonverbal communication, firmness and sincerity of belief, perception or ability to perceive, ability to remember, accuracy (+ consistency)

Supported by status of credentials and employment

Challenged by evidence of bias, prejudice, interest, or corruption, certain criminal convictions, prior bad acts, prior inconsistent statements, or untruthful character.

May be regained by explaining any damaging facts, having another witness testify that he/she is honest, (but mud sticks)

Means being trustworthy & believable.

The result of countless cues & signals

Reflection of our personal and cultural baggage. A function of our charisma, our physical features, and our world-views.

Tempered by our preparation for the task, our comfort level speaking in public, our health on a given day, and a hundred other factors.

Some of these factors are within our ability to control; others are not.

Credibility

Objectivity

An expert witness does not compromise objectivity by defending, forcefully if necessary, an opinion based on the experts specialised knowledge which is genuinely held

but may do so if the expert is, for example, unwilling to give consideration to alternative factual premises

or is unwilling, where appropriate, to acknowledge recognised differences of opinion or approach between experts in the relevant discipline.

guidelines from the Federal Court of Australia

Impartiality

Stick to the facts

Eliminate bias

This is NOT time to go out on a limb

Focus on the TRUTH

(the whole truth, and nothing but the truth…..)

Tips

Lawyers seldom tell other professionals about the tricks they use to “play” a witness in court.

Witnesses often feel as though they participated in a game they thought they understood but later realised their reactions to certain questions were entirely predictable.

Lawyers are trained to elicit certain reactions from witnesses.

We witnesses need to be aware of these techniques in order todevelop strategies to counteract themprovide much better quality testimonyprotect ourselves and our profession from exploitation protect ourselves from the consequences of doing less than an excellent job in court.

Familiarise yourself with Court

process

Ask advice from experienced peers.

Understand the layout of the court, the process of presenting your evidence and how to address the decision maker(s)

We play a role but on unfamiliar turf and we are not sure of all the rules.

Be aware of the format of the court you are attending – whether it is children’s court, family court, magistrates’ court, county court or the coroner’s court.

Know what will be expected of you as a witness. Be prepared to be flexible because no one can predict all eventualities.

The SubpoenaLawyers and protective workers have authority to subpoena you

/records. Discuss your availability - a time least inconvenient for you / your

patients.

Affidavit or a written report or statement INSTEAD ?2 hours “stand-by” rather than waiting at the court?

Phone the person who issued the subpoena ASAP - discuss your options.

Don’t panic. Receiving a subpoena does NOT mean that you will be spending that nominated day in court. There is a strong likelihood that that is NOT where you will be on the day in question.

If you do actually attend court, take ALL your records as requested.Records may need to be subpoenaed from employer

Talk to the barrister before courtThe best job a barrister can do for

their client is to know what you, the witness, will say under cross-examination.

If you have been subpoenaed by protective workers, talk with the allocated caseworker, their supervisor or someone in DHS legal unit.

If you are not able to talk to the barrister well in advance of your court appearance attempt to arrange to meet them at court for a brief discussion before you give your evidence.

You will probably BOTH improve your performance!

Format of Court Appearance

Remain outside the courtroom until it is time to hear your evidence.

Oath or affirmation

Sit or stand?

Your evidence will be heard in a three-stage process.Evidence-in-Chief Cross ExaminationRe-examination

Leave the courtroom, giving single polite nod to magistrate, judge or coroner

Do NOT discuss the case until the hearing has concluded.

Your Attitude = Impartial & Helpful.

Remind yourself before entering the witness box of qualities you consider important (mantra) eg. courage and integrity.

Be courteous and honest.

Give concise but comprehensive answers.

Your honesty and professionalism should be displayed more prominently than your wishes to advocate on behalf of the child.

Attitudinal preparation is probably most important aspect of your preparation.

Dress to impress.

Your credibility depends on how you look as well as what you say and how you say it.

Aim for power dressing – dark coloured conventional suits.

Minimal ‘frills’

Keep still

Look directly at the ‘key players’.

Be polite

Be courteously helpful.

Regardless of the degree of provocation – always remain excruciatingly polite.

Control your temper

This is one time when being obsequious may keep you out of trouble!

Look at anyone other than the barrister inflaming your temper. Place your hands in your lap or on the witness-box to avoid making a clenched fist. Look totally unfazed.

Avoid any signs that may indicate that you feel flustered, annoyed, impatient or irritated.

Never allow yourself to be intimidated

Doctors experience less intimidation than other witnesses.

Never “give in” and say something misleading or incorrect because you feel bullied. Always insist on being 100% accurate.

Remain extremely calm.

You are highly unlikely to actually faint, vomit or lose sphincter control.

Never be “smarter” than

barristers

A) It is too easy.

B) You run the risk of antagonising the barrister, the judge and the jury, which is just what you do NOT want to do.

Better to say “you moron” under your breath and hope the judge and jury feel the same way!

You are who you are

Be proud of who you are.

You are expected to have only the knowledge and experience that you could possibly have acquired given your age, training, and exposure to relevant clinical material.

Be factual, be polite but NEVER apologetic!! No-one will expect you to know more, do more, or see more than you have.)

Address the decision-makers

Direct your answers to those who are making the final judgement

Point your feet towards the decision-makers . Always turn from the questioning barrister to answer decision-makers

Your answers will be framed to appeal to a reasonable person

Don’t watch the wandering barrister.

Anticipate respectful cross-examination

Maintain your body posture and tone of voice. Treat all barristers in a similar manner.

It is the defense barrister’s job to cast doubt on your evidence. For example, the barristers may attempt to demonstrate that you are not qualified to make a valid assessment of the child, are incompetent or negligent, are ill educated or ill informed, are mistaken, biased, rigid and not able to consider alternative explanations or you are simply a pompous arrogant person who cannot be believed.

The overall issue is one of credibility. not (in)competence

Response to “yes or no”

questions

There is no obligation, legal or otherwise, for any witness to just answer “yes” or “no”.

You may say “it isn’t a “yes” or “no” question”.

You may wish to expand and discuss the variables which influence outcome.

You may wish to conclude that one alternative is most likely but other alternatives are also possible

Double questions

Commonly used “lawyer tricks” - a rolled-up question or two questions in the one sentence.

For example, “Could the child be making this up because she wanted more attention?”

• “Could she be making this up?” • “Is her reason for doing this to get attention?” Say “There are two parts to this question”. Answer each part in turn.

Two-part question with a true-true-non sequitor format. Clarify that although both parts of the question are true, part 1 does not cause or explain part 2.

Offer opinions only when invited

Unlike other witnesses, expert witnesses are allowed to offer opinions when directed by the court.

Try and always back up your opinions with observational data and, if necessary, with evidence from available literature.

It may be useful to do a quick MEDLINE search or check the Cochrane Library to ensure you are cognisant of all the relevant information.

Stay within the confines of expertise

This is MOST important advice for doctors.

Lawyers know that doctors tend to drift a little from their area of expertise with very little encouragement. (ego)

The risk of getting a little too carried away is considerable. We all like to have opinions about things and need to constantly remember that we can only give valid EXPERT evidence about things on which we are genuinely qualified to comment.

Admit if you don’t know. Admit if the rest of the world doesn’t know either. Don’t guess.

Accept you

CANNOT

know

every thing

Don’t bluff!

Consider alternative explanations

When asked to consider an improbable scenario LOOK as though you are really thinking about your answer.

Talk in terms of “is”, almost certain, probable, possible, undetermined, unlikely, highly unlikely, & almost impossible

or “I can’t imagine a sequence of events whereby that could occur but if you can think of one I am happy to consider it.”

Unless you are specifically invited to speculate do not comment on anything other than the facts before you.

Flattery precedes a fall

If a barrister is being especially pleasant and flattering -BEWARE!

When asked if you really are a clever expert with a wealth of experience answer with a factual statement about your experience.

It throws the barrister off course and tells the decision-makers that you will be accurate at all costs.

Lawyer: "Now sir, I'm sure you are an intelligent and honest man--"

Witness: "Thank you. If I weren't under oath, I'd return the compliment."

http://rinkworks.com/said/courtroom.shtml

A Courtroom Quote

Answer questions completely

Interruptions and interjections from barristers might prevent you from completing your answers. “Play on” if the matter is not important.

Interjections are part of the game. Barristers have to convince their clients they have done some work!

If it IS important and you MUST expand your answer to give the court the whole truth

– ask, “ Your honour, may I complete my answer?”

Recognise weakness in your evidence

Identify weaknesses in your evidence that might relate to bias, loosely defined terms or to test results.

Most tests are not 100% sensitive and specific

At the start of your evidence, admit if your report needs to be corrected or amended.

Better for you to correct it early, than a barrister highlight deficiencies in your work at a later time.

Know

when to

let go

Debrief

Unwind and discuss the experience.

Work colleagues, family or friends willing to listen and share

Self recriminations.Barristers were too good? I could do

better?

Remember that your task is to present your part of the evidence to the court; not to convince a judge or jury that the defendant committed the crime.

The decision and the sentence are not your responsibility.

After it is over - let it go.

More courtroom quotes• Lawyer: (realizing he was on the verge of asking a stupid question)

"Your Honor, I'd like to strike the next question.“

• Lawyer: "Doctor, how many autopsies have you performed on dead people?"

• Witness: "All my autopsies have been performed on dead people."

• Lawyer: "Have you lived in this town all your life?"• Witness: "Not yet.“

• Lawyer: "Do you recall approximately the time that you examined the body of Mr. Eddington at the Rose Chapel?"

• Witness: "It was in the evening. The autopsy started about 8:30pm."• Lawyer: "And Mr. Eddington was dead at the time, is that correct?