Guidance


Writing a medico-legal report: guidance for hospital consultants

By Dr Mike Roddis, Healthcare Performance - 4th July 2011 2:36 pm

The MDU has developed new guidance for doctors embarking on their first consultant post. In the seventh in a series of articles guiding you through the more common non-clinical challenges a consultant may face, Dr Mike Roddis from Healthcare Performance Ltd, discusses the duty of preparing medico-legal reports.

As a consultant, your role will extend far beyond hands-on patient care. There are many duties you may be obliged to take on and writing medico-legal reports is one of them.

A doctor may be requested to write a medico-legal report for any number of reasons. It may be that a complaint has been made, a clinical negligence claim has been brought against you or a colleague, there may be criminal proceedings against a medical professional, or a report may be required as part of a coroner’s inquest. This article shows how to meet your ethical obligations and ensure your report fulfils its intended purpose.

Basic principles for doctors

There are a few basic principles to follow when writing a report. Firstly patient confidentiality is an important consideration even if a patient has died. In the case of coroner’s inquests, you have a duty to assist, however in other circumstances you should make sure that informed consent has been given to your writing the report. Secondly, as a medico-legal report will usually be requested as part of formal proceedings, it is important that it is produced quickly to avoid causing delay. If for any reason you believe that you will be delayed in producing your report, then it is important to inform the appropriate person as soon as possible.

Advice on writing the report

The report should always provide a detailed but factual account of the situation, based on the medical records and your knowledge of the patient. Ensure you have a full copy of the patient’s medical records before writing your report.

All medico-legal reports will, to a certain extent, contain some of the same basic information. Your full name and professional medical qualifications should be written out in full (e.g. Bachelor of Medicine) with your job title also stated. This will allow the person receiving the report to easily identify your level of expertise.

Start by stating who has requested the report and for what purpose. You may also want to list the supporting documentation used to draft the report, such as medical records and drug charts. This will allow the recipient to easily see what additional information you have used in preparing your report and if necessary, ensure that they have it to hand when reading.

Ensure the report is easy to read by presenting information in a straightforward manner. Give a description of events in chronological order, referring to clinical notes when possible and noting each relevant contact with the patient, their family or other medical professionals. Include the purpose of each contact (e.g. clinical or forensic) and whether it was carried out under the NHS or privately, alongside any treatment options, diagnoses or referrals discussed. If there was another person present at the time of the consultation, include their name and status in the report, so they can be contacted if necessary. If medication was prescribed to the patient, its clinical name should be stated, along with the dosage and what format it was administered in.

Stating the facts

Concentrate on your observations and understanding at the time of the event, rather reporting exactly what the patient told you. A description of the patient’s presenting symptoms is important as it can be used to put your observations and interpretation of the situation into context. State what you looked for as well, even if it was not found as this demonstrates that you took the appropriate steps to make an adequate assessment of the patient and will hopefully avoid your evidence being challenged. If you are asked to provide an opinion then do so but be sure to only comment within the limits of your knowledge and expertise.

If at any time, another clinician has been involved in the care of the patient, list their full name and job title and state, to the best of your knowledge, what their role was in your patient’s care while avoiding commenting on the adequacy of the care they provided. Avoid criticising another clinician’s care of the patient.

Although it may be daunting when first asked to provide a medico-legal report, if the information provided is accurate, factual and presented in a clear manner, writing a medico-legal report is not something to be feared.

Seven top tips for writing a report

1. If possible, type the report on headed paper, sign and date it. If you are using your employer’s notepaper, check they know you are writing the report before you send it in.

2. Do not make the assumption that the reader has any of the background information referred to in your report. Always ensure that your report can stand alone as an independent document.

3. Write any medical terms in your report out in full.

4. Consider including the medical notes with your report. You may wish to provide a written transcript with abbreviations written out in full and state the dates which the notes span, but never change the original notes. Do not send original notes without the permission of your employing trust.

5. Write your report in the first person - this should allow the reader to clearly see who did what and when.

6. Make sure that everything you put in the report is honest, accurate and is not misleading, before signing it off, in line with the GMC’s Good Medical Practice.

7. Keep a copy of the report for your own records, in case you are called to give evidence in person about the incident.

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