medico legal report writing training

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Excellence in medico-legal report writing

A full day practical training course exploring what lawyers and the courts expect and require from a medico-legal expert’s report.

To join the waiting list and for priority information about future dates please email [email protected]

BMA members: £295 + VAT (£354) Non-members: £450 + VAT (£540)

About the event

A medico-legal expert’s report is a vital element in litigation. It must be clear, succinct, independent and well presented. Reports are seen by many professionals during litigation and often new instructions are received from opposition lawyers. Many medico-legal experts create their own report writing style or adopt other people’s generalised formats, having rarely received constructive feedback from lawyers on what is required from their medico-legal reports.

This course explores what lawyers and the courts expect and require from a medico-legal expert’s report. During the training you will be taught how to assess your own and other medico-legal experts’ reports.

Key learning points

• Identifying the issues to be addressed in your medico-legal report.
• Using a structured approach to preparation and writing.
• Expressing an independent view and arguing your conclusion.
• Handling supporting information.
• Developing an objective and critical eye in relation to your medico-legal report.
• Insulating your report against cross-examination.
• Dealing with different procedural requirements (Family, Civil and/or Criminal), including the Expert’s Declarations.

Further information

The BMA Medico legal committee recognises that online learning does not suit everyone’s learning style and are reintroducing face-to-face courses so that doctors can network and benefit from a more social educational event.

This small course will take place face to face at BMA House in London, subject to suitable booking levels. Please do not book non-refundable travel tickets until Wednesday 23 August when the course will be confirmed as face to face. If it is not viable to run the course face to face and you prefer not to attend an online course, then we will refund your registration fee in full.

Organiser details

Expert witness training

Expert witness report writing course (online).

This highly interactive course is designed to sharpen your skills in writing expert witness reports. It is aimed at medical professionals who work on clinical negligence cases.

Building your expert witness skills

As an expert witness, you play a critical role in the legal process. So, your written report needs to be clear, concise and well-structured. On this course, you’ll get some insider report-writing tips from some of the UK’s leading legal professionals. You’ll learn how to put together high-quality reports that meet all the latest legal requirements and can withstand cross-examination and scrutiny.

Key elements of the course:

• Watch top legal and medical experts explain the legal framework and give their guidance on writing expert witness reports.
• Review and critically assess reports written by other medico-legal experts.
• Write your own medical report using a real case (on breach of duty and causation).
• Get constructive feedback on your report from one of our medical negligence experts.

Learning outcomes

At the end of the course, you will have a good understanding of:

• what lawyers and judges expect from an expert witness report (including some tips from His Honour Judge Harris KC)
• how to structure and write your report in a clear and succinct way
• what information needs to be included and how to comply with court requirements
• how to express your independent view and write a report that withstands cross-examination
• how to critically evaluate your own and other experts’ reports.

Gain CPD points

This expert witness training course takes around ten hours to complete online. You will receive a CPD certificate on completion of the course.

Find out more about our other courses on the Conference with Counsel , the Meeting of Experts and Giving Evidence in Court .

Course overview

Task 1 – video presentations.

Addressing the legal issues – Paul Sankey

Paul Sankey, a highly experienced medical negligence solicitor, discusses the legal issues, including breach of duty, causation, prognosis, advice and consent.

Your duties as an expert witness and civil procedure rules – Paul Sankey

Next, Paul Sankey looks at:

• procedure governed by civil procedure rules (CPR)
• Part 35 and practice direction (PD)
• independence and objectivity
• experts’ duties and conflicts of facts
• providing evidence for your views and some cautionary tales.

Report writing – Dr Tom Boyd

Dr Tom Boyd provides his expert view on preparing a medical report, covering:

• content and form report – Practice Direction 35
• report layout
• chronology and investigation of the facts
• preparing your opinion and conclusion sections
• the statement of truth.

Tips for your report – Dr Simon Fox KC and His Honour Judge Harris KC

Dr Simon Fox and Judge Harris give invaluable tips for preparing your report for the court and how you can help the judge understand the medical issues.

Task 2 – Review of the sample reports

You critique five sample reports, submit your feedback and see how it compares to our legal team’s critique. This helps you to build your knowledge on how to write a high-quality report.

Task 3 – Video presentations

You review the medical records for a real case (with the client details redacted) and write a report addressing breach of duty and causation. Medical negligence expert Isabel Bathurst will then review your report and give you feedback.

Task 4 – Video/phone consultation with our medical negligence lawyer

You have a 30-minute video or phone call with Isabel Bathurst who will discuss the feedback and offer some individual advice on writing your report.

Book upcoming events

Select your chosen date below to book, expert witness report-writing masterclass, annual medico-legal conference (england), expert witness training for medical professionals (scotland), nadir osman, consultant urologist, robert mason, consultant urologist.

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elearning for healthcare

About the medico-legal training programme, more information, meet the team, how to access.

Being asked to write a report or attend a coroners’ or other court for the first time can be a daunting experience for doctors and other health and care professionals. This programme aims to provide resources that are both widely available and can be accessed at short notice if the need arises.

The videos and other materials in the programme were developed from a two-day course designed to prepare doctors in training for such experiences. The course was heavily over-subscribed, showing that there was considerable demand for such training.

The course was professionally filmed and edited with each lecture being condensed into one or more videos of about eight minutes each. The PowerPoint lecture slides are available within each module. A sample statement and references are also included.

The materials draw on the expertise of the staff of the London Havens. The Havens are sexual assault referral centres, the first of which opened in 2000. They provide 24/7 access to forensic examination, medical care and support following sexual assault.  Medico-legal training is a key component of forensic examination and aftercare, and the Havens have developed considerable experience in training clinicians to undertake this work.

More information about the Havens is available here: www.thehavens.org.uk .

Dr Bernadette Butler

Dr Emmeline Brew-Graves

Tina Freedman

Professor Jan Welch

In order to access the Medico-legal Training   programme, you will need an elfh account. If you do not have one, then you can register by selecting the Register button below.

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To check whether or not you qualify for free access via OpenAthens, you can view the eligibility criteria and register on the ‘ OpenAthens ’ portal.

Registering large numbers of users

If you are a HR, IT or Practice Manager and would like to register and enrol large numbers of staff within your organisation for access onto the Medico-legal Training programme, please contact elfh directly.

Organisations wishing to use their own LMS

For HR departments wanting to know more about gaining access to courses using an existing Learning Management System please contact elfh directly to express interest.

Please select the following link for more information on how to use the elfh Hub .

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Expert Report Writing Course

10 November 2023 - Online (Virtual via Zoom) -  Sold out

Expert Report Writing Course 10 NOVEMBER 2023 - Sold out

Online (Virtual - via Zoom Meetings)

REGISTER - Join the waiting list

This course is currently sold out. 

It is likely that we will have a few cancellation, so please email us directly at ac[email protected] to be placed on the waiting list. 

COURSE OVERVIEW

Aim Participants will appreciate the essence and content of a good legal medicine report, and will evaluate and improve their skills to establish a high standard of report writing.

Learning Outcomes - Understand the expert’s role and the requirements for one to be considered an expert.

- Understand the essential elements of a solicitor’s letter of instruction and appreciate when further material should be requested.

- Know the essential elements required in an expert report, common to all Codes of Conduct.

- Understand the difference between assumed facts, facts and opinion.

- Understand how an opinion is properly constructed showing how any conclusions were derived.

- Appreciate the proper use of language and understand common pitfalls in an expert’s report.

Who should attend?

The Expert Report Writing course will benefit any health care professionals who may be called upon to prepare expert reports. This includes medical, dental and allied health care professionals. If you are unsure about whether this course is right for you, simply call or email us to confirm.

About the Course

The Expert Report Writing course will benefit any health care professionals who may be called upon to prepare expert reports. It is a standalone course addressing the requirements of preparing an expert report. This Expert Report Writing course is a pre-requisite to the ACLM Expert Witness Training Program.

Further Training For those wishing to further their training in being an expert, we encourage participants to extend their training by attending the ACLM Expert Witness Training Program which focuses on presenting an expert report in court and includes critique of participants' submitted reports.

TEACHING FACULTY

Professor Roy Beran - Neurologist & Professor (ACLM Facilitator & Expert) Roy G. Beran is a consultant neurologist and accredited sleep physician. His qualifications include: MBBS, MD, FRACP, FRACGP, Grad. Dip. Tertiary Ed., Grad. Dip. Further Ed., FAFPHM, FACLM, FRCP(Edin), FAAN, FANZAN, FACBS, B Leg. S, MHL and FFFLM (Hon). He is a Conjoint Professor of Medicine at the University of NSW; Professor in the School of Medicine at Griffith University, Queensland; Conjoint Professor, Medical School, Western Sydney University. He was the inaugural Visiting Professor at the International Research Institute of Health Law Sciences at the Southern Medical University, Guangzhou, China. He is: a founding Fellow of the Australasian College of Legal Medicine (ACLM); Past President thereof, stepped down in 2011, still on Council and awarded Honorary Life Fellowship. In 2019, he was appointed ‘Joint Head of Teaching Faculty'. He is the Australian Governor and was elected as President of the World Association for Medical Law (WAML) in 2022. He was the first Honorary Fellow of the Faculty of Forensic & Legal Medicine of the Royal College of Physicians (London).

Professor John Devereux - Professor of Law, University of Queensland (Barrister) John Devereux teaches and researches the law of torts at the UQ Law School. He has a special interest in medical law, most notably in the areas of competency to consent to medical treatment and in epilepsy and the law. A Rhodes Scholar, John has worked as a lawyer in a variety of contexts including as a Barrister, as a consultant to a multi-national law firm, a Law Reform Commissioner for Queensland, a legal member of the Social Security Appeals Tribunal and as a Defence Force Magistrate. John was formerly Lecturer in Law at Keble College, Oxford University and Assistant Dean of Magdalen College, Oxford University. He is a former Associate Vice Chancellor of A.C.U. John is an Honorary Fellow of the Australasian College of Legal Medicine and joint Head of Teaching Faculty.

Bree Knoester - Principal Lawyer, Brave Legal (Solicitor) Bree Knoester is the founder of Brave Legal and one of Australia’s leading personal injury lawyers. Bree has practiced for over 18 years as both a barrister and solicitor; and has represented clients in some of Victoria’s largest compensation settlements. In recognition of her experience and exceptional client results, Bree has won numerous industry awards including ‘Lawyer of the Year’ in Personal Injury Litigation (Best Lawyers® in Australia 2020), Preeminent practitioner – Asbestos & Dust Diseases Compensation (Doyle’s Guide 2020), Preeminent practitioner - Work Injury Compensation (2020), and Partner of the Year Finalist - Litigation (Lawyer's Weekly 2019). As one of Victoria’s most experienced personal injury lawyers, Bree is regularly approached by the media for commentary on high-profile cases and as a spokesperson for the most seriously injured.

Dr Adam Griffin - Forensic Physician (ACLM Expert) Dr Adam Griffin is the President and a Fellow of the Australasian College of Legal Medicine. He received a medical degree from the University of Queensland and a Masters in Forensic Medicine from Monash University. He is also a foundation member of the Australasian Association of Forensic Physicians, and member of the Forensic and Clinical Toxicology Association.

(Draft program below - some elements may be updated closer to the date.)

LOCATION/VENUE

Virtual - Online via Zoom Meetings. Instructions will be sent to attendees after registration.

COURSE PREPARATION

Refer to the Program for more information.

2023 Fees:  

ACLM members - AUD $500 (inc. GST)

Non-members - AUD $650 (inc. GST)

Optional: Additional AUD $100 (inc. GST) for post-course submitted report marking

CANCELLATION POLICY & PRIVACY POLICY

By registering to attend, you agree that you have read and accept the Cancellation and Privacy Policies:

Cancellation Policy A refund less $100 administration fee will be provided for all cancellations received at least 14 days prior to the course start date. Any cancellations after this point will be non-refundable.

Privacy Policy View the ACLM Privacy Policy here.

CPD INFORMATION

Aclm cpd recognition.

ACLM current CPD progam:  20 points

ACLM new CPD program (coming soon) / CPD home:

Educational Activity: 6.5 hours Reviewing Performance: 2 hours Total: 8.5 hours

Program Level Requirements met: - Relevant to Legal or Forensic Medicine - Maintaining and developing professionalism

Format:  Virtual (synchronous via Zoom)

Frequency:  Twice per year

Cost:  See above  Fees

RACGP CPD Recognition

Activity No. 401559, allocated 8.5 CPD hours in the RACGP 2023-25 CPD Program

Note regarding optional post-course activity CPD claims

Additional CPD hours can be claimed for those who complete the optional post-course submitted report activity. This will be shown on your Certificate of Completion issued by ACLM.

Educational Activity: 2 hours Reviewing Performance: 4 hours (+ 1 hour reflection on report feedback) Measuring Outcomes: 2 hours Total: 9 hours

RACGP attendees please note: The optional post-course activity and hours is not pre-accredited with the RACGP so this component must be self-recorded by the individual practitioner.

Australasian College of Legal Medicine

You may opt out at any time. View our Privacy Policy here.

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The Expert Witness Institute offers a two part report writing course. These are an integral part of our Core Training for experts.

• Report Writing 1 - Developing the fundamental skills
• Report Writing 2 - Enhancing your practice

Report Writing 1

Provides the fundamental skills needed to write high-quality expert reports.

The framework of Court rules and procedure that form the context for expert reports will be explained, as will the basic evidential writing skills necessary to produce reports that fulfill all the requirements of the litigation process.

• Court requirements for expert reports
• Statement of truth
• Report types
• Timing of the expert instruction and its implications for report content
• Analysing the letter of instruction to ensure report meets the brief
• Report structures / templates
• Opinion writing
• Efficiency, proportionality and profitability through report writing
• Common mistakes in report writing

CPD Hours:  7 hours

To find course dates, check the training and events calendar.

Trainer: Beth Rigby

Beth trained with a national firm specialising in personal injury litigation and qualified as a solicitor in 2007. Over the course of almost ten years in practice she was involved in a huge range of civil cases including clinical negligence, personal injury, product liability and medical devices litigation on behalf of individuals and groups. In January 2018 Beth moved to work in house for a medico-legal expert company and provides advice on report content and structure in all types of civil litigation, as well as preparing for conferences, joint expert meetings and trials. She has a unique insight into the needs of solicitors based upon her own experiences, combined with the demands of her current role and understanding from an expert’s perspective.

Report Writing 2

This course explores all the latest developments in expert witness report writing and provides advice and tools to enhance your report writing skills.

Building on the fundamentals of Report writing 1, you will learn techniques and strategies that will enable you to deliver more impactful evidence across increasingly complex issues.

• Understand the latest updates to court procedures and rules as they apply to reports
• Explore the fundamental categories of legal test and understand its importance in evidence
• Understand the thought process for applying legal tests correctly using simple and complex factual and technical scenarios
• Understand how to generate a list of issues prior to the production of the report
• Develop and enhance opinion writing skills for complex cases, such as causation, damage and quantum
• Understand how to deal with causation in multi-incident compensation claims
• Understand how to deal with the range of professional opinion on issues in dispute
• Learn approaches for dealing with reporting situations involving technical or complex issues

Why should you attend?

• Receive specialist tuition on a vital area of expert witness practice
• Learn techniques that help to identify and highlight the key issues
• Learn how to present each stage of the opinion in a logical and ordered way
• Understand when and how to seek guidance from instructing lawyers
• Learn grammatical and presentational strategies that improve quality of evidence

CPD Hours:  7 Hours

Trainer: Giles Eyre

Giles Eyre is a barrister (recently retired) who practised from 9 Gough Square, London. Giles has extensive experience of conducting claims for personal injury, industrial disease and clinical negligence. He is a Recorder and a mediator on the CEDR Solve Lead Mediators Panel. He is a contributing editor of Asbestos Claims: Law, Practice and Procedure, published by 9 Gough Square and Clinical Negligence Claims - A Practical Guide, published by 9 Gough Square. He is also the co-author of Writing Medico-Legal Reports in Civil Claims, now in its second edition.

Giles regularly presents seminars for lawyers on a wide variety of topics and for expert witnesses on effective expert report writing and giving evidence.

• Sign In / Register

+44 (0) 20 7549 2549 [email protected]

Excellence in report writing - england and wales, public course: £395 + vat, in-house course: call for details, qualification: can count towards the cardiff university bond solon (civil, criminal and/or family) expert witness certificate - please call for details, duration: 1 day, key learning points.

• Identifying the issues to be addressed in your report
• Using a structured approach to preparation and writing
• Expressing an independent view and arguing your conclusion
• Handling supporting information
• Developing an objective and critical eye in relation to your report
• Insulating your report against cross-examination
• Dealing with procedural requirements, including The Expert’s Declarations

Excellence in Report Writing - overview

An expert witness’s report is a vital element in litigation. It must be clear, succinct, independent and well presented.

Many experts develop their own report-writing style or adopt other people’s. But they’ve rarely received constructive feedback from lawyers on what’s actually required from their written evidence.

This course explores what lawyers and the courts expect and require from an expert witness’s report. You’ll be taught how to assess your own and other experts’ reports, and to produce, quickly and consistently, reports that are court-compliant and that can withstand cross-examination.

This course can count towards the  Cardiff University Bond Solon Expert Witness Certificate . 

The Digital Hub

 When you book a place on this public course, you will be given free access to the Bond Solon Digital Hub, our new resource for expert witnesses. Find out more.

Due to VAT regulations, if you are booking outside the UK, please contact the office.

To book this course:

1. check availability, 2. select a date, need some help call or e-mail us.

If several of your colleagues are interested in this course, it may be more effective to run this course in-house at your organisation. To discuss this further, please call us on +44 (0) 0207 549 2549 or contact us via email.

Want more information? Please call us on...

020 7549 2549.

If you require any help or would like to discuss how Bond Solon can assist you in your training needs, please call us on: +44 (0) 20 7549 2549

10/06/2023: Mastering Medical Legal Report Writing: Navigating QME Requirements

Friday, october 6, 2023.

12:00 PM - 3:30 PM Pacific, Online via Zoom

Delve into the intricacies of medical legal report writing and unlock your potential to create reports that withstand scrutiny, effectively communicate findings, and serve as compelling evidence in legal proceedings. Gain a comprehensive understanding of the statutory and regulatory requirements that govern medical legal report writing, and learn to navigate these complex legal frameworks as you apply standards to your practice.  Learn to identify common mistakes, such as insufficient documentation or inadequate analysis, that can compromise the integrity of your reports. Discover how various stakeholders utilize these reports throughout the QME system, and develop a structured and meticulous approach to appraise and communicate your findings. 

Led by esteemed experts in the field, this course combines in-depth knowledge, practical insights, and interactive learning to empower you as a physician. 

Not able to attend this session live?

This activity will be recorded and converted to an online enduring material available for credit. 

Learning Objectives:

At the completion of this activity, the learner will be able to:

Describe the components and characteristics of a high-quality medical legal report

Discuss characteristics of an objectionable report, including potential pitfalls

Complete a thorough history and physical examination (H&P)

Summarize statutory and regulatory requirements, and apply these standards to evaluation and report writing

Prepare a written medical legal report in compliance with §10682. Physicians' Reports as Evidence

Course Agenda

12:00 PM - 12:45 PM: Lecture - Introduction to Report Writing; Medical Legal Regulations & Legislation

12:45 PM - 1:30 PM: Panel Discussion and Q&A

1:30 PM - 1:45 PM: Break

1:45 PM - 2:30 PM: Lecture - Report Quality Checklist; Components of H&P

2:30 PM - 2:45 PM:  Breakout Room Discussion

2:45 PM - 3:30 PM:   Panel Discussion and Q&A

This educational activity is intended for Qualified Medical Evaluators (QMEs), clinicians including MD/DO, physician assistants, registered nurses, nurse practitioners, and others involved in the California Workers' Compensation system.

Registration Fees

Single Course Registration: $75.00

4-Course Series: $200.00

Click here to learn about the other courses in the series, and to register for the 4-Course Package.

Course Format

This course is a live, synchronous offering, and will be taught online via Zoom.

Accessibility

If you require an accommodation for effective communication (ASL interpreting/CART captioning, alternative media formats, etc.) to fully participate in this event, please contact Michelle Meyer at (510) 642-8365 or  [email protected] .

Accreditation:

The Center for Occupational and Environmental Health is accredited by the California Medical Association to provide continuing medical education for physicians.

The Center for Occupational and Environmental Health designates this live course for a maximum of 3.25  AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Provider approved by the California Board of Registered Nursing, Provider Number 12983, for 3.25  contact hours.  The UC Berkeley Center for Occupational and Environmental Health is a DIR DWC approved QME Continuing Education Course Provider (Provider No. 420). Qualified Medical Evaluators may report up to 3.25 hours of credit for QME reappointment.

Dr. Steven Feinberg:

Speaker Biography:

Dr. Steven Feinberg is Board Certified by the American Board of Physical Medicine and Rehabilitation, the American Board of Pain Medicine and the American Board of Electrodiagnostic Medicine. He is a California Qualified Medical Evaluator (QME). Dr. Feinberg is a past president (1996) of the American Academy of Pain Medicine. He served as a longtime member of the Board of Directors of the California Society of Industrial Medicine and Surgery (CSIMS) and served as Year 2001 President. In 2006, he received the Silver Scalpel Award from CSIMS. He serves on the Board of Directors of the American Chronic Pain Association.

Dr. Bobbie McDonald

Bobbie McDonald, PsyD, QME, has worked in the field of psychology since 2000, and has practiced as a qualified medical evaluator (QME) since 2014. In addition to her private practice and QME work, she is the Executive Director of Equity Evaluations, Inc., a company focused on the mentoring of QME evaluators in all specialties. She has extensive knowledge of all aspects of the qualified medical evaluator system including regulatory requirements, workers’ compensation case law, and billing practices. Dr. McDonald is on the Executive Board of Directions for the California Society of Industrial Medicine and Surgery. Based on her expertise as a qualified medical evaluator, she has presented at California Psychological Association and California Society of Industrial Medicine’s annual conferences. She has also recently published a comprehensive QME manual.

Julius Young, Esq.

Julius Young has represented injured workers in California for over 30 years. A longtime partner at Boxer & Gerson LLP in Oakland CA, Julius also has been the author since 2007 of Workerscompzone.com. The blog has won national awards for commentary on workers' comp case law, regulator developments, and the politics surrounding the California system. A graduate of Davidson College, Pacific School of Religion and the University of North Carolina Law School, Julius lives in Hillsborough CA on the San Francisco Peninsula

Khanh Le Kwan, Esq.

Khanh Le Kwan is the supervising attorney at Pacific Compensation Insurance Company, a Copperpoint Insurance Company. She is a certified workers' compensation specialist and has been a defense attorney for over 20 years. She worked for several defense firms before going in-house with Pacific Comp in 2016. She graduated from the University of California at Santa Barbara and received her law degree from University of La Verne College of Law.

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Workshop 7: Expert report writing

This workshop is one of a series of  10 practical workshops designed and presented by the Faculty of SAMLA.  The Workshops have been accredited by UCT and CPD points are awarded for each workshop.

This course comprises 42 lectures on expert report writing. The lectures are presented by medico-legal experts from the law, medicine and allied professions. The topics include:

• a judge's perspective on expert reports;
• legal requirements of medico-legal reports;
• generic fundamentals for all disciplines;
• apportionment/thin skull cases;
• lectures from specific branches of medicine and rehabilitation including orthopaedics, surgery, physiotherapy, occupational therapy, clinical psychology, neuropsychology, educational psychology, industrial psychology including a lecture on what the industrial psychologist requires from other disciplines; and a lecture from the HPCSA tribunal's perspective.

Please note that one cannot register or pay for this workshop on this website.     Azlyn Creative is the service provider that manages the administrative aspects of the SAMLA workshops. All registrations, payments, and access to the workshops is through   http://samla.co.za

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Writing a medico-legal report

Summary: When asked to provide a medico-legal report you are usually providing information to be used in possible court proceedings. We outline crucial elements to consider and the practical steps needed to respond.

This video will give you some basic information about writing a report and what you might expect from the process when asked to be an expert witness.

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La Touche Training offer a variety of medico-legal presentations to medical audiences, covering topics that are highly relevant to any medical practitioner, in the current litigious environment in which they work. These courses can be tailored to suit either a single or multi-disciplinary group.

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The presentations used during this training focus on health and social care issues with legal implications.

Presentations can be hour-long, half-day or full-day presentations and can be on a range of medico-legal topics including:

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How to write a medico-legal report

09 Jun 2021

by Ms Janet Harry

Doctors receive requests for treating doctor reports from a variety of sources including patients, their lawyers, insurers, employers, and the police. These are important documents and should be completed with care.

Am I obliged to provide a treating doctor medico-legal report?

There is rarely a legal obligation to provide a medico-legal report, although some statutory bodies (e.g. Ahpra, Workcover) can require the preparation of a report in certain prescribed circumstances.

A treating doctor has a professional and ethical obligation to assist by providing factual information concerning a patient’s condition or injury to the patient’s legal advisers or, with the patient’s authority, to other nominated third parties. You may be asked to provide your clinical opinion based on your knowledge of the patient, and the circumstances leading to the request.

Unless compelled by law, consent should be obtained from the patient (or their parent/guardian) before any personal health information is released. It is recommended that consent is obtained prior to the report being prepared.

Format for the report

It can be useful to include headings or numbering if the report is long. It is appropriate to include each of the questions you have been asked, with your responses below, so that the report can be read as a “stand alone” document.

A suggested format for a medico-legal report includes:

• your credentials, including professional address, qualifications, experience and position at the time you were involved in the patient’s care
• the requesting party’s name, the date of the request, the purpose of the report, and the date of the authority
• the patient’s name and date of birth
• presentation (history and symptoms)
• examination findings
• investigations
• provisional diagnosis
• treatment/management
• current condition
• your response to any specific questions
• your clinical opinion (where appropriate)
• your signature and the date the report was completed.

If you have no independent recollection of your management of the patient, the information in your report will be based solely on what is recorded in the medical records (e.g. ‘I have no independent recollection of my involvement in the patient’s care. According to the medical records, the patient presented on [date]. I recorded the following history…’). You may be asked to provide a report where several colleagues have also treated the patient. This should be noted at the outset.

The extent of the medical information included in the report will depend on the nature of the report and is a matter of clinical judgement for the author.

Information that is not relevant to the report need not be included, but relevant matters must not be omitted. If the patient only consents to certain portions of the relevant information being released, then you should consider whether this a withdrawal of consent and advise the requesting party that consent has been withdrawn. Gratuitous comments, and information about third parties, should generally not be included e.g. “he attended with his wife who is a claims manager at an insurance company and knows all about Workcover”

Preparation tips

• Allocate time to review requests and prepare reports. Rushing or trying to attend to this important task between patients is not good practice and increases the risk of providing a sub-standard report.
• Practices can assist by having clear policies around requests for reports. This might include a minimum timeframe for a report (e.g. 14 days), a schedule of fees, and a requirement for pre-payment prior to the release of the report.
• If you are unsure about fees, you can use your normal hourly rate, or you can consult your professional body. The RACGP guide ; AMA NSW and Law Society schedule of fees can be useful guides. Statutory bodies who can direct the provision of a report often have a prescribed fee schedule which may be provided with the direction or order.
• Before commencing work on a report, consider the amount of work involved and provide a cost estimate so the fee can be agreed before you start drafting the report.
• Ideally, the report will be prepared in response to a written request or direction accompanied by an appropriate authority from the patient, or a legal direction to prepare the report. You can decline to respond to questions which are outside of your scope of knowledge or your area of expertise.
• Be familiar with the difference between a medico-legal report by a treating doctor, an expert opinion , a letter of support or a police statement .
• Be familiar with your professional obligations (see below).
• Be clear on the nature and purpose of the report and the expected audience. Clarify with the requesting party if you are unclear and discuss any unresolved concerns with MDA National.
• Refer to the medical records, and don’t rely on your memory or information provided by the requesting party. It is acceptable to include information provided in the records by other doctors - for example if a colleague saw the patient while you were on leave - provided you make the reference clear.
• You should address the report to the requesting party, and not “to whom it may concern”. If you don’t have a specific addressee, you can address the report to the patient.

Professional Obligations

Good medical practice: a code of conduct for doctors in Australia states that:

The community places a great deal of trust in doctors. Consequently, doctors have been given the authority to sign a variety of documents, such as a Medical certificate of cause of death (death certificates and sickness certificates on the assumption they will only sign statements that they know, or reasonably believe, to be true.

Good medical practice involves:

10.9.1    Being honest and not misleading when writing reports and certificates and only signing documents you believe to be accurate.

10.9.2    Taking reasonable steps to verify the content before you sign a report or certificate and not omitting relevant information deliberately.

10.9.3    Preparing or signing documents and reports if you have agreed to do so, within a reasonable and justifiable timeframe.

10.9.4    Making clear the limits of your knowledge and not giving opinion beyond those limits when providing evidence.

Legal obligations

A number of courts have an Expert Witness Code of Conduct, which a person must comply with in order for their report and evidence to be admissible in court. These codes are applicable to a medical expert who is providing an opinion at the request of one of the parties in the matter before the court. In most cases, these doctors will be independent medical experts who have had no direct involvement in the care of the patient.

On occasion, however, a treating doctor may be asked to provide a report and abide by the Expert Witness Code of Conduct. If you are asked to abide by the Expert Witness Code of Conduct, you should ask the requesting party to provide you with a copy of the relevant code and seek advice if you are unsure of your obligations. Requirements in an Expert Witness Code of Conduct vary in different jurisdictions but often reference your duty to the court, and the required format of the report.

It is important to be aware that any opinions expressed in a medico-legal report may be publicly tested and challenged in court. The weight given to the opinion will generally depend on the expertise and experience of the author. As outlined above, a treating doctor should only provide an opinion which is within their expertise and knowledge. There may be times when a treating doctor feels it is inappropriate to provide an opinion and may agree to provide factual information only. An independent expert medical opinion may then be sought, based on the facts provided by the treating doctor and/or the medical records.

Tips and traps

• Ensure that you are legally compelled or have the patient’s permission to provide a report. The most common cause of complaints arising from the provision of treating doctor medico-legal reports is a breach of confidentiality and privacy. Special care needs to be taken in Family Court matters where you may have treated both parties and you are asked to prepare a report by one of your patients involved in the proceedings. It is essential that your report does not divulge any information you have received from any other patient.
• Prepare your report within a reasonable time frame – if necessary, discuss this with the party who has requested the report.
• Always refer to your medical records when preparing the report.
• Remember that you may be cross-examined on your report – only write what you would be prepared to say under oath in court.
• Do not alter your report at the request of your patient or a third party – if you receive additional information, or you need to correct an error, provide a supplementary report.
• Explain medical abbreviations, terms and concepts in plain English.
• Avoid the use of legal terminology.
• Do not record the patient’s history of events as ‘fact’ – e.g. ‘When asked what happened, Mr A said he was hit by a car’ not ‘Mr A was hit by a car’; and ‘In my opinion, Ms B’s depression has been caused by the reported behaviour of her husband’ not ‘The behaviour of Ms B’s violent and aggressive husband has caused her depression’.
• Differentiate fact(s) from opinion(s).
• Beware of providing an opinion that is beyond your knowledge or expertise.
• Do not act as an advocate for your patient – you should not deliberately omit any relevant information.
• Avoid emotive language.
• Seek advice from your medical defence organisation if you have any concerns.

Subscribe to MDA National’s biannual Member publication, Defence Update, for the latest medico-legal updates, articles and case studies.

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