Don’t forget that you can contact our forensic advisory service for assistance, including a review of your draft report
PHYSICIANS receive requests to process physician reports from a variety of sources, including patients, their attorneys, insurers, employers, and the police.
In general terms, there is no legal requirement for doctors to provide a report, although some statutory bodies (eg the Guardianship Council) may order you to provide a report. However, an attending physician has a professional and ethical obligation to assist by providing factual information regarding a patient’s condition or injury at the patient’s request to the patient’s legal counsel or, with the patient’s permission. , to other designated third parties.
It is important to note that while there is an ethical obligation to assist the patient by providing a factual report, you are not required to provide an opinion in your report.
What is expected and how to prepare the report
Allocate sufficient time to review applications and prepare reports. Rushing or trying to take care of this important task between patients is not good practice, and it increases the risk of providing an inadequate or incorrect report.
Familiarize yourself with all practice policies regarding report writing. A fee schedule and prepayment of fees may be required.
If in doubt about fees, consult your professional body. Some useful guides are those of the Royal Australian College of General Practitioners (RACGP) How to write a medical report and the Australian Medical Association (AMA) New South Wales and Law Society Fee Schedule. Statutory bodies that can order a report to be provided often have a prescribed fee schedule that can be provided with the direction or order.
A treating physician may be asked to provide a report and abide by an expert witness code of conduct. Ask the requesting party to give you a copy of the relevant code and seek advice if you are unsure of your obligations.
Ensure you have an up-to-date patient authorization or prescription/instruction from the appropriate statutory body.
Read the application carefully and check for any due dates. If you are unable to comply, notify the requesting party immediately.
Make sure it is appropriate for you to write the report and that it falls within your area of expertise or knowledge. Consider the work involved and, if applicable, provide an estimate of the report fee and obtain agreement to be prepaid.
Understand the difference between a medical-legal report from a treating physician, an expert opinion, a letter of support, or a police statement.
Know your professional obligations Good medical practice: a code of conduct for doctors in Australia to provide an honest, precise report, containing all the relevant information and specifying the limits of your knowledge.
Be clear about the nature and purpose of the report and the intended audience.
Use medical records to prepare the report. Do not rely on your memory or information provided by the applicant. It is acceptable to include information in records written by other physicians – for example, if a colleague saw the patient while you were on leave – as long as you specify this.
Generally, you should address the report to the requesting party and not “to whom it may concern”.
It is perfectly acceptable, and perhaps appropriate, to answer a question with “I don’t know”.
You are not obligated to answer the questions if they require you to give an opinion, but only to provide the facts as you know them.
Include in your report all of the requesting party’s specific questions and your responses below so that it is a “stand-alone” document.
Remember that you may be cross-examined on your report, only write what you would be willing to say under oath in court.
Do not modify your report at the request of your patient or a third party; if you receive additional information or if you made a mistake, provide an additional report.
Explain medical abbreviations, terms, and concepts in language that non-physicians understand.
Do not record patient event history as a “fact”. Say: “The patient has reported that…”.
Do not act as your patient’s advocate or deliberately omit relevant information.
Avoid emotional language.
Suggested format
- Headings can be helpful and use numbered paragraphs if the report is long.
- Your references – professional address, qualifications, experience, position at the time you were involved in the care of the patient;
- Name of applicant, date of request, subject of report, date of authorization given by the patient.
- Patient name and date of birth – refer to the patient by name; for example, “Mrs. Smith”.
- Clinical information – overview (history and symptoms), test results, investigations, tentative diagnosis, treatment/management, current status, treatment plan.
- Response to questions (if any).
- Your opinion, only if appropriate
- Sign and date the report.
Check out our in-depth guide to writing the medical-legal report at [URL to come].
Janet Harry is a medical-legal advisor at MDA National.
This article is provided by MDA National. They recommend that you contact your insurer if you need specific advice in relation to your insurance policy or medical-legal issues. Members can contact MDA National for specific advice on the freephone number 1800 011 255 or use the ‘contact us’ form on mdanational.com.au.
This case study is based on an actual request for forensic advice; however, certain facts have been omitted or edited to ensure the anonymity of the parties involved.
