Medico Legal Report Structure

The circumstances of many emergency rooms, especially those involving violence, greatly increase the likelihood of seeking forensic advice. The request must be addressed specifically to the chief physician who was involved in the clinical management of the patient. Although it is possible to direct the request to anyone involved or to someone who can only compile a report from the medical notes, this is less satisfactory. If this happens, there will always be uncertainty as to why the attending primary physician was not requested, implying that they may be something to hide. The amount of medical information contained in the report depends on the type of report and is based on clinical judgment. It is not necessary to include information that is not relevant to the report, but relevant elements should not be omitted (e.g. a pre-existing history of back pain must be disclosed in a claim for a back injury). It is important to know that all opinions expressed in a forensic report are often subject to special scrutiny by the reader of the report and may be publicly reviewed and challenged in court. The weight given to opinion usually depends on the expertise and experience of the author. Sometimes, however, a treating physician may be asked to submit a report and comply with the Code of Conduct for Experts. If you are asked to comply with the Code of Conduct for Experts, 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. The requirements of a code of conduct for experts include: There is rarely a legal obligation to prepare a medico-legal opinion, although some legal bodies (e.g.

Ahpra, Workcover) may require the preparation of a report in certain prescribed circumstances. In the modern world, expert evidence plays an important role in establishing an accidental link between behaviour and harm. When a physician receives a request for assistance in assessing the treatment provided in a particular case, his or her professional judgment is implicitly recognized. Due to the increase in litigation against physicians, the adversarial court decision calls on the medical profession to conduct peer review and educate them about the complexities of medicine. The role of a medical specialist will have serious implications for the plaintiff, the defendant, the legal system and society as a whole. The main objective of the preparation of expert opinions is to train those involved in the adversarial judicial decision in a given case. Legal disputes against physicians are largely evaluated, negotiated, and decided based on physicians` opinions on other physicians` standards of practice. In such disputes, the doctor is often the main target and the quality of medical care is often the key issue of legal action. The three judges in Dr. J. J.

Merchant and others v. Shrinath Chaturvedi [1] accepted the position that it should be left to the discretion of the Commission to question experts if necessary in an appropriate case. In Jacob Mathew v. Punjab [2], the Supreme Court issued guidelines to be followed in cases of negligence of physicians. The report should be comprehensive without being unnecessarily wordy and inconclusive. Its length should depend on the complexity of the material to be tested. It is important to be clear from the outset about what a particular case is. If the report was requested by an external agent, read the request letter from time to time to ensure that issues are properly addressed during the drafting of the report and to verify that they have been clearly resolved.

It is unusual for hospital staff to have to collect forensic samples. Details of all samples obtained must be included in the forensic report It should clearly indicate where the samples came from, how they were labelled, details of handling, and why the sample was obtained (for example, bacteriology for comparison purposes). Comments should also be made on the time and date of transfer of samples to the care of another person. This ensures that the continuity of evidence can be proven later in court. The report should refer to all photos taken and the text should uniquely identify each photo. Finally, if possible, ask a colleague to review and comment on the report before sending it. It is difficult to edit a report after it has been published. At this point, constructive criticism is preferable to cross-examination on the witness stand. The review of notes, reports, diagrams and photos must be carried out before the legal proceedings begin. If errors are found in the report at this stage, they should be openly admitted in court. A year later, the GP received a letter stating that the Australian Health Practitioner Regulation Agency (AHPRA) was investigating his professional behaviour.

In her letter of communication to AHPRA, Ms. Z. had stated that the patient had used the family physician`s report in the family court proceedings. This had caused considerable distress to Ms. Z. and revealed confidential information of which her family was not known. 10.9.3 Prepare or sign documents and reports, if you have consented, within a reasonable and reasonable time. It is important to know that any opinion expressed in a medico-legal report can be publicly reviewed and challenged in court. The weight given to opinion usually depends on the expertise and experience of the author. As described above, an attending physician should only give an opinion that is within his or her expertise and knowledge. It may happen that a treating physician deems it inappropriate to give an opinion and agrees to provide only factual information. Independent medical advice can then be obtained based on the facts and/or medical records provided by the attending physician.

It is important to remember that a forensic report is usually addressed to laymen who are not themselves experts. Although lawyers and judges who frequently deal with medical issues gain knowledge of medical terminology, it can often be inaccurate and no assumptions should be made. The report should be clear, understandable and use as little technical terms and jargon as possible [6]. Physicians receive requests for processing of medical reports from a variety of sources, including patients, their lawyers, insurers, employers and the police. These are important documents that must be completed carefully. It is important that medico-legal reports are fair to patients, but also to physicians. These reports are the tools lawyers use to crucify surgeons, it requires careful thought and discussion about who should write and what training should be given to those who do. A number of courts have a code of conduct for experts that a person must follow in order for their report and evidence to be admissible in court. These codes apply to a medical expert who, at the request of one of the parties, gives an opinion on the merits of the case before the court. In most cases, these doctors are independent medical experts who have not been directly involved in patient care. The role of the expert is to educate those involved in the justice system on the standard of care, taking into account all facts and variables relevant to the case, including the practice setting. The authors were aware of a number of cases of negligence in order to give their opinion estimated on the basis of the facts of the case.

The second author, with many years of experience in the forensic field, has prepared expert opinions before various courts and has also drafted a number of opinions on medico-legal cases. The judicial system`s ignorance of the medical field became evident when the authors encountered questions from legal staff in a number of cases. The general rule of evidence is that witnesses testify on the facts of the case, while the conclusion to be drawn from those facts rests with the judge. When the witness gives an opinion, the function of judge is usurped [3]. However, there are exceptions to this rule. The opinion of experts is admissible if the competence to form and express opinions on the subject can only be acquired by special studies and if the judge could not form an opinion otherwise.