Medico legal reports are required to claim for personal injury or medical negligence and are prepared by a medical expert chosen for legal processing. Evidence from qualified and experienced medico legal expert is vital for the litigation of a client’s case.
Medico legal reports inculcate client’s information, history, incident, and injury details along with any treatment needed, based on expert investigation. The medico legal reports are written under rules given in Part 35 by the Ministry of Justice. This blog provides guidelines for writing good MOJ compliant medico legal report.
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What must be included in Medico Legal Report?
As medico legal reports plays a very important role in litigation, it should be clear and specific about the facts stated. To prepare an accurate report, one should be a medico legal expert. Moreover, to prepare an apt report, expert’s advice should be limited to the information required for litigation only.
Title page with all the required information of the claimant
Date of the report submission
Date of examination
Client’s full name and date of birth
Identity of the involved parties
Nature of the report
Expert’s details (name, current post, registration number, license, and area of expertise)
The report should be in a chronological order with numbered pages. The report is to have a detailed summary of the evidence, based on factual description and accurate information. The expert should refer to important parts for clarity in the report. All the information written in the report must be clear, avoiding any sort of ambiguity, and it is also significant to mention the source of information to prove its authenticity. A good report must have full forms of abbreviations and an explanation of technical terms.
The history of the claimant also plays a vital role, so it is suggested to the highlight relevant parts of history for the case. The report must cover details of the investigation like the exact date, time, place, and results of the investigation. If some of the investigations are carried out by some other expert, it must be mentioned explicitly and as a medico legal expert for the case, it is also important to mention whether the examination took place under your supervision or not.
All the records of findings, either positive or negative, must be precisely stated to avoid ambiguity. The report must make mention of sources of all the evidence such as the clinical record, medical investigation, etc. Experts are required to provide their opinions and judgments. A Medico legal expert is responsible for all the statements written in the report which is why a thorough understanding of all the information is critical. Additionally, it is suggested to write within your area of expertise: any dwelling into the unknown makes the report susceptible to unreliability. The expert should elaborate the reasoning for all the clinical judgments made.
Medico legal reports should be prepared honestly: all the statements, evidence, and documents provided should not be false, unclear, or misleading. As these documents and judgments are vital elements for the legal proceeding of the case, any delusive or false information can expose the expert to the risk of being sued in court. It is very important to have a complete understanding of the case and the information needed for the report.