As medico legal reports play a very important role in litigation, they should be clear and specific about the facts stated. To prepare an accurate report, one should be a medico legal expert, with years of clinical experience. Moreover, to prepare an apt report, an expert’s advice should be limited only to the information required for litigation.
The report should have:
Title page with all the required information of the claimant, including:
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).
Moreover, the report should be in chronological order with numbered pages. The report is to have a detailed summary of the evidence, based on factual descriptions 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 highlight the 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 mention the sources of all the evidence, such as the clinical record, medical investigation, etc. Moreover, the 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 delving into the unknown makes the report susceptible to unreliability. The expert should elaborate on the reasoning for all the clinical judgments made.