Guide
How to structure a medico-legal report
A medico-legal report is a written opinion from a medical expert for a legal process: a personal injury claim, a negligence case, a workers' compensation matter or a coroner's inquest. Its reader is a lawyer, a tribunal or a court, not another clinician. The report has to show not only what the expert thinks, but why, and on what material.
The usual sections
- Instructions: who asked for the report and the exact questions put to the expert.
- Qualifications: the expert's training and experience relevant to those questions.
- Material reviewed: every record, scan and document relied on, listed so the reader can find it.
- History: the relevant background, attributed to its source (the patient, a record, a witness).
- Examination findings: what the expert observed, if there was an examination.
- Opinion: the answer to each question, in the order asked.
- Reasons: the reasoning and literature behind each opinion.
- Limitations: what the expert could not assess and what further material would change the opinion.
- Declaration: the statement required by the court's expert code of conduct.
Keep findings apart from opinion
The most common weakness in a medico-legal report is a paragraph where a recorded fact, an inference and a guess run together. Opposing counsel will find it. Write findings with their source, then the opinion, then the reasons that connect them. Say plainly where the record is silent.
Courts have codes of conduct for experts. In Australia, for example, the Federal Court's Expert Evidence Practice Note and the expert witness code of conduct in the uniform civil procedure rules require the expert to state the facts and assumptions relied on and to say when a question falls outside their expertise. Follow the code that applies to your court.
A worked example (fictional)
The patient, records and dates below are invented for illustration.
Question: Was the delay in diagnosing the fracture likely to have changed the outcome?
Finding: the emergency department X-ray report of 2 May records "no acute fracture" (Record 4). An MRI on 23 May reports a scaphoid fracture (Record 9).
Inference: a scaphoid fracture can be missed on initial X-ray, and the published literature describes higher rates of complications such as non-union when treatment is delayed.
Gap: the file contains no record of follow-up imaging being offered between 2 and 23 May, and no record of the patient's symptoms in that period.
Opinion: stated by the expert, with the reasons above, and qualified by the gap.
Where MIA helps
MIA is a literature desk for medicine, biotechnology and the medico-legal file. Put the records, papers and questions down and MIA writes a working that keeps finding, inference and gap apart. It can help you find and read the literature behind an opinion, order the material reviewed, and see where the file is silent.
MIA does not examine anyone, does not give the opinion, and does not sign the report. Imaging and pathology are read as supplied, in educational pattern-language, not as a radiology report. It is not medical advice, not a clinician and not a medical device. Human judgment remains the authority.
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