Medico legal reports are often required in the context of litigation. They are used by solicitors to support their client's claims of injury and to help determine the cause.
GPs are not obliged to prepare medico legal reports but are generally free to do so, provided they have the patient's express consent. Be aware that these reports are addressed 'to whom it may concern' and will be released to third parties.
EXPERTISE
Medico legal reports are essential evidence in various court cases, including personal injury claims and medical malpractice. They can help the courts make sound decisions based on medical facts and expert opinions. Consequently, these reports must be prepared by a qualified doctor.
A GP should only prepare a medico legal report upon request, with the patient's consent and the patient's knowledge of what information will be included. It is also advisable for doctors to avoid putting forth unsubstantiated opinions and judgements in medico legal reports. They should write within their expertise and elaborate on the reasoning behind any clinical judgments.
Moreover, doctors should be wary of requests for medico legal reports addressed 'to whom it may concern', as this could suggest that the information is being provided without the patient's consent. It is a good idea to always obtain signed permission before preparing medico legal reports.
CONFIDENTIALITY
The professional duty of confidentiality covers more than just the information patients reveal to their doctors. It also includes doctors' opinions and conclusions during their medical examinations and assessments. For this reason, it is essential to ensure that medico legal reports are prepared only in response to a request accompanied by the patient's express written permission.
In some cases, physicians may be required to breach patient confidentiality to protect public safety. However, this can be difficult to justify, especially when the public safety threat is not overt.
The quality of a medico legal report is crucial for the legal outcome of a case. Therefore, the doctor who prepares it must take the time to ensure that the report is comprehensive and accurate. Hiring a medical-legal editor can save doctors valuable time and help them produce high-quality reports. It can also help them avoid errors, undermining their credibility as an expert witness.
FORMAT
Medico legal reports are an essential part of the claims process. Whether for personal injury, disease, or medical negligence, they need to be accurate and current. However, arranging a medico legal report can be time-consuming and frustrating for both the client and solicitor. Medical agencies can take the stress out of organising an examination by liaising with the client and experts to arrange a convenient appointment and ensure the report is produced on time.
Doctors are legally required to prepare a medico legal certificate whenever the patient or their solicitor asks for them. A medico legal certificate is an opinion given by the doctor after observing a patient's history and clinical examination. This opinion will be used as evidence in court proceedings. Incorrect or incomplete medico legal reports can ensure the process and prevent a loss of patient rights. Therefore, doctors should be prepared to be cross-examined in court for their opinions.
SIGNING
Medico legal reports are often required in medical negligence or personal injury cases. These can help solicitors to establish the cause of an accident and to quantify the injuries suffered by a client. It is a doctor's moral and professional responsibility to provide such a report upon request by a solicitor, as failure to do so could deprive the patient of benefits to which they are entitled.
Ensure that you have the express permission of the patient to produce a medico legal report. It is advisable to confirm this by asking them directly rather than leaving it to the solicitors to ask 'to whom it may concern'.
CONCLUSION:
If you are a GP producing medico legal reports, ensure that your e-signature software allows dual signatures. This allows scribes and assistants to type entries or documents with a subsequent physician or provide authorisation. As per organisational policy, a scribe's initials and supervisor's name should appear on the final document.