15 tips for writing effective medical/legal reports:

Presented to: The Hamilton Civic Hospitals
Written by: Rhona L. Waxman Law Offices
  1. If you are asked for an opinion, give one.
  2. Avoid the pitfalls of using legal terminology. Although your report will be used in the context of a lawsuit, you should not provide legal opinions.  You are providing medical opinions. Legal terminology should be avoided.
  3. Avoid the temptation of optimism. You are being asked for your realistic opinion.
  4. Be very careful of loaded words. For example, saying that your patient “claims to have pain”“complained of pain” or “had pain” leaves very different impressions.
  5. Keep very good notes. 
  6. Generally, no one wants you to report on discussions from the referral sources.
  7. Avoid red herrings.  Don’t discuss issues that have no relation to the matters at issue.
  8. Be careful not to climb out on a limb. By that, I mean don’t express opinions outside of your area of expertise.
  9. Be very careful and cautious when commenting on entitlement issues as opposed to clinical issues.  Be aware of the difference!
  10. Be very careful when commenting on things such as lack of effort and motivation. These will have a significant effect on your patient’s entitlement to compensation.  Comments of lack of effort and motivation will often be interpreted as malingering. However, there can be many causes for lack of motivation and lack of effort.  For example, lack of effort could be caused by depression.
  11. Read everything that you are given from the referral source, and everything that you have concerning the patient.
  12. Be very careful when evaluating surveillance.  You may not know the context.  You also may not have all of the surveillance.
  13. If you are not the treating health care professional and the patient has been referred to you strictly for the purposes of a medical/legal assessment, be cautious when making recommendations for treatment. 
  14. Do not shy away from using medical terminology but please provide definitions or explanations of the terminology where necessary.
  15. In your report, discuss all meetings and assessments of the patient.