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Background
The preparation and provision of medico-legal reports by the treating doctor is an inevitable but sometimes unwelcome part of general practice.
Objective
This article outlines the steps involved in preparing a 'good' medico-legal report, including some of the common pitfalls to avoid.
Discussion
General practitioners play an important role in providing medico-legal reports about their patients for a wide variety of purposes. A medico-legal report may be seen by a diverse, non-medical audience. Once prepared, the report may be used as evidence in court proceedings and subjected to close scmtiny. A stmctured and comprehensive medico-legal report may minimise the chances of having to give evidence in court.
Keywords
medicolegal aspects; medical records; ethics, professional
Case history
The general practitioner (GP) received a letter from solicitors acting for one of his patients, with an enclosed authority signed by the patient. The patient's solicitors requested a report outlining the GP's involvement with their client, including the patient's initial presentation, diagnosis and management. The GP provided a report that included the following statement as part of the description of the initial consultation:
'The patient first came to see me with Mrs Z, her mother-in-law. I had treated Mrs Z for many years for chronic depression, which was the result of domestic violence, and she thought the patient would benefit from my considerable expertise in managing mental health problems.'
One year later, the GP received a letter stating that the Australian Health Practitioner Regulation Agency (AHPRA) was conducting an investigation into his professional conduct. In her letter of notification to AHPRA, Mrs Z had stated that the patient had used the GP's report in Family Court proceedings. This had caused Mrs Z considerable distress, revealing confidential information that was not known to her family.
Types of medico-legal reports
A request for a treating doctor to prepare a report for legal purposes may be received from:
* a patient
* a solicitor
* an insurer
* a statutory authority (eg WorkCover)
* an employer
* the police
* a court.
Am I obliged to provide a treating doctor medico-legal report?
In general terms, there is no legal obligation for you to prepare a report, although some statutory bodies (eg AHPRA, WorkCover) can require the preparation of a report...