Writing a treating practitioner medico-legal report

• Be familiar with your professional and legal responsibilities before writing a report.
• Provide factual information and be clear about the source of the information (the medical records or your recollection).
• Ensure you have a formal request and patient consent before providing a report.
• If you are asked to provide a report for a coronial inquest, disciplinary complaint or civil/common law claim, seek legal advice before submitting any documents.

A medico-legal report is a medical report prepared for legal purposes, such as a coronial inquest, disciplinary complaint, civil/common law claim for damages, third-party motor vehicle accident case, workers’ compensation matter, or determining testamentary capacity.

You may be asked to prepare a medico-legal report as the ‘treating doctor’ or to give your opinion as an independent medical expert. You need to be clear in which capacity you are being asked to complete the report.

You are not legally required to provide a report when asked, but it is a professional obligation to provide a treating practitioner report.

For information about preparing a medico-legal report as an independent medical expert, refer to our factsheet Writing an expert witness medico-legal report.

If you provide a medico-legal report, you may be called upon to give evidence in court.

A treating practitioner report is a factual account that summarises the patient’s condition and the care you have provided to that patient.

You should not give your opinion about the care given by others, nor be asked to.

You may be asked for your opinion about an issue that directly relates to your care, such as whether the patient is fit to return to work. This may fall into the realm of your opinion as an expert but only in relation to your expertise as the patient’s treating practitioner, not to be confused with being an ‘independent expert’. If you are confident that you can address this type of question, you can do so, but if you think it is outside the scope of your qualifications and experience and input from another speciality is required, you should say so. It may be that you can answer some questions but not others.

Occasionally you may be asked to provide a treating practitioner report when you have not been directly involved in the patient’s care. An example might be when the relevant doctor has left the practice, and it may not be practical to track them down. A senior doctor could write a report based on the medical record alone – providing that it is clearly stated to be the case.

If you are a junior member of the team and you are asked to prepare a report on behalf of your unit, you should make it clear the report has been generated by a review of the records alone, and ensure a senior member of the team reviews the report before it is sent. The hospital may have processes that need to be followed for providing reports like this – always check your hospital’s policies or with hospital admin before providing a report in these circumstances.

Do you have authority?

You need the patient’s consent to provide the report. Ideally, this should be in writing. A request from a third party, such as a solicitor or insurer, should be accompanied by a written authority signed by the patient. If in any doubt, contact the patient directly to confirm.

If you receive a request from the coroner (or the police on behalf of a coroner) for a statement or report about a patient who is now deceased, seek legal advice.  

It is appropriate to familiarise yourself with the details of the patient’s care by referring to the medical records as needed.

Depending on your health service, you may need to make a formal written request to the Medical Records department to access the records – check your health service’s policy and procedures to ensure you comply.

If you do access the medical records (particularly electronic medical records) to help draft your report, make an entry into the record stating why you were reviewing them. 

If you have been asked for a report on a patient’s testamentary capacity, refer to our factsheet Determining testamentary capacity for more information.

If you do not have access to the records (for example, because you no longer work at the location where you saw the patient), let the requesting party know. They may be able to provide you with a copy of the records, or you can decline to provide the report on that basis.

There is no set format for a treating practitioner report. We recommend that the report is written on your letterhead and contains:

• patient name and DOB
• your qualifications and experience at the time the incident occurred and currently, if different
• who has asked for the report and its purpose
• what documents you are referring to (for example, a solicitor’s briefing letter)
• the medical facts and the care you delivered to the patient in chronological order. For example:
  • relevant history and symptoms
  • examination and investigations (both positive and negative findings)
  • diagnosis (and provisional or differential diagnoses)
  • treatment and management specifying your particular involvement.
• answer any particular questions directed to you.

Be clear about the source of the information contained in your report, whether it is the medical record or your recollection.

If you cannot remember the patient, or elements of the patient’s care, it is appropriate to state this in your report.

If you clearly remember aspects of the patient’s care that are relevant and are not documented in the medical record, include this and specify that the source of this information is your recollection. 

Similarly, if your recollection of what happened varies from what is written in the medical record, make this clear in your report. Never amend the medical record.

Using artificial intelligence (AI) to generate your report

Do not use general-purpose generative AI tools (such as Chat GPT) to draft or generate your report.  

If you do use an AI scribe to generate your report, include a statement to this effect in your report and let the requesting party know.

Courts may not accept AI-generated reports as evidence in court proceedings and there may be privacy issues if you enter a patient’s identifiable health information into a third-party AI tool to generate the report. 

Professional responsibilities

The Medical Board’s Good Medical Practice: a code of conduct for doctors in Australia states that a doctor’s professional responsibilities include:

• Being honest and not misleading when writing reports and certificates, and only signing documents you believe to be accurate.
• Taking reasonable steps to verify the content before you sign a report or certificate, and not omitting relevant information deliberately.
• Preparing or signing documents and reports if you have agreed to do so, within a reasonable and justifiable timeframe.
• Making clear the limits of your knowledge and not giving opinions beyond those limits when providing evidence.

Legal responsibilities

If your report is going to be used in court, there are rules that a witness must comply with for their evidence to be admissible. These rules vary between jurisdictions and generally apply only to those giving expert witness testimony as an independent medical expert although may be useful if you are called to give evidence as a treating practitioner.

You can charge a fee for your time to prepare a report, depending on who has requested it.

When preparing a report for a third party (that is not a statutory body like WorkCover), you can set your own fees. Fees charged should be reasonable and not excessive.

The fee for a report should reflect the effort, skills and resources associated with the provision of that report. Many practitioners calculate their hourly rate (for consulting) and multiply this by the time taken to complete the report.

When calculating the fee to charge the following factors should be considered:

• the amount of income you will lose by spending time writing the report
• whether other employees will be involved in the preparation and at what cost their services are provided
• whether there are other costs directly associated with the service (for example, photocopying, and telephone calls).

It is important to be able to justify the fee charged.

When providing a report under a legislative scheme (such as WorkSafe), there is an expectation you will charge the rates as set out in the regulations governing that scheme. 

It is reasonable to ask for payment of the fee before providing the report (other than for reports requested by a statutory authority where this can be prohibited under their legislation).

If you are unsure about what to charge, seek advice.

When preparing a report, avoid emotive language and be careful not to make derogatory remarks about patients, parties to litigation, or your colleagues. 

You should also be aware of using medical terminology as your report will be read by non-medical people who will benefit from plain and clear language.

Take care with your language when outlining the patient’s history. You can include in your report as fact any symptom or sign that you observed (for example, “I observed bruising on the arm” or “the patient exhibited signs of significant distress when recounting the history”). Signs and symptoms that you have not observed directly are considered hearsay and so should be noted as part of a history given only, not as a fact (for example, “the patient reported suffering a fit before attending the ED but was not observed to have any absences or other indicia of a fit while in the ED”).

Do not alter your completed report at the request of your patient or third party. If you receive additional information or you need to correct an error, provide a supplementary report.

Remember that you may be cross-examined on your report one day and therefore should only include information you would be comfortable giving as evidence in court.

Your role is not to act as an advocate for your patient. You must not omit information that you think will be "unhelpful" to their case.  

Video - Writing a medico-legal report

Factsheet - Giving evidence in court

Factsheet - How to write a coronial statement

Factsheet - Determining testamentary capacity

Factsheet - Writing an expert witness medico-legal report

For medico-legal advice, please contact us here, or call 1800 128 268, 24/7 in emergencies.