Our members often ask for our advice on writing medical reports; here, Dr Stephanie Bown offers her tips on what makes a good report
Various situations exist in which the writing of a report may be necessary. It may be written for an employer, such as if something has done wrong, or for the coroner, a solicitor, the police or the insurance company of a patient. Doctors and health practitioners may consult the advice of a medicolegal expert on writing a report when they are required to do so as a professional witness or lay witness, the latter meaning that they are writing as a member of the public. Professional witnesses, meanwhile, are those with involvement in some aspect of the patient's care.
There are various different ways in which an incident can be investigated, including as a complaint, a criminal case, a clinical negligence claim, a disciplinary matter by your employer, a complaint to the GMC or a Coroner's request. However, a written report on the circumstances of the incident is an important starting point. The medicolegal expert would always advise that this report is based on medical records, the health professional's own recollection and their usual practice. The report should also be detailed, clear and objective, with the facts stated and ambiguity avoided.
The GMC states that reports must be written in an honest and trustworthy manner, and they should not include criticism of others or general comments on hospital politics. A medicolegal expert can be consulted if the health professional has any concerns or questions about the writing of the report. Most reports that are requested to be written will be statements of fact, providing an account of what took place. The author must only report facts they know, in addition to only commenting within their expertise. This can include an account of what they were told, and what they read in the patient records (even if the record was made by someone else).
If, as is likely, the disclosure of confidential information about a patient is required, the report writer should make sure they have the authority to disclose this information. They should get the consent of the patient (if appropriate) and ensure that they clearly understand the information that is to be provided and why it is needed.
"The author should also not exceed their level of competence, or deliberately conceal anything as this may cast doubts on their probity"
The report should incorporate, in addition to patient details, the personal details of the author, including their qualifications and relevant clinical experience and background. The report should also include the details of other healthcare professionals involved, as well as presentation and history, findings on examination, diagnosis, investigations and subsequent management and follow up arrangements and information the patient or relatives have been given.
Other sound medicolegal expert advice on report writing includes to write in the first person singular, address the report to an intelligent layperson and organise the report chronologically. The report should be written honestly, with no influence from others, and as soon as possible after the event. However, the author should also not exceed their level of competence, or deliberately conceal anything as this may cast doubts on their probity. A supplementary report may also need to be produced on occasion, dealing with issues arising after the composition of the original report.