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Introduction to medical reports

Doctors and other healthcare professionals are sometimes asked to provide medical information about their patients. These requests may come from a variety of sources including employers, insurance companies, government agencies, regulatory bodies, lawyers and others. The information may be asked for in the form of a medical report, a certificate, a statement or a letter.

This article looks specifically at the issues surrounding medical reports prepared for employers, insurers and similar organisations, and offers advice to healthcare professionals who are asked to write these reports.

Advice on reports requested by the Coroner or Procurator Fiscal following the death of a patient is provided in our essential guide to inquests.

What are medical reports?

A medical report is an official document written by a medical professional following a medical examination.

Medical reports form part of a patient's overall medical records. 

Consent

When asked to provide information about a patient to a third party, a healthcare professional before doing so must be satisfied that the patient has consented to the disclosure.

It is the responsibility of the person or organisation requesting the report to obtain consent from the patient, and it should be in writing. It is advisable that the individual providing the report should see the written consent, alternatively they may accept an assurance from an officer of a government department or agency that the patient has consented.

If the information relates to an adult who lacks capacity, authorisation may be granted by a power of attorney who has been appointed to make decisions on the patient's behalf. Where no attorney has been appointed, information can be released where there is both a legitimate need for the information, and releasing the information would be in the best interests of the patient.

If the report is covered by the Access to Medical Reports Act (1988), the person or organisation requesting the report should let the patient know about their rights under this Act.

More information about consent and disclosure of medical records and patient information can be found in our essential guide to confidentiality in medical practice and healthcare.

Read more on: Access to medical reports

Scope & probity

When preparing a report it is important to understand who has requested the information and why, checking carefully any instructions before agreeing to undertake a report, raising any questions or concerns formally and at the earliest opportunity.

It is essential to be satisfied that the patient has received sufficient information about the scope, purpose and likely consequences of the disclosure of the information to be contained within the report and the fact that relevant information cannot be concealed or withheld.

If there is concern that disclosing certain information may cause problems for the patient, it is important to discuss this with the patient before agreeing to provide a report.

 

The General Medical Council (GMC), in Good Medical Practice (2024), states that registrants must be honest and trustworthy in all their professional written, verbal and digital communications. This means that it is important to make sure any information provided is accurate and not false or misleading, taking reasonable steps to check the information is accurate and not deliberately leaving out relevant information.

Only factual information that can be substantiated and relevant to the request should be disclosed and it should be presented in an unbiased manner. It is important to restrict a report to areas of direct experience and relevant knowledge.

Format

The format of a report will often depend on the nature of the request, for example, reports at the request of a Coroner following the death of a patient should take a particular form and include particular details, more information on what to include in a report for a coroner can be found in our essential guide to inquests.

It is advisable that a report is written on headed paper (when available) and it should contain the authors personal details, including full name, professional registration number (for example GMC number) and qualifications. In the introduction to the report, it is helpful to set out the professional role of the individual writing the report and nature of the contact with the patient. It is also helpful to indicate who has requested the report and why, and to list the documentation used to prepare the report.

A report should be capable of standing alone. It should not be assumed that the reader will know anything about the patient, the context of the request, or have access to the patient's medical records. It is important to explain medical terms or abbreviations, a report may need to be read by people who are not medically trained, including the patient.

Dates and times for each relevant consultation or patient contact should be described in a separate paragraph in chronological order, along with details of history and examination findings, the working diagnosis and management plan including details of medication provided, advised or prescribed. Where possible, significant negatives as well as positive findings should be included, and a description of any information given to the patient and plans made for follow-up. Where relevant, referrals made should be detailed, identifying the name of the person to whom the patient was referred.

It is important to include information only, within the scope of patient consent, this might mean providing information relating to a particular time period, incident or medical condition, or in response to particular questions, this is especially important when providing information to an employer or insurance company. Although it is essential to ensure that all information relevant to the request is included, if including certain information may cause problems for the patient then a discussion with the patient should take place.

Ideally the report should be typed, not handwritten, and checked carefully before it is signed and dated.

Finally, a copy of the report should be retained along with a note of when and to whom it was submitted.

A report should be sent without unreasonable delay and within the time frame agreed, if there is likely to be a delay then those that instructed the report should be informed of the delay and an extension to the time frame for providing the report agreed.

Access to Medical Reports Act (1988)

The Access to Medical Reports Act 1988 and Access to Personal Files and Medical Reports (Northern Ireland) Order 1991 give patients the right to see medical reports written about them, for employment or insurance purposes, by a doctor who they usually see in a doctor/patient capacity. This includes reports written by the patient's GP or a specialist who has provided direct care to the patient.

A report must be kept for 6 months and patients have a right to see the report during this time, even if they did not previously express a wish to see the report.

Under this legislation and as part of the consent process patients must be informed by an organisation of their intention to seek a report and of their rights to have access to the medical report either before it is sent or for up to six months after it is sent. The patient should also be informed of their right to instruct a doctor not to send the report (if seen before sent) and to request amendments to inaccuracies contained within a report.

It is the responsibility of the requesting organisation to inform the doctor if the patient would like to see the report. If a patient expresses a wish to see a report before it is submitted, they must arrange to do this within a 21-day period, and the report must not be sent before this time has elapsed, unless the patient has seen the report and agreed to it being sent.

In accordance with the Data Protection Act (DPA) 2018 and the General Data Protection Rules (GDPR) information may be withheld from the patient if providing the information would be likely to cause serious harm to them or to another person's physical or mental health or condition. Disclosure would provide information about another person or identifies another person as a source of information (excluding another healthcare worker), unless that other person consents or it is reasonable in the circumstances to supply the information without their consent.

For more information on the provisions of the DPA and GDPR please see our essential guide to record keeping.

Amendments

If patients believe there are factual inaccuracies within a report they may apply in writing for the information to be amended. If there is agreement between the doctor and patient that the information is wrong then the report can be amended. If the doctor does not agree that there is an error, a note may be appended to the report regarding the disputed information.

Doctors must not comply with patients' requests to leave out relevant information from reports. If a patient refuses to give permission for certain relevant information to be included, the doctor should indicate to the requesting organisation and patient that they cannot write the report, taking care not to disclose any information the patient did not want revealed.

Information can still be disclosed if required by law, or if it is in the public interest to do so. Disclosing personal information about a patient without consent may be justified in the public interest if failure to do so may expose others to a risk of death or serious harm. This could arise, for example, if a patient may pose a serious risk to others through being unfit for work.

For more information please see our essential guide to confidentiality in patient care.

Read more on: Confidentiality
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Independent medical practitioners and healthcare professionals

The legal requirements set out in the Access to Medical Reports Act do not directly extend to doctors or other healthcare professionals writing reports on individuals who are not their “usual patients” for example occupational health doctors.

However, the DPA and GDPR will still give an individual a right of access to their own medical records.

The GMC also places an obligation on all registrants to offer to show a patient, or give them a copy of, any report written about them for employment or insurance purposes before it is sent, unless:

  • The patient has already said they do not wish to see it
  • Disclosure would be likely to cause serious harm to the patient or anyone else
  • Disclosure would reveal information about another person who does not consent.

Legal, contractual obligations and fees

In many cases, there will be a legal, contractual, professional or statutory obligation to provide a medical report, for example to assist a Coroner with their inquiries or as part of a formal investigation or process. In many of these cases a fee for providing the report may not be charged, or there may be a statutory or “agreed” fee.

In some situations, doctors may charge for the completion of non-NHS medical reports, letters, and certificates. Typically, these requests come from insurance companies, employers, or from patients directly and include the types of letters, reports and certificates that are not funded by the NHS. This work does not form part of the NHS contract and as such, charges for these services cover the cost of the administrative and clinical time required to complete them.

More information about fees and NHS contracts is available from the British Medical Association.

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