How To Write A Report for Medical Purposes?

The doctors and the legal system have a method of communication, and this is usually done by making a report. A medical report helps in the process of communication but there are a lot of things that you must keep in mind. The format has to be an organized one. Things to be included are background information, physical examination, medical history, treatment details etc.

The report creates a bridge between the doctors and the legal system. Now you might ask why that is necessary. This does not always happen in the case of any and every patient. This is applicable for unique cases where the law might get involved.  A medical report must be generated in case of an accident victim or an assault victim where without a report the legal proceedings cannot continue.

Medical Report

Structure

As mentioned above the report must follow a proper structure so that it is easy for the legal practitioners to find out the necessary points.

  1. First of all you must provide a proper background information, or data. This data must include the basics like the date, time and place and also the examination reasons. A medical report should also include a report on the kind of offence committed. Also if there are any medical conditions that the patient is suffering from that should be mentioned too.
  2. There should be a detailed account of the different states of the patient as per seen though examinations conducted on them. The states include physical and psychological states. These things are especially noticeable in rape victims. If there is any lack of co operation on the part of the patient then that to should be included in the medical report.
  3. There are lots of specimens that are usually involved with a report and those details should most definitely be a part of the report as well. These work as evidence in court and are extremely important for the proceedings to be conducted properly. There should be general information report provide on the specimen that has been collected, like where it has been found and also when.
  4. The facts that you provide can be backed up by your own opinion as a medical examiner but there should be a clear demarcation between the two. However you must know that it will not be taken as a given and will undergo a lot of scrutiny. Make sure that the opinion is at par with the facts provided, so that they do not sound too farfetched.

The end result should ideally be a well organized and informative medical report that has all the required materials and that can be produced in court as substantial evidence. The drafts of the report that you have made need to be destroyed so as to avoid confusion on the part of the reader.

You can get your report reviewed by some expert or some experienced colleague so that you find out any mistakes before it is sent out to court. But proper flawless organization of the reports is of utmost importance.