Medico-legal report

Definition:

A medico-legal report is a structured way for communication between the doctors and
the legal system.

Implications of medico-legal reports:

Medico-legal reports may be used in criminal or civil proceedings with consequences

for:

• The patient
• The doctor
• Third parties
• The judicial system

Who could request for medico-legal reports?

Requests for medico-legal reports are common and originate from:

● Police ● Lawyers ● Government tribunals

● Insurance companies ● The patients themselves

To whom request for reports directed?

• The request should be directed specifically to the most senior doctor who was
involved with the clinical management of the patient.
• It is less satisfactory to direct the request to any person involved or to someone
who may only compile a report from the medical notes. There will always be
uncertainty as to why the senior treating doctor was not asked.

Medical Report Ass. Professor/Mona Ghoneim

 Medico-legal report

Elements of request for medico-legal reports:

The request should specifically state:

• Who should write the report

• The name and preferably the date of birth of the patient concerned
• The time and date of any incident
• The purpose of the report
• Any specific issues that need to be addressed
• The request should be accompanied by a signed statement of consent completed by
the patient or legal guardian, allowing release of medical information.

Criteria for valid consent:

• The subject (or their legal guardian) must be competent to provide it

• It must be informed. The subject must have a clear understanding of the
implications of the release of the information
• It must be specific
• It must be freely given

Requirements for medico-legal reports:

Medico-legal reports must be prepared with:

• Accuracy
• Diligence
• Understanding of basic legal principles.
• Clear communication as they are used by a diverse non-medical subjects
Medical Report Ass. Professor/Mona Ghoneim
 Medico-legal report

Pitfalls of medico-legal documentation:

• You must be honest and never attempt to change an existing record

• The record should maintain a professional tone.
• Refusal to write a medico-legal report is not a warranty for staying out of court. All
medical documentation may be requested & the responsible person called to court to
testify.
• Medical records must be interpreted by medical practitioners: the medical practitioner
shares to achieve justice and has the responsibility of helping the court in finding the
evidence for a crime or a solution in various legal issues.
• Failure to keep good clinical records is a form of negligence.
• Informed consent to conduct a medico-legal examination, compile medico-legal
documentation, collect evidence, investigate the evidence, take photographs, and most
importantly, release information about the person, must be obtained.
• The release of information about a patient is only legal when the user consents to that
disclosure in writing except if there is a court order or law that requires disclosure, or
if non-disclosure of the information represents a serious threat to public health

Photographic documentation

• A new memory card must be used.

• The settings of the camera must be selected according to certain rules, i.e. the
numbering of photographs must be set on “continuous”.
• The images must be in a complete series; therefore, all photographs, even
photographs accidentally taken or out of focus must be submitted.

Medical Report Ass. Professor/Mona Ghoneim

 Medico-legal report

• The processing of the photographs must be performed in such a way that the
possibility of change can be excluded.
• It is suggested that photographic material is retained as part of the practitioner’s
confidential medical notes, and stored in a locked cabinet at locked premises.
• Anonymity must be preserved by labeling the material.
• With the specific consent of the patient, the material can be shown to other
colleagues for a second opinion, viewed by a named doctor providing expert
testimony for the defence, and used for teaching purposes. The material should not
be released to nonmedical parties, except on the directions of the court.
• Genital images: To safeguard the practitioner against criminal charges in this
respect:
i) Sensitive photographs should not be kept on cellular phones.
ii) The material must also be password protected on computers.
iii) Photographic images are of value for training purposes if the consent includes
this, and are invaluable for peer review and consultation purposes.

A suggested structure for medico-legal report:

• Background: date and place, and the reason for the examination, detail the nature
and extent of your involvement in the case, a brief account of the alleged offence
and the sources of that information should also be included.
• Medical history: brief account of any relevant medical conditions is appropriate.
• Examination: general presentation of the subject, emotional, psychiatric and
intellectual state and the effects of alcohol or other drugs should be described,
specific attention should be given to sites of particular interest, relevant negative

Medical Report Ass. Professor/Mona Ghoneim

 Medico-legal report

findings should also be recorded and if there are any difficulties or limitations
encountered during the examination.
• Specimens: It is uncommon for hospital staff to be required to take forensic
specimens. Details of all specimens obtained should appear in the medico-legal
report (the site from which the specimens derived, the way they were labelled,
details of handling and the reason for obtaining that specimen, the time and date of
transfer of specimens).

N.B.: If investigation or treatment is ongoing, a further (supplementary) report may be

required.

• Opinion
i) It is advisable to distinguish between fact and opinion. The facts being what was
seen or done and the opinion being what was inferred or assumed ‫الرأي هو ما تم‬
‫استنتاجه أو افتراضه‬.
ii) The authors experience and expertise are fundamental to the weight given by the
court to their opinion.
iii) Some opinions sought may be beyond the expertise of the author. Under these
circumstances, the requesting agency may seek an opinion from another more
experienced practitioner based upon the earlier report.
iv) When formulating an opinion, it is essential to maintain impartiality and
objectivity.
v) Only say what you would be prepared to repeat under oath in court.

Reference: Young S and Wells D (1995): “The Medico-Legal Report in Emergency

Medicine”Emergency Medicine, 7:233.

Medical Report Ass. Professor/Mona Ghoneim