Lex Medicus’ 12 rules to write a winning Medico Legal Report

May 12, 2016

Here are Lex Medicus' 12 rules to write a medico legal report:

1.     Create a general template of a standard MLR for your practice.

2.     Prior to conducting a medical examination, add on the template patients’ personal data and copy questions from the lawyers’ letter of instruction.

3.     Structure the MLR into:

      Client information - name, address, date of birth, DOB, date of incident, DOI

      History - chronological medical history with reference to diagnostic / objective evidence and symptoms onset and further development

      Present complaints

      Past history - injurious events and other relevant facts that may affect client’s health and work capacity

    Work description

      Lifestyle evaluation - personal status, profession, ability to perform daily activities and recreational activities

      Physical/Medical evaluation - provide measurements for range of movement for the body part of interest and the healthy counterpart, level of pain or any changes in body  appearance and function

      Enclosures - if available include in chronological order e.g. plaintiff and defendant medical reports


     Analysis and discussion


     Answers to lawyer’s questions - written concisely of max 10 lines

     Examiner’s signature of the agreement on

    Acknowledgment of the Expert Witness Code of Conduct.

4.     Keep the report concise to a maximum of 6-12 pages

5.     Use layman language and explain every medical abbreviation.  

6.     Write short sentences 

7.     Answer questions directly and adhere to the topic

8.     Give a clear, objective opinion on facts and suggestions on further examinations and directions if symptoms have not been investigated properly

9.     Be respectful of patients’ racial, religious, physical characteristics and sexual orientation

10.  Deliver the MLR within the timeframe

11.  Preserve client privacy and handle the report with maximal confidentiality

12.  Set a quality assurance process in place to provide high standard and style consistent MLRs

Thomas Kossmann

Mr Kossmann is an Orthopaedic and Trauma Surgeon, Independent Medical Examiner. Founder and CEO of Lex Medicus and Co-Founder of Medicus Publishing

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