Preparing a legal medicine report

Introduction The Australasian College of Legal Medicine (ACLM) created the Expert Witness Training Programme (EWTP) and Expert Report Writing course. Receiving Instruction The lawyer instructs the expert whose letterhead should confirm the expertise. If not suitably qualified or unable to satisfy the lawyer, (s)he should advise accordingly. The expert's duty is to the court. Experts must read the letter of instruction, including assumptions and questions, determining what is expected. If in doubt, contact the lawyer. The expert must decide whether to see the patient or report on provided material. The Legal Medicine Consultation If a consultation is required, it must include: informed consent; a medical history; and physical examination. After the consultation, the expert must read all provided information. Preparation of the Legal Medicine Report The report should include: an introduction describing the nature of the consultation; who requested it; presenting symptoms; history of the present illness or injury; and any additional data. It should provide: social history; past medical history; medications; employment history; and any other information as relevant to the case; followed by a list of complaints, and the physical examination. Having completed the patient assessment, and reviewed all additional material, the expert should formulate his/her opinion, explaining the reasoning, and answer posed questions. There should be a 'potted' resume and adherence with the 'code of conduct'. Other Considerations If the expert feels that something is missing (s)he should contact the instructing lawyer. (S)he should not prepare draft copies of reports. Some lawyers ask for a tele-conference before preparing the report. Avoid unnecessary jargon and acronyms, adopting correct grammar and avoid emotive language.