In the second article following MPS’ 15th Ethics For All conference, Dr Shivani Chirkut, medico-legal consultant for Medical Protection Society (MPS), highlights some top tips when it comes to clinical report writing. This follows her presentation in which she took delegates through some common pitfalls on report writing and how to avoid them. This article will provide high level advice, while a replay of the session can be watched in full.
Dr Chirkut writes:
When would you be required to write a clinical report?
There are various circumstances in which the writing of a report may be necessary.
A request to prepare a report for legal or other purposes may be received from the following:
• the patient,
• an attorney,
• the patient’s insurance company,
• a statutory or regulatory authority like the HPCSA,
• an employer,
• the police (e.g. in criminal proceedings or an inquest investigation), or
• a court.
Any report, like your clinical records, should be considered a medico-legal document, so you need to be mindful of what you write and how you express yourself.
Before preparing the report
Given that the report would contain the patient’s personal information, ensure you have permission from the patient to provide the report. Ideally, any medico-legal report – generally one written to be used in legal proceedings – should be prepared in response to a written request, accompanied by an appropriate signed authority and/or the patient’s permission.
What if the request comes from any authority other than the patient?
In that case, it may be appropriate to confirm with the patient that the authorisation is valid by ensuring that he or she is aware of what has been requested, and agrees to release this information. A breach of confidentiality and privacy is one of the most common causes of complaints after a practitioner has provided a report.
Before agreeing to compile a medical report, it is crucial to understand its purpose and intended use. Seek clarification from the requesting party if the purpose is unclear. When writing it, it is important to remember three key questions:
- Who and what is the information for?
- Who will read it?
- How might it be used and possibly misused?
- This will help guide your writing in terms of content, tone and clarity.
Am I obliged to provide a report when requested?
Most practitioners do not delight in writing reports. Nevertheless, it comes with the territory of clinical practice and is a vital and empowering skill.
A question often asked is: just because a report has been requested, am I obliged to provide it? Can I simply decline the request?
In general terms, there is no legal obligation for you to prepare a report, although some statutory bodies may compel the preparation of one in certain circumstances.
However, a treating practitioner has a professional and ethical obligation to assist by providing factual information concerning a patient’s condition or injury, at the patient’s request, to the patient’s legal advisers or, with the patient’s consent, to any nominated third parties.
Importantly, while there is an ethical obligation to assist the patient by providing a factual report, you are under no obligation to give an opinion in your report. Of course the context is different if you have agreed to be an expert witness, in which case your professional opinion is a requirement.
Some tips for a good report
1. Ideally, you would use your clinical records to prepare your report. Therefore, ensure your day-to-day clinical notes are clear and comprehensive.
2. Be clear and accurate in your writing, and always be objective. Avoid ambiguity. Be clear about who did what, when, why and to whom.
3. Write in the first person for clarity. So instead of saying, “Mr X’s left knee was examined”, rather say, “I examined Mr X’s left knee”.
4. The report must be factual, relevant to the request, and understandable to a non-clinical audience. Always consider who will read the information and write for their understanding.
5. Sufficient and relevant detail is required. While information that is obviously unnecessary should be excluded, if in doubt, err on the side of caution and include information that may be relevant. The extent of the clinical information contained will depend on the report’s nature and purpose, and is a matter of clinical judgment. You should decide that on a case-by-case basis.
6. Only report on facts you know, and comment within your expertise
7. The report should be structured and well organised. Lay out your points in chronological order. If the report is long, use headings and subheadings, and numbered short paragraphs for ease of reference for the reader
Common pitfalls to avoid
1. Rushing due to a deadline – Ensure you have a reasonable time frame within which to prepare. If necessary, discuss this with the party who has requested the report.
2. Failure to adequately proofread your draft – Dictation issues, typographical errors and spelling and punctuation faults are unpleasant. It is careless, chaotic and irritating for the reader. It comes across as unprofessional and disrespectful.
3. Using jargon and abbreviations – If you have to use pure clinical terminology, explain the terms and concepts in layman’s language, either in the text or in a footnote. Make sure your terminology is technically correct. If you are challenged or cross-examined, be prepared to explain the meaning accurately.
4. Using legal terms – Some concepts, like “grievous bodily harm”, “rape”, and “sexual assault”, have clear legal definitions and are not technically clinical terms. In your report, simply write what the patient said or describe the injury you saw.
5. Providing an opinion on negligence – There is a tendency, even for experts, to opine on negligence when it is not really their gift. Experts can opine on duty of care, foreseeability, standard of care and medical causation, but should be cautious of opining on the composite of all these factors – negligence.
6. Altering reports – Do not alter your report at the request of the patient or a third party – if you need to amend your report or you have made an error, you may always provide a supplementary report or addendum. This is acceptable in legal proceedings and indicates transparency and good intent.
7. Providing opinions beyond your knowledge – Stick to what is within your expertise and don’t provide an opinion in an area in which you lack expertise. You may have a reasonable and sensible opinion on an issue, but it may not be within your professional capacity to indicate so at that point.
However, if you feel you need to provide an opinion for any reason, be sure to clearly distinguish between fact and opinion. An opinion may come under particular scrutiny and publicly tested in court. Accordingly, be confident in those instances and be prepared to explain your reasoning if required.
If you are asked for your opinion and are not comfortable opining because the matter is beyond your expertise, you may state this and decline to provide an opinion. Do not be pressured into stating anything with which you are uncomfortable or not confident about. If you wouldn’t say something under oath in court, you should not write it in your report.
8. Using emotive and personal remarks – towards the patient, family or colleagues. Remember that the patient or their family may have sight of the report, so avoid humorous and unnecessarily subjective remarks.
Furthermore, unreasonably criticising or slating colleagues comes across as unprofessional and unethical. Ensure your language is impartial and that your words don’t have hidden assumptions. Be careful and read through your draft report with a critical eye.
Final task
Finally, sign the report, date it, and make a copy for your records. When you submit the report, indicate in your records to whom you gave it, in what format, and the date and time you did so.
Conclusion
The preparation of a clinical report for medico-legal or other purposes is an essential part of the service provided by healthcare practitioners. Sadly, it is seldom, if ever, mentioned or discussed during undergraduate or even postgraduate training. However, it forms a significant part of our professional duties to our patients.
Consequently, we must accept and embrace the responsibility by developing the skills required to write well-structured, clear reports that will assist patients effectively. Whatever the reason for the report, a good one will lead to an early resolution of the case, resulting in better outcomes for all concerned, including you. From a medico-legal perspective, a good quality report is incredibly valuable in addressing and resolving a host of issues.
If MPS members are in doubt about an aspect of report writing, they can contact us to seek assistance.
The full session from MPS’ 15th ‘Ethics For All’ conference can be viewed online.
See more MPS columns from MedicalBrief archives:
How to navigate medico-legal matters in healthcare practice
Badmouthing colleagues unethical and risks healthcare reputational damage
Understanding why and how to manage patients’ expectations