Patient follow-up-Legal issues

Question 1

What are the risk management strategies to avoid legal hassles in patient follow-up?

Answer 1

• Adequate medical records
• Appropriate explanation to the patient about further MX and documentation of the same
• Striking the right balance of not alarming the patient if not urgent and still emphasising the importance of further Ix
• Follow-up reminders is very important on the records

Question 2

What is a medico-legal report?

Answer 2

• Once prepared, the report may be used as
  evidence in court proceedings and subjected to close scrutiny.
• A structured and comprehensive medico-legal report may minimise the chances of having to give evidence in court.

Question 3

What are the types of medico-legal report?

Answer 3

A request for a treating doctor to prepare a report for legal purposes may be received from:
• a patient
• a solicitor
• an insurer
• a statutory authority (eg WorkCover)
• an employer
• the police
• a court

Question 4

Is the doctor obliged to provide a medico-legal report?

Answer 4

• In general terms, there is no legal obligation for you to prepare a report, although some statutory bodies (eg AHPRA, WorkCover) can require the preparation of a report in certain prescribed circumstances.
• A treating doctor 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 other nominated third parties.
• Importantly, although there is an ethical obligation to assist the patient by providing a factual report, you are under no obligation to provide an opinion in your report.

Question 5

What are the principles of preparing a medico-legal report?

Answer 5

• Ideally, any medico-legal report
  should be prepared in response to a written request, accompanied by an appropriate signed authority and/or the express permission of the patient.
• Know the nature and purpose of the report.
• Use the medical records to prepare the report.
• In the report, it is useful to include headings and,
  if the report is long, numbered paragraphs
• Medical facts in chronological order
• If you have no independent recollection of your management of the patient, the information in your report will be based solely on what is recorded in the medical records
• being honest and not misleading when writing
  reports and certificates, and only signing
  documents you believe to be accurate

Question 6

What are the legal obligations of a medico-legal report?

Answer 6

• On occasion, however, a treating doctor may be asked to provide a report and abide by the Expert Witness Code of Conduct. If you are asked to abide by the Expert Witness Code of Conduct, you should ask the requesting party to provide you with a copy of the relevant code, and seek advice if you are unsure of your obligations.
• An expert has an overriding duty to assist the
  court on matters relevant to the expert’s area
  of expertise.
• It is important to be aware that any opinions
  expressed in a medico-legal report will often come under particular scrutiny by the reader of the report and may be publicly tested and challenged in court.
• Remember that you may be cross-examined
  on your report – only write what you would be
  prepared to say under oath in court

Question 7

What are the tips and traps of a medicao-legal reports?

Answer 7

• Ensure that you have the patient’s permission to provide a report
• Special care needs to be taken in Family Court matters where you may have treated both parties and you are asked to prepare a report by one of your patients involved in the proceedings.
• Remember that you may be cross-examined
  on your report – only write what you would be
  prepared to say under oath in court.
• Do not alter your report at the request of your
  patient or a third party
• Avoid the use of legal terms and explain medical jargon
• Do not record the patient’s history of events as ‘fact’
• Differentiate fact(s) from opinion(s).
• Beware of providing an opinion that is beyond
  your knowledge
• Do not act as an advocate for your patient –
  you should not deliberately omit any relevant
  information and avoid emotive language
• Seek advice from your medical defence
  organisation if you have any concerns, including asking to review your draft report.