Doctors and Lawyers Perfect Together

A neurologist recently asked me to help him write a medical report for one of my injury cases.  Every medical report in a legal case must cover certain key points.  Here is what I told this neurologist. 

A medical report to be useful in litigation must cover the following:

• History
• Description of complaints of pain, symptoms and loss of function
• Diagnosis
• Statement of causation
• Degree of medical certainty

A final report must also contain a sixth element, a prognosis.

1. Let’s start with history.  The medical report must describe the cause of the
 injury in a very general way.  For example, it should indicate that the client was
 involved in an accident.  It should not be too detailed since the more detail there is,
 the more chance that a defense lawyer will be able to point out inconsistencies between
 what the client says happened and what the doctor has written in his report. 
 
 The history should also briefly describe how the client was feeling before the accident and
 should also discuss prior treatment and any prior relevant medical conditions.  These
 would include symptoms and findings in any parts of the body that were injured in the
 accident.   Finally, the history should include what the client did immediately after the
 accident, for example, called 911 and went by ambulance to the emergency room.
 
2. The report should include a complete description of the complaints of pain,
 symptoms and loss of function as of the time of the visit with the doctor.
 
3. The doctor should indicate a diagnosis. This can be a brief statement as to each and
 every part of the body affected by the accident.  If the client aggravated body parts
 that were previously injured, this should be clearly stated.
 
4. The report must indicate clearly how the accident affected the client, that is, it must
 describe the causal connection between each separate diagnosis and the
 accident. 
 
5. At the end of the report, the doctor must state that all of the opinions in the report
 are stated to “a reasonable degree of medical certainty”.  That is the standard in my state, Pennsylvania.   Something similar is required in every other state.

When the neurologist is preparing his report after the client’s final visit, he will need to state a prognosis.  This involves what he expects the future to hold for the client with regard to his accident-related injuries.  This would include the need for additional therapy, surgery, etc.  It should state that the prognosis is excellent, good, guarded or poor, depending on the reality at that time.

Properly armed with a well written medical report, the attorney will be well on the way to  successfully settling the case.