A guide to preparing factual medico-legal reports

Mr Liam Heffernan advises on the steps to take when writing reports for the purpose of being a factual medical witness

Doctors are often asked by or on behalf of their patients for medical reports for the purpose of personal injuries litigation or other court matters.

At the outset, it is important to differentiate between acting as an expert witness and a factual witness.

Witness to fact vs Expert witness

A factual witness (or witness to fact) can give evidence concerning matters that they have personally witnessed such as an examination of the patient and any treatment provided. The focus of their evidence is on first-hand facts and observations; it is not their role to give evidence of their opinion, analysis, or speculation. This article will address medico-legal reports by a factual medical witness.

An expert witness is an independent individual with no link to a case, who is retained by a party to litigation or other proceedings to provide an expert opinion on matters outside the ordinary knowledge of the court (or other adjudicating body). The primary role of the expert witness is to provide objective, evidence-based opinions on clinical standards, and causation helping the Court to arrive at its own independent opinion on the facts.

Medical Council guidelines

The Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners provides some guidance in relation to the provision of medical reports. Paragraph 51 states:

“Doctors may be requested to provide medical reports relating to their patients to third parties, eg, insurance companies, legal professionals or employers.

51.1 If the report relates to the patient’s current state of health, you should, where appropriate, carry out an up-to-date examination.

51.2 You should be satisfied that the patient understands the purpose and scope of the report and of any examinations or investigations required to support its preparation and that the professional standards for consent and disclosure are followed. (See chapters 2 and 3).

51.3 The report should be confined to the purpose for which the report has been requested. You should inform the patient that you have a duty to the third-party as well as to the patient and that you cannot omit relevant information from the report.

51.4 In producing your report, you should distinguish clearly between facts identified and verified by you, and information provided to you by the patient or by others.

51.5 You are entitled to request a professional fee for providing a medical report. The fee should be appropriate to the service provided and must not be based on the outcome of litigation. The content of reports must not be influenced by financial or other inducements or pressures.

51.6 You should provide reports promptly so that the patient does not suffer any disadvantage from delay.”

Content of the report

The most common request for medical reports arises in the context of personal injuries litigation and doctors should, where possible, use the template provided on the Injuries Resolution Board (formerly PIAB) website when providing a report.

By way of general guidance, a medico-legal report should include the following:

▶ Patient’s name, date of birth, occupation, and registered address;
▶ Requesting party’s name, date of request, purpose of the report, and any reference number they give;
▶ Your own name, position, address, professional qualifications, practice experience, and Medical Council registration number;
▶ Date of report;
▶ List of documents considered and relied on for the purposes of the report;
▶ Patient’s medical history (only relevant to the injury). This may include previous accidents;
▶ List of all relevant clinical entries and details in chronological date order, including any relevant telephone consultations and where possible:

• Any details given by the patient in relation to the accident, including the date of the accident;
• Presentation history and reported symptoms;
• Examination findings at time of presentation, noting investigations, and provisional diagnosis;
• Condition at time of the last consultation;
• Treatment and management of the patient’s condition;
  ▶ Refer to any specialist involvement and their findings;
  ▶ Include details of any physiotherapy attendances if known;
  ▶ Results of any relevant x-rays, blood tests, or any other relevant examinations or investigations, where known;
  ▶ Address any specific questions if any are posed by the requesting party;
  ▶ If the injury is an aggravation of a pre-existing condition, this should be specified and details provided;
  ▶ When doctors are asked to provide a factual medico-legal report, they are sometimes asked to provide an opinion on condition and prognosis. The doctor can give this opinion where appropriate, but should be careful not to stray outside their area of expertise. Any opinion on condition and prognosis should include expectations for recovery with timelines and a focus on how the symptoms might affect the patient’s everyday life. If it is not possible to give a prognosis, this should be stated.

Report on the basis of clinical notes

If you do not recollect the patient’s attendance or if you did not actually see the patient at the relevant time, it is still possible to assist your patient, and provide a report based solely on the patient notes. If providing a report on this basis, it must be clearly recorded in the report. For example:

“I have no specific recollection of my involvement in the care of the patient and am providing a report solely on the basis of my contemporaneous records at the time of attendance” or “I did not examine the patient at the time of the accident, but I have reviewed the notes of my colleague Dr X/the discharge letters from her treating consultants, Dr Y at Hospital Z.”

Alterations to your report

After releasing your report, if you are requested to alter it by the patient or a third party having either made an error or received additional information, you should provide a supplementary/addendum report rather than alter your original report. You may be asked to give evidence at a later date so it is important you record your reasons for writing the supplementary report, eg, to correct an erroneous accident date.

Additional advice

Other general points to consider when drafting a medico-legal report include:

▶ Doctors should work within their own competencies and expertise;
▶ Consider including a short bio outlining your qualifications and experience;
▶ Write in the first person;
▶ Refer to any relevant records in your possession. If some are not accessible document this fact in the report, eg, emergency department letters, etc;
▶ Explain abbreviations or technical terms;
▶ Include the names of any other health professionals involved in the patient’s care, eg, practice nurse;
▶ Number the pages in your report;
▶ Keep sentences short;
▶ Use subheadings to order the report;
▶ Check for lack of clarity or contradictions/inconsistencies;
▶ Remember your role is not to act as your patient’s advocate in this instance, but to provide a factual report of your patient’s condition;
▶ Differentiate between facts and opinion;
▶ Ensure the report is delivered by a secure method (eg, hand-delivered, courier, registered post, or by way of password-protected attachment to an email).

To whom should the report be furnished

Where a solicitor is instructed, the report should be furnished to the solicitor requesting the report. As a general rule, the report should not be copied to the patient unless there are particular reasons for doing so. It is then a matter of legal professional judgment as to whether the report should be disclosed by the solicitor to their client. In order to avoid any confusion or misunderstanding, ensure you inform your patient during your assessment that the report will be provided directly to their solicitor. Where a patient is not represented by a solicitor, then the report should be furnished directly to the patient.

Payment for reports

Doctors are entitled to request a professional fee for providing a report. The patient, and not the solicitor, is responsible for paying for the medical report. A solicitor requesting a report does so as an agent for his client, but the overall responsibility for the fee rests with the patient.

Finally, always keep in mind that you can be cross-examined on your medico-legal report on oath in court, so great care should be taken to ensure reports are accurate. For further reading in relation to the role of an expert witness, refer to the recent article in the Medical Independent, published in the 14 July 2026 issue, written by my colleague Ms Sile O’Dowd (www.medicalindependent.ie/comment/medico-legal/acting-as-a-medical-expert-witness/).

Finally, always keep in mind that you can be cross-examined on your medico-legal report on oath in court, so great care should be taken to ensure reports are accurate

If you have concerns or queries in respect of a request to provide a medico-legal report, you should contact your indemnifier for specific advice.