Aspects of dento/medico-legal report writing

If you have not done so already, it is likely at some point in your career that you will be asked to provide a report, perhaps in pursuance of a claim, on one of your patients or even a patient of another practitioner. A report may be requested to provide a factual witness-type statement relating to the practitioner's role in the treatment of a patient before or after a specific incident, eg sport-related injury, assault, ‘tripping’ accident or, possibly, the result of a hard foreign body allegedly found in a food product and bitten on by a patient. Under Civil Procedure Rules in England and Wales an ‘expert’ is a person who has been instructed to give or prepare expert evidence for the purposes of proceedings. A more detailed ‘expert’ report request could come from an insurance company; solicitor for the Civil or Criminal Courts; HM Coroner; Professional Body or even an individual patient. These requests could be for a report on ‘Liability and Causation’ or a ‘Present Condition and Prognosis’ report. However, a request for an opinion on ‘Liability and Causation’ in cases of negligence or for a GDC or other hearing is more likely to be asked of a relevant specialist rather than the general dental/medical practitioner, as it may be outside his/her own field of expertise. However, some practitioners in general practice may be asked to produce such reports, as solicitors require opinions as to what would be considered acceptable care from a reasonable, respectable, responsible body of dental professionals,1 should the litigation involve the care given by a practitioner in general practice. Undergraduate dental/medical courses give little guidance on how to write a report, but there are several organizations offering instruction/courses on legal report writing. Realistically, most practitioners will only be asked very occasionally to produce a report but, nevertheless, it should be regarded as if it were a legal document because it may well become one. It is important that any report is both clear to all that read it and easily understood, while addressing the points and/or questions detailed in the letter of instruction. In a civil case in England and Wales, the report must also comply with the current Civil Procedure Rules for it to be acceptable to the Court.2^,3^,4 The purpose of this paper is to give some guidance on aspects of medical/dental report writing citing anonymized examples from the author's caseload for clarification and to illustrate that sometimes not everything is as straightforward as it may initially appear.