Physicians may be asked to prepare various types of medico-legal reports, most commonly “treating physician reports” and independent medical examination (IME) reports. Knowing how best to respond and prepare these reports will mitigate the risk of a potential regulatory authority (College) complaint, human rights complaint, or legal action.
Legal proceedings against physicians related to the preparation of medico-legal reports are uncommon. In the event there is a dispute related to a medico-legal report, physicians who author these reports will be judged by whether they exercised the degree of care that could reasonably be expected of a prudent and diligent physician in the same circumstances, including ensuring the statements and conclusions in the report are accurate and reasonable. There is some possibility that physicians would be criticized for making inaccurate or misleading statements about patient injuries and prognoses, or failing to request the necessary background information needed to complete the requested review.
Treating physician reports
You are generally obliged to comply with requests you receive for a report about the care provided or medical condition of a patient you are currently treating or had previously treated. A treating physician report is typically used as evidence of the patient’s medical condition, treatment, or prognosis. For example, it may be used by an insurance company or the court in a legal claim for injuries the patient sustained in an accident or in a medical negligence claim.
A request for a treating physician report should be received in writing and should specify the purpose of the request. A written authorization, signed by the patient before releasing information or the report to someone other than the patient, is required. If the patient is incapable or deceased, written authorization from the substitute decision-maker or the estate representative is similarly required. You may charge a reasonable fee for the report.
If you receive a request to provide copies of the patient’s medical records along with your report, first verify you have written authorization from the patient, substitute decision-maker or estate representative. Provide copies of the relevant records for which you are the custodian, unless the information may cause harm to the patient or a third party, or if another exception set out in privacy legislation applies. Consider contacting the CMPA to discuss your obligations before disclosing medical records.
IME reports
You may be asked to conduct an IME of an individual who, for example, is claiming compensation for injuries and to report on their current status, physical limitations, and prognosis. An IME report is commonly used when assessing an individual’s entitlement to compensation in the context of a legal action, a claim for insurance benefits, or a worker's compensation claim.
It is your decision whether or not to perform an IME. If you agree to perform an examination, the report should be an objective summary of your findings and conclusions.
You should also be mindful of any applicable College policy on conducting IMEs. Privacy legislation generally provides examinees with the right to access the report and parts of any notes you made in preparing the IME, unless a statutory exception applies.
Preparing the report
Consider the following suggestions when preparing any medico-legal report. In addition, check with your College for policies and statements it may have on the preparation of medico-legal reports in your province or territory.
Get started
- Confirm the date on which the report is needed. If you feel you likely cannot meet the deadline, raise this with the requester at the earliest opportunity.
- If appropriate, conduct a medical examination or request a screening test to determine the patient’s present condition.
- Review the scope of the questions or issues you have been asked to address.
Your process
- Respond only to the specific questions posed, and seek clarification if the questions are unclear.
- Feel free to say “I don’t know” if you lack specific factual information or if questions are outside your area of expertise.
- Refrain from making corrections to a report at the patient's request, unless you are satisfied the correction is warranted. Where appropriate, document your rationale for making the correction.
Your statements
- Avoid making pejorative comments about the patient, which may call your objectivity into question and undermine your credibility.
- Avoid making statements or offering specific conclusions on issues related to the patient’s credibility.
- Avoid “borrowing” (restating) the words of others. If you rely on statements made by others, attribute these in your report.
Suggested content
A medico-legal report might typically comprise the following information.
- The purpose of the report, for example, to answer questions about an individual’s current medical condition or to review the care provided by a physician.
- Your credentials and experience. Your CV will typically be appended to your report, though a summary within the report may be helpful or required.
- The documents and information you have reviewed, including any photographs, diagrams, calculations, and other research.
- Any assumptions you have made in preparing the report.
- Relevant details of the patient’s history.
- If applicable, your examination of the patient and functional enquiry.
- In your conclusions, a summary of your response on the specific issues on which you were asked to comment. For long reports, consider also including an executive summary.
- Do not discuss fees in the report. (Such details should be discussed in separate correspondence with legal counsel.)
Additional reading
