Key Components of a Medical Legal Report

Medical legal reports have a big impact on analysing the medical condition of an individual related to a workplace incident. This report will help the court, legal professionals and insurers to understand the relevant medical information regarding a case.

A medical report will provide details

On the individual that is being assessed along with the reason for assessment and the part that has referred them. There should be detailed information about the individual on the report such as their age, name, occupation, gender, address etc. This allows the parties to understand the complete profile of the person that is assessed. You can visit azuremedicolegal.com to find medico legal experts. They will review the medical history of the individual thoroughly. They will include details about their past illnesses and whether they have undergone any surgeries or are taking medications. Relevant family medical history will also be included in the report. The medical examiners will clearly articulate the symptoms the individual has presented and their complaints that have led to the execution of the medical assessment. This will give some context to the person examining this case so that they can better understand the health trajectory of the individual.  

The core of the medical report is the examination findings.

The medical examiner will explain the results of the physical examination carried out along with diagnostic tests. Maybe there are other medical assessments carried out and these will be included as well. The objective observations of the examiner will be detailed here such as the physical limitations of the patient, their vital signs and if there are any abnormalities that were detected during the examination. A detailed account of the findings of this examination will ensure the credibility of the assessment. In many cases, there will be imaging studies and diagnostic tests conducted and the medical examiner will include these results in the report. For example, the details of MRI’s, X-rays and lab reports will be incorporated into the report and this will help others understand the medical condition of the individual in depth. And these details can be evidence to support the conclusions of the examiner.

The diagnosis of the medical legal report

And the clinical impressions will outline the professional assessment of the medical examiner when it comes to the patient’s condition. This is a clear statement and there will be a primary diagnosis provided along with secondary diagnoses. The clinical impressions of the examiner will be provided in this section along with their interpretations. This will give a valuable insight into the overall health of the individual. It is very important to assess how the medical condition of the patient is caused and the medical examiner will give an opinion on how this is related to a specific event, incident or injury. This can explain the connection between the patient’s health and the incident so that appropriate compensation can be decided. The report will also outline any treatments or therapies that are recommended based on the findings of the examiner. This can be rehabilitation plans, prescriptions or surgical recommendations.

Hester Griffith
the authorHester Griffith