How to Write Medical Reports for Jury Trials
If you're a practicing physician who has been retained by a law firm to offer an expert medical opinion, you should know some of the basic guidelines that veteran experts have been following for years. The attorney who retains you will provide you with the facts on which to base your judgement. He will also send you material produced in discovery that you'll need to render an opinion. Most often, that material consists of police accident reports, engineering accident reconstruction reports and medical records.
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Instructions
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Check the website maintained by the court system in the state where the case is pending. Look for Model Civil Jury Charges, which are standard instructions that judges give to jurors about to deliberate a case. These charges explain the kinds of facts and opinions that the judge considers admissible as evidence.
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Check the rules of evidence in your state.These books are updated each year with the most recent rules on standards for medical experts' opinions. For example, the New Jersey Rules of Evidence explain the kinds of inferences experts are permitted to make in their reports and what constitutes an inadmissible medical expert opinion in that state.
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Begin your medical report by identifying the plaintiff, or the party who is bringing the suit, or the defendant, the party who is being sued. If the case involves claims of injury following a car accident or other traumatic incident, identify the date of that incident.
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Start the report by listing the fact and medical reports you reviewed in order to make the opinion. These reports were sent to you by the attorney for either the plaintiff or defendant. Be specific. For example, if the case involves a car accident, you can write: "Reviewed police accident report dated January 1, 2005" or "Reviewed emergency room records from Essex Medical Center dated January 1, 2005."
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State whether or not you performed a physical examination of the plaintiff. If so, identify the plaintiff's medical complaints.
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Describe the physical examination by noting the tests you performed and the results obtained. For example, you might write, "Examination of the neck showed muscle spasm."
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Describe your background in the field, especially if you are giving an opinion in a medical malpractice case. For example, you should specify your area of specialty, state whether you are board certified and how many years you have been a practicing physician. If you are preparing a report that suggests a knee operation was not done properly, state the number of knee surgeries you have performed. Make sure to base your opinion on the standard of care you followed in performing those surgeries.
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Explain any diagnostic testing that was done, such as X-rays, ultrasounds or MRIs. Then state whether or not you reviewed the films from those studies as opposed to just the reports. If you reviewed the actual films, state whether or not you agree with the radiological interpretation on the reports.
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Conclude your medical report by stating your opinion on whether the accident or incident caused the injury. State whether or not the injury is permanent and whether or not the individual needs additional treatment.
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