Writing reports

As a GP, you may be asked to write a report at some point in your career, for a variety of reasons. Find out how to provide a detailed, clear and objective professional report, says Charlotte Hudson

Why might a report be required?

A written report may be the starting point of an investigation into the circumstances leading to or surrounding an adverse incident. This could be an investigation into a complaint, a clinical negligence claim, a criminal case, disciplinary matter by an employer, coroner’s inquest or a complaint to the Medical Council.

You may also be required to provide a report for any of the situations below:

For your employer, possibly after something goes wrong
For a solicitor
For the Gardaí
For a patient’s employer or insurance company.

Disclosure of information – are you authorised to disclose this data?

The first point to consider is whether you are authorised to disclose the patient information that is likely to be required as part of the report. You need to make sure you get your patient’s consent and check that they are clear about the information you will be providing and why it is necessary. Disclosing the information may also be in the wider public interest (for example, assisting the Gardaí in preventing or resolving a crime), or the disclosure may be required by law (statutory obligation) or to comply with a court order.

The Medical Council states that where the report relates to the patient’s current state of health, you are encouraged to carry out an up-to-date examination where appropriate.¹

Fact vs opinion

Where a report has been requested in relation to a specific incident, it is likely that you will be asked to provide a statement of fact as a professional witness, ie, giving your account of events leading up to and including the incident. You should only report the facts as you know them. If, however, you are asked to give an opinion, you must only comment within your area of expertise.

Writing the report

Your report should be based on:

The medical records
Your own recollection of events
Your usual practice.

Your report should be:

Detailed – it is better to provide too much information than too little
Clear – avoid ambiguity and explain who did what and when
Objective – state the facts. Do not use the report to criticise others or make general comments.

What should your report include?

Your personal details: Include your full name, date of birth, address and contact details, your qualifications and relevant clinical experience.
Relevant local factors: If, for example, your surgery is on two sites and this affects the time taken to get to an incident.
Details of other healthcare professionals involved: Where possible, include your colleagues’ full names and disciplines.
The patient’s details: Name and date of birth.
Presentation and history: You should include dates and, where possible, times.
Findings on examination and other relevant factors: If the patient was very difficult to examine because he was agitated and aggressive, provide details of how that behaviour was exhibited.
Diagnosis and whether a differential diagnosis was considered.
Investigations and subsequent management, including dates.
Follow-up arrangements and information given to the patient or relatives.

The report should be typed, signed and clearly dated by you.

Report writing tips

Write in the first person singular – “I did this…”
Avoid jargon and abbreviations
Bear in mind that the patient or their relatives are likely to see the report; avoid personal remarks
Write your report honestly; don’t be influenced by others
Check spelling, grammar and punctuation before submitting
Ensure that your use of medical terminology is correct
If the report is a result of a complaint or claim, make sure you have seen the complaint or Letter of Claim, or details of any court proceeding before writing.

Making a supplementary report

It may be necessary for you to make a supplementary report to deal with issues that come to light after you have written your original report. Before doing this, review your original report, the medical records and any new documentation.

A second opinion

Finally, you should strongly consider showing your report to MPS before submitting it.

Reference

Medical Council, Guide to Professional Conduct and Ethics (2009), Section E, paragraph 57.

Please note: this article only covers writing a medical report. You may also be asked to provide a report as an expert witness, in which you will be asked to give an independent opinion on the facts of a case in court. For guidance on writing an expert report, read our factsheet, A Guide to Writing Expert Reports.

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