Reports from treating doctors

Do I have to provide a report at all?

If you have been involved in the care of a patient, obtained relevant consent, have access to suitable records, and a reasonable fee is offered for your time, it will generally be appropriate for you to provide a report which summarises your care of the patient. Failure to provide a report can result in regulatory complaints, particularly if there is no other appropriate care provider who can produce the necessary information.

If agreement on fees cannot be reached, or no other suitable treating doctor is able to assist, then one option is to suggest that records can be made available (with relevant consent) for the requesting party to brief an independent expert to provide a report. Consider seeking advice from MDA National if declining to provide a report where no other alternative is available.

Independent expert versus treating doctor

Treating doctors are not ‘independent experts’. A treating doctor report will provide a relevant factual chronological history, and historic clinical opinion (diagnoses, prognosis). The report may also draw on information in the medical records from other health practitioners, including specialists and allied health.

If the information sought is outside the expertise of the treating doctor (and not contained in medical information on the file), then it may be appropriate to suggest that the requesting party seek a separate report from other treating specialists who are in a better position to provide an opinion.

If you provide an opinion, make sure it is clear what facts underline your findings. While opinion evidence can be given by treating doctors, there are many circumstances where this isn’t appropriate. Information sought on some issues is better provided by an independent expert – for example:

• causation (did the health outcome arise from a specific situation, or did other issues outside of your knowledge contribute to the injury);
• where you are asked to critique the care of others, or your own care;
• apportionment (what percentage of the health outcome is attributable to a specific cause); or
• the assessment of permanent impairment (a very specific assessment skill).

In addition to the guidance provided by our previous article (How to write a medico-legal report) [1], you should indicate early in the report that you are providing the information in your capacity as a treating doctor, not as an independent expert. You should also make reference to any information you don’t currently have access to, which might better inform your conclusions.

List the question you are answering so your report can be read as a standalone document. Some questions may be difficult to answer. One example is where the best answer when asked about prognosis may be “at the present time, the prognosis is guarded”. You may be reluctant to respond when the question is outside of your knowledge or expertise, in which case it may be best to decline and suggest the question be posed to a specialist.

All doctors have professional obligations under section 10.9 of the Medical Board Code of Conduct when providing reports, certificates and evidence. These include being honest and accurate, making reasonable steps to verify content, clearly indicating the limits of your knowledge (and not giving opinions beyond this), not misleading, and not omitting relevant information deliberately.

This professional obligation can be relied on if you need to set boundaries around patient requests to withhold or include specific information you do not agree with. It is vital that you communicate the source of information throughout the report and restrict your opinion to medically relevant details.

Be careful of stating information in a way that looks like you are the source of the information, or that it is an established fact (short of a judgment, court order or official finding) when dealing with collateral information. You otherwise risk a complaint from others impacted by your report.

What if a treating doctor is provided with information for the report?

Most information provided would be clinically relevant and would therefore need to be stored in the patient file (to which the patient has a right of access). This additional material should be referred to.

If you are provided with material (e.g. surveillance footage) but you are directed to not share this material with the patient, seek early advice from MDA National before you review the footage.

What information should not be provided?

Treating doctor reports should generally be limited to factual and opinion clinical evidence. It is not a doctor’s role to conduct an investigation into issues which may later be the subject of a finding of fact in court.

The patient and their legal representatives will typically capture non-clinical information in a witness statement or an affidavit (the workplace injury, the alleged assault, the motor vehicle accident, etc).

Providing detailed and non-clinically relevant information in a report (and even recording it in the notes) can expose the patient to a finding of a prior inconsistent statement, if the non-clinical details are different to what has been reported elsewhere.

For complex matters, contact our Medico-legal Advisory team at MDA National on 1800 011 255 or advice@mdanational.com.au. Early advice can be the difference between a simple fix or a long, drawn-out matter.

References

1. MDA National. How to write a medico-legal report: mdanational.com.au/advice-and-support/library/articles-and-case-studies/2021/06/how-to-write-a-medico-legal-report