Obtaining a medical report is an important part of the claims process. It is an independent document prepared by a qualified, medical professional. You have now received your Medical Report, but here’s a helping hand to understand it!
The vast majority of soft tissue injury reports are now prepared by General Practitioner’s or similarly qualified Doctors, also known as “medical experts”. Many of them are now using computer software known as a “report writing tool” (RWT). Different RWT’s may have different report layouts, but typically, within the report, all will address the following headings containing useful information which will be used for the purposes of capturing the circumstances of your accident related injuries as directed by the Government’s Ministry Of Justice.
COVER PAGE
This will capture factual information about you, such as your name, date of birth and date of accident. It is important that these details are correct. You will also see that the report is addressed to the Court, as the Medical Expert’s independent obligation is to provide their medical evidence to the Court, regardless of who it is for, who is paying for it, or who has instructed them to provide it.
REPORT SUMMARY
This section is a short summary of the key information recorded in your medical report.
METHODOLOGY
This explains why your medical report has been produced and the Expert’s role in this process. The Expert’s duty is to produce a report that can be used by the Court and to do this, they must be independent in their review and opinion of your case. The Expert will also document what information they have used to prepare the report.
ACCIDENT DETAILS
This section is based on the information you provided to the Medical Expert during the appointment. It will be your personal account of the accident you were involved in. The Expert will capture information relating to the circumstances of the accident and this will be used to form a medical opinion and prognosis.
There may be certain additional pieces of information that you personally feel are important, which is understandable, yet they have no material impact on the Expert’s medical opinion or the value of your claim, so these may not be captured in the report. Examples of this type of information could be the colour or make of the car, the name of the street/road you were travelling on, or who was to blame.
INJURY/SYMPTOM DETAILS
This section is based on the information you provided to the Expert and/or claim representative when asked about any physical or psychological injuries/symptoms you may have sustained as a result of the accident. The physical injuries/ symptoms will refer to areas of the body, when they presented and how severe you felt they were. This will also apply to any psychological symptoms experienced. In the event that you think that the Expert has not referred to all symptoms or injuries that you had declared or has referred to them incorrectly, we would ask that you notify us immediately.
TREATMENT DETAILS
This section is based on the information you provided to the Medical Expert. It will relate to any treatment (such as
medication or physiotherapy/visits to A&E etc.) that occurred after your accident and prior to the appointment with the Expert.
PROGRESS OF SYMPTOMS
This section is based on the information that you provided to the Medical Expert. It will address the injuries and symptoms recorded in section 4. It will comment on whether you advised the Expert that the injuries had fully recovered prior to the appointment, or if they were still on-going. If you advised the Expert that the symptoms were still on-going, you will have also discussed their current progress and severity.
PREVIOUS ACCIDENT HISTORY
This will be based on information that you provided to the Medical Expert. If you were involved in any accidents prior to the index accident, it is important that this information was disclosed to the Expert. The reason for this is that it needs to be considered when the Expert is forming their medical opinion for the index accident and whether there is any overlap of symptoms or injuries.
PREVIOUS MEDICAL HISTORY
This will be based on information that you provided to the Medical Expert. In the event that you have any pre-existing medical conditions that are unrelated to the index accident, the Expert has to consider these in relation to the injuries you sustained in your accident. The information is relevant because the Expert has to assess whether the accident caused pre-existing conditions to be exacerbated or not.
MEDICAL RECORDS REVIEW
If required, this will be based on factual information recorded in your medical records. The Medical Expert will record any information that is relevant when considering your accident.
LOSSES CONSEQUENTIAL
This section is based on information that you provided to the Medical Expert. It will focus on your domestic/social/
lifestyle and/or your employment/work and any impacts that the accident may have had upon them. If you discussed any of the above impacts with the Expert, this section will record how long the impact lasted or whether it is still on-going.
Domestic/social lifestyle relates to activities in your everyday life, excluding work. Employment/Work effects will focus on your employment and reference any time off that you may have taken and any financial losses incurred.
PHYSICAL EXAMINATION
The purpose of the appointment is not for the Expert to conduct a full medical review and health check; it is to address specific aspects relating only to your personal injury claim.
As such, a physical examination will only focus on the relevant injured areas. The section will also be based upon any medical observations that the Expert made during the appointment.
REASONABLENESS
This section is based upon the professional opinion of the Medical Expert only. The Expert will comment upon whether the injuries and their consequential effects that you described are in keeping and proportionate to the severity of the accident described and your own individual circumstances.
OPINION AND PROGNOSIS
This section is based upon medical expertise and the balance of probabilities, taking all of the information made available, into account. It will address each injury/symptom that you have previously described to the Expert, from which, they will make a clinical diagnosis and provide a prognosis for how long the symptom(s) should reasonably take to fully resolve, from the date of the accident.
FUTURE COMPLICATIONS
This section is based upon the professional opinion of the Medical Expert. It can outline whether the Expert believes that you will suffer further consequences in the future as a result of the accident that you have been involved in.
RECOMMENDATIONS
This section is based upon the opinion of the Medical Expert. If appropriate, the Expert may have made a recommendation for treatment or investigations to aid your recovery. This could be in the form of Physiotherapy, or x-rays. Alternatively, the Expert may refer you to a Consultant Expert if the injury is considered to potentially be more complex and beyond the scope of their own expertise.
PROSPECTS ON THE OPEN LABOUR MARKET
This section is based upon the opinion of the Medical Expert. The Expert will comment on whether they believe that you will be disadvantaged in future employment as a result of the injuries sustained in the index accident.
STATEMENT OF TRUTH
This is required for the Court and is a legal requirement that the Expert must sign.
MEDICAL EXPERT CURRICULUM VITAE
These are the Expert’s qualifications and experience.