What goes into a personal injury medical report? key elements and structure

A personal injury medical report is the cornerstone of any personal injury claim. It forms the clinical and legal backbone that links an individual’s injury to an incident, establishes causation, and provides a basis for calculating compensation. At our medico-legal reporting agency, we ensure that every report is meticulously structured, legally compliant, and defensible in court.

Introduction to Medico Legal Reports

Medico legal reports are formal documents prepared by healthcare professionals with expertise in reporting for legal proceedings. These reports are not casual summaries; they are objective, factual, and written in a legal context, tailored for use in litigation, insurance claims, and tribunal proceedings. They often become key exhibits in personal injury, employment, or criminal cases.

Core Components of a Personal Injury Medical Report

Each personal injury medical report is structured methodically to ensure accuracy, completeness, and legal robustness. Below is a breakdown of its essential elements:

1. Client Identification and Background

• Full name, date of birth, gender, and contact details
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• Employment and medical history
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• Details of the referring solicitor and claim reference number
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2. Incident Description

• Date, time, and location of the incident
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• Client's account of the accident
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• Mechanism of injury (e.g., fall, RTA, workplace hazard)
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3. Medical History

• Pre-existing conditions
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• Prior similar injuries
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• Psychological or emotional vulnerabilities
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• Medication history
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4. Examination Findings

• Physical examination outcomes
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• Range of motion, swelling, bruising, neurological assessments
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• Any observable functional impairments
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• Psychological or psychiatric observations (if relevant)
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5. Diagnostic Investigations

• Imaging (X-rays, MRI, CT scans)
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• Blood tests or other pathology findings
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• Hospital and GP records review
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6. Diagnosis

• Primary and secondary diagnoses
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• Differential diagnoses considered
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• Relationship of injuries to the incident (causation analysis)
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7. Prognosis

• Expected recovery timeline
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• Permanent or long-term impairments
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• Impact on work and lifestyle
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• Future treatment recommendations
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8. Expert Opinion

• Likely outcome had the incident not occurred
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• Extent of disability or impairment
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• Summary of the case with medical reasoning
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• Statement of compliance with the Civil Procedure Rules (CPR Part 35)
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Timeline and Guidelines for Preparing Medico Legal Reports

We ensure that reports are delivered within standard turnaround times, adhering to best practices:

• Initial appointment arranged within 7 days of instruction
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• Report delivery within 10–15 working days post-assessment
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• Independent and unbiased format, compliant with CPR Part 35
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• Consent and GDPR compliance included in all processes
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Common Conditions Covered in Personal Injury Medical Reports

• Whiplash injuries
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• Back and neck strain
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• Fractures
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• Head injuries
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• Psychological trauma (e.g., PTSD, depression, adjustment disorder)
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