SN7 SHORT NOTE 5M

Describe the principles of writing a medicolegal report and the framing of opinions.

Forensic Medicine · 2nd Professional — Para-Clinical

A medicolegal report is written for a reader who is not a doctor — a police officer, a magistrate, a lawyer, a judge — and its usefulness depends entirely on being intelligible to them. Technical language that requires translation in the witness box has failed at the point of writing
It is a legal document, produced in court, on which the writer will be cross-examined, sometimes years later and often after all memory of the case has gone
The cardinal principle is that fact and opinion are kept separate. The findings are recorded as observed; the opinion follows in a distinct section and states the reasoning that connects it to the findings

Requirement	Detail
Contemporaneous	Written at the time of the examination, not reconstructed afterwards; a report written from memory days later is worth a fraction of one written at the bedside
Complete	Including negative findings, which are frequently the most important — the absence of defence wounds, of ligature marks, of hymenal injury. What is not recorded is presumed not to have been looked for
Objective and factual	Describing what was seen and measured; the history recorded as alleged and attributed to its source
Measured	Injuries in centimetres from fixed anatomical landmarks and from the heel; never described only as "small" or "on the arm"
Within competence	An opinion is given only on matters within the writer's expertise; a general duty doctor does not opine on ballistics
Qualified appropriately	Stated as "consistent with", "could have been caused by", or as a range with a margin of error — never with more certainty than the findings support
Legible, dated, timed and signed	With name and registration number in capitals; no blanks, no erasures, corrections initialled
In duplicate	With a copy retained by the doctor and by the institution

CLINICAL PEARL

A negative finding recorded is evidence
a negative finding not recorded is assumed never to have been sought. If a report on an alleged assault does not mention the hands, the court will not conclude that the hands were normal — it will conclude that nobody examined them. This is why systematic reports include explicit negatives: "no defence injuries on either hand", "hymen intact with no fresh tear".
Silence in a report is read as absence of examination, not absence of finding.

Heading — the institution, the report number, and the authority on whose requisition it is written, with the date and time of receipt of the requisition → identification — name, age, sex, address
two identification marks
who identified the person or body
thumb impression or signature
the date and time of the examination → history — recorded as alleged and attributed
the time and place of the incident as stated
and, in the dead, the treatment given and the hospital record → findings — a systematic description
injuries numbered, each with situation, size, shape, margins, direction, depth and age
general and systemic examination
explicit negative findings → samples and evidence — what was collected, how labelled and sealed, and to whom handed over — the chain OF custody → opinion — in a separate section, answering the question asked, with reasoning
kept pending where investigations are awaited, and supplied later as a supplementary opinion → signature with name, designation and registration number, and the date and time of completion

Question asked	How the opinion is properly framed
What weapon caused this injury?	"consistent with a blunt/sharp weapon such as the one produced" — never "was caused by this knife". A doctor can exclude a class of weapon; they cannot identify an individual one
What is the age of the injury?	A range with a stated margin — "about 3 to 5 days", not "4 days". Contusion colour is an unreliable guide and this must be acknowledged
What is the age of this person?	A range, from dentition, physical development and radiological fusion, with the margin of error stated — commonly plus or minus 2 years in adolescence
What is the time since death?	A range, given the many variables; a single figure cannot be justified and is destroyed in cross-examination
Is the injury simple or grievous?	Answerable, since the categories are statutory — but kept pending until the radiograph or specialist opinion is available
Was it suicidal, homicidal or accidental?	The doctor may state what the findings favour and why, but the manner of death is ultimately for the investigating and judicial authorities, who have the circumstantial evidence the doctor does not
Was the deceased conscious after the injury?	An opinion may be offered with reasoning, but with explicit acknowledgement of uncertainty — and this question is frequently pressed because it decides whether a dying declaration stands

Common defects — illegibility; injuries described without measurement or location; the history written as fact; a final opinion given prematurely; omission of negative findings; unexplained abbreviations; overwriting and correcting fluid; missing time entries; and an opinion stated with a confidence the findings cannot bear

Write it at the time, in your own hand where possible; the contemporaneous document is what you will rely on in court, and a later reconstruction is both weaker and open to the suggestion that it was composed with hindsight
Record the negatives explicitly; they are frequently the findings on which the case turns, and their absence from the report is read as absence of examination
Say "consistent with", not "caused by"; this single habit of phrasing prevents most of the damage done to medical evidence in cross-examination
Give ranges, not points, for age, time since death and age of injury, and state the margin; a precise figure invites the destruction of the entire opinion when a single variable is shown to have been ignored
Keep the opinion pending rather than guessing, and issue a supplementary opinion when the investigations arrive; there is no penalty for waiting and a heavy one for retracting
Never alter a report after it has been issued; if a correction is genuinely required, issue a clearly dated supplementary or corrigendum report explaining the reason, which is honest and defensible where an alteration would not be

All questions in Introduction, Legal Procedures & the Courts