PI Brief Update

How to write a personal injury template - Dr Mark Burgin

08/08/22. Dr. Mark Burgin BM BCh (oxon) MRCGP explains why every expert should write their own personal injury template.

In my role as an independent auditor of medical expert reports I am asked whether I consider any of the report writing software (RWS) to be the best.

My answer is that each have advantages and disadvantages but the expert should avoid selecting default settings all the time.

Where the author of the software has created a drop-down menu pre-filled by defaults it is lazy practice to choose a general statement rather than write what was said.

To the casual reader it looks reasonable but when the same phrase appears time after time it starts to look like the RWS’s author rather than the expert’s opinion.

Instability

Templates need to be stable so that a change in one place does not require many changes throughout the report.

This is because inevitably the expert will forget to change one of the places so that the report will become internally inconsistent.

One way that templates achieve this is by writing general phrases that do not need amending as they lack any detail.

The worst offender is ‘no relevant history of significant problems’ which is so devoid of facts that it is an opinion (and in breach of CPR35).

Inconsistencies

Even in a perfect report there will be inconsistencies, partly because humans respond very differently to trauma and partly because memory can be distorted.

The claimant may insist the pain was severe and yet did not attend for medical attention or have significant restrictions.

It is difficult to create a standard statement that addresses inconsistencies in general and each situation really is best dealt with bespoke reasoning.

Experts will often simply ignore the inconsistency using the default statements in the template thus leaving a gap in their reasoning.

Record your work clearly, accurately and legibly.

The GMC states in good medical practice at 19 ‘Documents you make (including clinical records) to formally record your work must be clear, accurate and legible’.

Examinations are often recorded as ‘neck examination was normal’ without any indication of what examination was performed.

Whilst this makes it difficult for the court to compare different expert’s reports, it is also likely to be insufficient to satisfy the GMC.

A personalised template comprising the expert’s usual practice (even if very brief) can avoid this problem even if under time pressures.

Conclusions

Personalising of report writing software can avoid many of the problems associated with using a template written by another expert.

The past medical history is the one section that can be checked objectively (by review of medical records) and a detailed PMH template can assist.

Having one’s own examination technique in an examination template can ensure that the reader can understand the expert’s approach.

There are some parts of a report that the expert must write themselves; dealing with inconsistencies, the CV and where the default is incorrect.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

Image ©iStockphoto.com/BrianAJackson

This is part of a series of articles by Dr. Mark Burgin. The opinions expressed in this article are the author's own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand.