Junior doctors can be asked to write reports on many different things, but it need not be a daunting experience, says Sara Williams from MPS.
You witness an adverse incident while working in A&E. There are a number of ways in which this incident could be investigated – as a complaint, a criminal case, a clinical negligence claim, a disciplinary matter, a coroner's inquest, or a GMC referral.
You may be required to write a report, either as a lay witness or a professional witness. If you are writing as a lay witness, this means you are writing as a member of the public. If you are the doctor involved in some aspect of the patient's care, you will be asked to provide a report as a professional witness.
There are various situations in which you may be required to write a report:
• for your employer
• for the coroner
• for a solicitor
• for the police
• for a patient's employer or insurance company.
How to write your report
An important starting point is your written report on the circumstances of the incident. Your report should be:
• Objective – state the facts. Do not use the report to criticise others.
• Detailed – providing too much information is better than too little.
• Clear – avoid ambiguity and be clear about who did what and when.
Your report should be based on:
• Your usual practice
• Your own recollection
• The medical records.
Facts or opinions?
The majority of reports that you are asked to provide will be statements of fact – giving an account of what took place. You should only report the facts as you know them. If you are asked to give an opinion, you must only comment within your expertise.
What should your report include?
• Personal details – your qualifications, the number of years you've worked, any relevant clinical experience
• Relevant local factors – for example, if your hospital is on two sites and this affects the time taken to get to an incident
• Details of other healthcare professionals involved
• Patient details
• Presentation and history – you should include dates and, where possible, times
• Findings on examination
• Diagnosis and whether a differential diagnosis was considered
• Investigations and subsequent management, including dates
• Follow-up arrangements and information given to the patient or relatives
• It should be clearly signed and dated.
Disclosure of patient information
A report will, more often than not, involve the disclosure of confidential information about a patient. You need to make sure you have the authority to disclose this information, by getting your patient's consent and checking they are clear about the information you will be providing, to whom, and why it is necessary and how it will be used.
• stray beyond your level of competence or expertise
• deliberately conceal anything – this will cast doubts on your integrity and will make subsequent comments less credible
• comment on behalf of others – you can say "Dr X said..."
• write your report honestly; don't be influenced by others
• write it as soon as possible after the event, while the incident is still fresh in your mind
• make sure that you have seen the complaint or Letter of Claim, or details of any court proceedings, before writing
• include details of only the events that you were personally involved in
• include relevant facts; your opinion is only necessary if specifically asked for
• ensure that you review your original report, the medical records and any new documentation, if you are asked to write a supplementary report.
Report writing tips
• Write in the first person singular – "I did this..."
• Address the report to an intelligent lay person; avoid jargon and abbreviations
• Bear in mind that the patient or their relatives are likely to see the report; avoid any pejorative, humorous or unnecessary subjective remarks
• Organise the report chronologically – give actual dates, and use either a 24-hour clock to give times, or state whether you are referring to am or pm
• Give each incident or event a separate paragraph or section
• Check spelling, punctuation and grammar before submitting
• Your report should be typed, signed and dated
• Keep a copy of the report in your notes and a note of how, when and to whom you submitted it
• If you are asked to change the report, you should think very carefully about the event before doing this, and only make changes if a factual mistake needs to be rectified.
Asking for help
If you have any questions or concerns about what you have been asked to produce and what you are allowed to disclose, you should contact MPS for further advice.
• GMC, Good Medical Practice (2006) – www.gmc-uk.org
• GMC, Confidentiality (2009) – www.gmc-uk.org
• MPS, Confidentiality factsheets series – www.mps.org.uk/factsheets
• DH, Confidentiality and Access to Health Records – www.dh.gov.uk/en/index