If a report clearly and logically describes your total involvement with the patient, you are less likely to be called upon to have your evidence tested in court.
What should the report include?
When preparing a dento-legal report you should include, as appropriate:
- the patient's complaints on presentation
- the patient's histories (medical, dental and social)
- examination findings, including any special tests
- diagnosis and treatment plan
- treatment given, including any mishaps or complications
- details of costs
- any further treatment proposed and the cost.
It is important to include negative information, ie. not only what you found but also what you looked for but did not find.
- Your report must be based on first-hand evidence. The emphasis must be on your findings or discussions with the patient, rather than on their history.
- Include the nature of your professional relationship with the patient, eg. private or NHS, clinical or forensic, or a combination of both.
- Write in the first person. The reader needs to be clear who did what, why, when, to whom, and how you know what occurred. Use the active voice, ie. 'I examined the patient' rather than 'the patient was examined'.
- The report should specify which details are based on memory, which on contemporaneous notes, and which describe your 'usual practice'. Just provide the relevant information. It is not necessary to reproduce the clinical notes of each and every consultation.
- State whether the patient was seen alone or accompanied by another individual during each consultation. Give the name and status of the other individual.
Attention to detail
- Be as thorough as possible. Include all your relevant personal information and background details to the report. List all documents used or relied on. If a drug is mentioned, say what type it is (eg. antibiotic, analgesic), give its full generic name, dosage and route of administration.
- Avoid abbreviations; don't assume the reader has any background knowledge of the case - or even of dentistry.
- Avoid using jargon, as your report will almost certainly be read by people who are not dental professionals. If you have to use jargon, explain the terms used so that a lay person will understand them.
- Check your report carefully before you send it.
- Unless you are under a court order, make sure you have sought and obtained the patient's consent when providing a report or disclosing their notes.
- Your report should be typed, ideally on headed paper, with your full name, professional dental qualifications, postal address and work telephone number.
- State who requested the report, naming the individual or organisation concerned.
- Take care not to breach the confidentiality of third parties.
This guidance was correct at publication 25/06/2019. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.