There is no “correct” way to write a consultative report, and so much depends upon what your attorney wants. What do you think the attorney needs to see?
This is just my personal style. The first thing I write is an introductory paragraph that cites the patient’s name, claimed injury, and brief description of that injury and residual damages. I end it with my opinion, right up front. This may be the last sentence I actually write, but it should be prominent, with any disclaimers.
I might then have a section that lists the supportive evidence. Bullets are great for this. I follow with mitigating information that may work against the claim, probably in paragraph form, to allow your positive bullet points to take center stage.
I also have a bullet list of pre-existing or comorbid conditions that influenced the outcome of the injury. If these conditions are likely to be unfamiliar to the attorney, I will footnote rather than clutter up this section with parenthetical references. If there is a complicated concept I may use a graphic (who wants to describe a foot orthotic or a fundoplication or ICP screw when a simple image says everything). I only use one or at the most two to maximize the impact without my report resembling a comic book.
What comes after depends upon the type of report. If I have done a chronology, I do not include all that data into the report – that is why I wrote a chronology. If it is a stand-alone report, I will include more information about the timeline of events and injury, but a chronology is always preferred.
This is where I would address standards of care, if applicable, contributory negligence, and how the case might have resolved but for those issues, whatever they may be.
If I can clearly see the opposing position, I will point that out and offer any counter points.
I end with a list of considerations for the attorney to pursue. This includes the experts that he will need to support his case; specific records to request (always get the ones that predate the event and the most recent since you will rarely have all of either). No matter how strong the evidence, I know that an expert “will be needed to confirm the…” because the attorney cannot base his case upon my opinion. Attorneys will often go forward with a mediation without an expert, and with great success. The decision is theirs.
Elements I like:
• Bullets, as mentioned – using phrases instead of complete sentence structuring allows me to express things succinctly and with more impact
• The use of only one font unless I do something different in a section header
• Bolded headers in a larger font, usually in dark gray so that it stands out but isn’t too heavy
• Sentences that are no longer than the ones in this blog
• A header beginning on page two that lists “Confidential Attorney Work Product”, with case name under that and the page number under that.
• A complete absence of the use of first person – my opinion is based upon objective evidence, not my feelings
• Absence of emotional input – state the facts clearly and strongly and they will speak for themselves – “this poor dear lady” is just not my style and does nothing to support the case. The attorney will often use that language in his pleading.
• I end with appreciation for the consult, state my availability for further communication, and offer to review further medical records as they arise or fulfill other needs such as expert location
• I sign with “Respectfully Submitted” even if it is an attorney I work with all the time, because it is respectfully submitted
• If I used reference materials for the report, I will cite them.
It is a “process”, and you will find a way that works best for you. There was a time when my reports were in paper, like a portfolio. But in those days, records came in banker’s boxes. Shudder. For quite some time, all data exchange has been electronic between the attorney and me. Records have to be in pdf form; a product like Adobe Distiller AC with its ability to OCR, combine files and reorganize pages, is a must.