What this report is for
Someone in a legal process, a court, a tribunal, a lawyer preparing a case, an insurer in dispute, needs a psychiatric opinion on defined questions, and your report is that opinion in a form that can be tested. The reader may be a judge, a barrister on either side, or another expert instructed to disagree with you. None of them is your patient's clinician and all of them will read the report against the clinical records, which they will have.
Every Australian jurisdiction applies an expert witness code of conduct to reports tendered as evidence. The codes differ in wording and are broadly harmonised in substance: the expert's paramount duty is to the court and overrides any duty to the party instructing or paying them; the report must state the questions asked, the facts and assumptions relied on and the materials reviewed; it must give the reasoning for each opinion; it must distinguish fact from opinion and flag where an opinion is provisional or the question is outside the expert's expertise; and it must acknowledge the code. The Federal Court's practice note and the New South Wales schedule are linked under Sources as representative examples; the instructing solicitor will tell you which applies.
For a treating psychiatrist the report has one extra job: declaring the treating relationship, so the reader can weigh it, and then writing as if there were none.
What it must contain
- The instructions and the questions, verbatim. Who instructed you, when, and the exact questions asked, numbered. The report answers these in order; anything else is unrequested.
- Your qualifications and experience, briefly, and relevant to the questions. A curriculum vitae may be attached.
- The declaration. That you have read and agree to be bound by the applicable code of conduct, that the report is complete and accurate to the best of your knowledge, and that the opinions are your own. Where you are the treating psychiatrist, say so here.
- The materials reviewed. Every document, listed, with dates. Records you did not see are as important to state as those you did.
- The facts and assumptions. What you are treating as fact, and from where: the records, the person's account (labelled as such), collateral. Assumptions you were asked to make, labelled as assumptions.
- History. The relevant history, sourced line by line to records or account, without the interview transcribed.
- Examination. Dates of examination, what was assessed, the mental state findings, and any instruments used with their results.
- Diagnosis. In the terms of a recognised classification, with the criteria met and the differential where it matters.
- Opinions, one per question, each with its reasoning. The reasoning is the report. State the opinion, then why: the findings that support it, the alternatives considered and why they were set aside, and the degree of confidence. Where a question has a clinical part and a legal part, answer the first and say the second is for the court.
- Causation, where asked, as a clinical opinion on the relationship between events and the condition, with the reasoning, in the framework the instructing solicitor identifies, and without asserting the legal conclusion.
- Prognosis, treatment and capacity, where asked, each specific: course, treatment with modality, duration and cost where requested, functional capacity in concrete terms.
- Limitations. What you could not assess, what would change your opinion, where an opinion is provisional.
- Summary of opinions. The answers to the numbered questions, in a paragraph or a numbered list, at the end. This is what is read first.
- Signature, date, registration and provider numbers.
Facts, opinions, and the line between them
The commonest failure in medico-legal writing is a sentence that is both. "Mr X developed depression after his dismissal" reads as fact and asserts causation. Separate them: the record shows that Mr X was dismissed on a date; Mr X reports that his mood declined from around that time; on examination on a later date he met criteria for a depressive episode; in my opinion, for these reasons, the dismissal contributed to its onset. Four sentences, each of a known kind, each defensible on its own. Cross-examination lives in the gap between fact and opinion, and a report that closes the gap sentence by sentence gives it nothing to work with.
Where reports fall short
- The report advocates. Once a reader senses which side it is on, every opinion in it is discounted.
- The questions are not answered in order, or not all answered, or answered with questions of the author's own choosing.
- Facts and opinions are blended in the same sentences.
- Assumptions are not stated, so a change in one fact silently collapses an opinion.
- The materials list is incomplete, and the missing record is the one the other side has.
- Opinions are asserted without reasoning: "in my opinion" followed by a conclusion and a full stop.
- The report strays outside expertise, on law, on another discipline, on the credibility of a witness.
- It is inconsistent with the author's own clinical notes.
- The code of conduct is not acknowledged, and the report is challenged on admissibility before its content.
- It is late for the timetable the court set.
A skeleton that works
The specialised reports
The general structure holds across the library's legal presets, each of which carries the specifics of its setting: Legal - Fitness to Stand Trial, Legal - Sentencing / Mitigation Report, Legal - Family Court Report, Legal - Victims of Crime Support and Legal - Guardianship / Capacity Support. Tribunal reports, where the reader is a tribunal member applying a statute rather than a court applying the rules of evidence, have their own guide in this library.
How PsychDispatch drafts this
The Legal - General Medico-Legal Report preset drafts the report in the structure above, against the questions you paste in from the letter of instruction, with facts and opinions kept in separate sentences. This is the document where verification is not a nicety: every clinical statement in the draft is traced to the record before you sign, which is exactly what cross-examination will do afterwards. Patient Intelligence supplies the sourced history, the dated treatment record and the course over time, so the facts section rests on what was documented when it happened rather than on recollection under a court timetable.