Take note: tables make best sense
Our medico-legal work series continues with advice from Michael R. Young on making your notes
Cases obviously vary in their complexity, but even for the simplest ones you have to start the preparatory phase of writing a report by reading through the records.
LOGIN OR REGISTER TO READ MORE……………You should begin by reading all of the records once, but without making any notes.
Number the pages if the solicitor has not already done this. Numbering the pages helps you quickly locate information later after you have made your notes.
You should then read the records again, but this time paying very close attention to the text. I never used a highlighter because highlighted text is very distracting when you later read the records through again.
I suggest the following method when making notes:
✍ Annotate in the margins in pencil as you read, but be aware that this too may make subsequent readings difficult. Make more extensive notes on a separate sheet of paper or in a notebook.
✍ Note everything that is relevant:
❍ Chronology;
❍ Any treatment that was carried out, why it was done and the outcome;
❍ Any care that was given, why it was given and the outcome;
❍ Any advice that was given, why it was given and whether or not it was followed;
❍ Anything that stands out as having not been done.
✍ The doctor’s version of events may be at odds with the patient’s and you need to draw this out without giving one side primacy over the other.
You must never omit information just because you think it would favour the other side’s case if you include it. Your report must be balanced and objective and so must the evidence you uncover.
✍ Medical records are notorious for their incomprehensibility. If you are unsure what an entry means or if there could be more than one interpretation, then make a note.
The other side in the case will try to emphasise the version that best suits their argument – you should have already spotted the various interpretations.
As well as making notes in sentence and paragraph form, it might help to set everything out in a table.
Tabulating information (see example below) is sometimes the only way to compare and contrast the various versions of events. Things that at first may not be obvious sometimes begin to stand out.
Resist the temptation to start writing the report as soon as you receive the records. As in an exam, time spent planning the answer is never wasted.
Read the records, make some notes, and then leave it for a few days while you mull things over. Only when you fully understand the background, complexity and what you are being asked to do should you move on to the next stage – that is, writing the report.
Adapted from The Effective and Efficient Clinical Negligence Expert Witness, by Michael R. Young, price £60 from Otmoor Publishing
