Sample Report Structure
A section-by-section breakdown of a Dr Granot medicolegal neurology report, so instructing solicitors know what they will receive.
Submit a BriefAll medicolegal reports follow the same overall structure. Specific sections expand or contract depending on the matter type and complexity. The illustrative excerpts below are completely de-identified composites, written to demonstrate format and tone — not actual reports.
Report Structure
1Cover and Identifying Information
Report title page identifying the matter, parties, instructing solicitor, date of examination and date of report. Includes Dr Granot's credentials and accreditations on the cover or letterhead.
Re: [Plaintiff name and date of birth]
Instructing solicitor: [firm and matter reference]
Date of examination: [date]
Date of report: [date]
Examiner: Dr Ron Granot, MBBS FRACP — Consultant Neurologist; SIRA Accredited Permanent Impairment Assessor; PIC Medical Assessor
2Letter of Instruction Acknowledged
The letter of instruction is acknowledged and the specific questions to be addressed are restated. This ensures alignment between brief and report.
1. The nature and extent of any neurological injury arising from the index event of [date];
2. The whole person impairment under the SIRA Permanent Impairment Guidelines, 4th edition;
3. Prognosis and likely future treatment needs;
4. Work capacity for the pre-injury role.
3Documents Reviewed
Complete list of documents provided and reviewed, dated. Provides an audit trail and demonstrates the breadth of the review.
4History Taken from the Plaintiff
The plaintiff's account, taken at examination, of: the index event; symptoms at the time and their evolution; current symptoms in detail; treatment received; impact on work, family, hobbies, activities of daily living. Discrepancies between the plaintiff account and documentary record are noted neutrally for later consideration.
5Past Medical and Background History
Pre-existing conditions, prior injuries, medications, family history, social context (occupation, education, supports), and relevant lifestyle factors. Critical for causation and apportionment analysis.
6Neurological Examination
Documented neurological examination — mental state, cranial nerves, motor system (tone, power, reflexes), sensory system, coordination, gait, and any specific examination directed at the clinical question. Positive and relevant negative findings are recorded.
Motor: Tone normal in all four limbs. Power 5/5 in all major muscle groups tested. Reflexes brisk and symmetrical (2+) in upper and lower limbs. Plantar responses flexor bilaterally.
Sensory: Light touch and pinprick intact symmetrically. Joint position sense and vibration intact at the toes and fingers.
Coordination: Finger-nose, heel-shin, and rapid alternating movements normal. Gait normal stride length, arm swing and turning.
7Investigations Reviewed
Imaging, neurophysiology, neuropsychology and other investigation reports reviewed and summarised. Where actual imaging is available, independent assessment is included.
8Diagnosis
Diagnosis or diagnoses, stated clearly. Where multiple conditions coexist, each is addressed separately with respect to attribution.
9Causation
Analysis of whether the diagnosed conditions are attributable, in whole or in part, to the index event. Pre-existing conditions are considered. Apportionment where applicable.
10Permanent Impairment Assessment (where requested)
Whole Person Impairment calculated under the applicable guidelines (SIRA Permanent Impairment Guidelines for motor accident; AMA Guides 5th edition for workers compensation neurology, or as specified). Each contributing impairment shown with the calculation pathway. Combined value where multiple impairments apply.
11Prognosis and Treatment
Expected trajectory, likely future treatment needs and costs (where requested), work capacity assessment for the pre-injury role and reasonable alternative roles.
12Specific Answers to Instructing Questions
Each question posed in the brief is answered in turn, clearly numbered. This is the section most likely to be excerpted in mediation or negotiation.
13Declarations
Expert Witness Code of Conduct acknowledgement (UCPR Schedule 7 NSW) where the report is for court use. Statement of independence. Statement of facts assumed.
14Signature, Date, Credentials
Signed and dated, with full credentials and accreditations clearly stated for the record.
What the Report Will Not Do
Equally important — what an independent medicolegal report from Dr Granot will not do:
Not provided
- ✗ Advocate-by-omission — selective exclusion of unfavourable findings
- ✗ Opinions outside Dr Granot's specialty (e.g. psychiatric diagnosis, orthopaedic impairment) — referred onward instead
- ✗ WPI before maximum medical improvement is reached — premature WPI is not valid
- ✗ Speculation beyond reasonable inference from the evidence
- ✗ Legal opinion on liability — that is for the court
Standards Met by Every Report
Each report meets
- Expert Witness Code of Conduct (UCPR Schedule 7 NSW) where the report is for court use
- The Royal Australasian College of Physicians' Position Statement on Doctors as Expert Witnesses
- The relevant SIRA Permanent Impairment Guidelines or AMA Guides for impairment assessment
- Plain English where possible, technical terminology where necessary (with explanation)
- A structure that addresses every question posed in the instruction
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