When a patient suspects that he has suffered a medical negligence, one of the first questions that is usually asked is if you really have enough evidence to claim. The answer, in most cases, goes through an essential document: the Medical report.

Although the clinical history, diagnostic tests and treatments received are an important part of the documentation, none of these elements have the same value as a Expert medical report prepared by an independent professional. This document allows objectively to analyze the health action, to determine if there was malpractice and to assess the consequences suffered by the patient.

In any judicial procedure or extrajudicial claim, the medical report usually becomes the fundamental piece on which the entire case revolves. The possibilities of success of the claim will depend largely on their quality, rigor and scientific foundation.

What is an expert medical report?

An expert medical report is a technical document prepared by an expert doctor, usually specialized in legal medicine and assessment of bodily damage, whose objective is to objectively analyze a health action.

Unlike a conventional clinical report, which simply collects the evolution of the patient, the expert report responds to very specific legal questions:

• If the medical action was adjusted to the accepted clinical practice.
• if there was a diagnostic or therapeutic error.
• if there was a delay in the diagnosis.
• if the care protocols were not complied with.
• If the damage suffered directly derives from that action.
• What sequelae does the patient present?
• What repercussions have these sequelae in their daily lives.

In other words, the report transforms medical facts into understandable and solid arguments for lawyers, insurers, and judges.

Why is it so important in a medical malpractice claim?

In law it is not enough to affirm that a doctor acted incorrectly. It is essential to prove it through tests.

The medical report constitutes precisely that technical test that allows accrediting three fundamental aspects:

1. The existence of an incorrect action

Not all unfavorable results constitute medical negligence.

Medicine involves risks, complications and unpredictable results even when professionals act correctly.

Therefore, the report must analyze whether there really was a deviation from the so-called Lex Artis, that is, the set of norms and criteria accepted by the scientific community for each clinical situation.

Only when it is shown that health action departed from these standards can we speak of possible negligence.

2. The relationship between medical action and the damage suffered

This aspect is called causal link.

It is one of the most complex points of any procedure.

It is not enough to show that there was a medical error.

It is also necessary to prove that this error was directly responsible for the damage suffered by the patient.

For example:

• a delay in diagnosing cancer.
• a nerve injury during surgery.
• an avoidable hospital infection.
• contraindicated treatment.
• a misunderstood diagnostic test.

The medical report studies all the clinical documentation to determine if there is such a direct relationship between health action and subsequent injuries.

3. The assessment of the sequelae

A claim is not only intended to prove that there was a negligence.

You must also quantify the consequences.

The medical report evaluates:

• Physical sequelae
• Functional sequelae
• Labor limitations
• permanent disability
• aesthetic damages
• psychological repercussions
• Need for future treatments

This valuation is essential for calculating a possible compensation.

What documentation does the expert doctor analyze?

A serious medical report is never based solely on the patient’s account.

The specialist is thoroughly studying all the available documentation, including:

• complete medical history.
• Emergency reports.
• hospital reports.
• informed consents.
• radiological tests.
• Resonances.
• TAC.
• analytics.
• Surgical reports.
• pathological anatomy.
• Rehabilitation reports.
• Psychological reports.
• reports from other specialists.

On many occasions it is also necessary to review national and international clinical protocols and updated scientific literature.

What characteristics should a good medical report have?

Not all reports have the same value.

A really useful report must have several essential features.

Objectivity

The expert must analyze both the favorable and unfavorable aspects for the patient.

Its function is not to defend a position, but to offer an impartial scientific assessment.

Scientific foundation

All conclusions should be based on:

• Clinical Guides.
• medical protocols.
• scientific publications.
• current medical evidence.

Personal opinions have very little value in a judicial procedure.

Clarity

Although the content is technical, it must be written so that lawyers, insurers and judges can easily understand the facts.

Coherence

Each conclusion must be derived from the analyzed data.

Contradictions subtract credibility from the report.

When should you request a medical report?

Many people wait for the judicial procedure to be started.

However, it is best to request a specialized medical assessment from the first moment.

This allows:

• know if there really is a negligence
• Avoid baseless claims
• Keep relevant documentation
• Correctly guide the legal strategy
• Calculate the real chances of success

In many cases, a preliminary report avoids long unnecessary legal proceedings.

The role of the coroner and the expert doctor

It is common to confuse both figures, although they perform different functions.

The Forensic doctor He usually intervenes when he is appointed by a court to issue an independent assessment within a judicial procedure.

For his part, the expert part doctor It works for the patient or for the defense, preparing a technical report that will serve as the basis for the claim.

Both must act with scientific independence, technical rigor and absolute objectivity.

The quality of the report will depend a lot on the experience of the professional in Legal Medicine and assessment of bodily damage.

Frequent mistakes when claiming medical negligence

One of the most common mistakes is to present only the clinical history thinking that it shows by itself the existence of negligence.

The medical history contains medical facts, but does not interpret whether these facts constitute malpractice.

Other common errors are:

• Start the claim without specialized advice
• Do not collect all medical documentation
• Let legal deadlines pass
• Go to professionals without experience in Expert Medicine
• Rely only on clinical care reports

All these aspects can greatly reduce the chances of success.

The importance of the report in a trial

During a judicial procedure, the medical report takes on a leading role.

The expert usually appears before the judge to:

• Explain your conclusions
• answer questions from lawyers
• Clarify technical aspects
• Scientifically defend your report

On many occasions, the clarity, solidity and ability to explain the expert are decisive for the resolution of the case.

It is not strange that two seemingly similar claims get completely different results due to the quality of the expert reports provided.

Can a good report avoid going to trial?

Yes. In fact, it happens more often than many people imagine.

When an insurer receives a technically sound medical report, prepared by a well-founded and well-founded specialist, it is much more likely that it will value reaching an extrajudicial agreement.

This allows:

• Reduce costs
• Shorten the deadlines
• Avoid emotional wear and tear of the patient
• obtain compensation without the need for judgment

For this reason, investing in a quality expert report from the beginning is usually one of the most important decisions within the entire claim process.

Conclusion

In a claim for medical malpractice, emotions, suspicions or personal perceptions are not enough to obtain a favorable resolution. What really makes the difference is the ability to demonstrate, with scientific and legal criteria, that there was an incorrect medical action, that it caused damage and that said damage can be assessed objectively.

The Expert medical report It is the essential tool to achieve that goal. Its elaboration requires specialized knowledge in medicine, health legislation and assessment of bodily damage, in addition to an exhaustive analysis of all clinical documentation.

Having a complete, objective and well-founded report not only significantly increases the chances of success of a claim, but also allows you to know from the beginning the real viability of the case. Therefore, go to a Medical Examiner or Medical Expert with Medical Negligence Experience It is an essential step to protect the rights of the patient and face any procedure with the maximum guarantees.