It is preferable to issue the medicolegal report on official letterhead of your institution.
The heading of the report as: Medicolegal Report and Opinion on the Clinical Examination of (name of the victim).
The Information and Qualifications of the Expert.
Declaration of the Expert stating: “I have examined the patient (name) on (date) and (place) and/or I have reviewed the case synopsis and digital images of the patient.”
Statement of the Expert: “I understand that my overriding duty is to the court, both in preparing reports and in giving oral evidence. I have complied and will continue to comply with that duty. I have done my best in preparing this report to be accurate and complete. I have mentioned all matters that I regard as relevant to the opinions I have expressed.”
Qualifications and a short biography of the expert.
The list of items reviewed.
Background information with subheadings: Nature of Referral, Specific History, and Examination Findings.
Special Investigations and Findings.
Medicolegal Issues (One can choose a questions and answers format).
Observations and Findings of Specific Injuries. If they are fresh, state it and categorize them into abrasions, contusions, lacerations, fractures, and other. If they are old, it is necessary to state the stage of healing. The scars will be described later. The injuries should be described with different descriptors including general location, size, shape, position according to major body landmarks, borders of the injury, and the color. Specific descriptions and examination findings may be described for the response to gentle touch and palpation, such as tenderness versus nontender.
Opinion can be given under the following subheadings:
The Nature of the Injury
How Did the Injury Occur?
Were the Injuries Life-Threatening?
Are the Weapon or the History Given in Keeping with the Injury Findings?
Are There any Limits to the Expert Opinion in This Case?
The Conclusion should include the final opinion in point form.
The signature, date, and name of the expert, including designation and the office address.
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