Medico-legal Assessment

For Medical Students

What It Tests

A medico legal examination records the current state of the knee, its history and the examiner's reasoning, for a reader who was not present and may be hostile. 4.1.8 covers examination documentation.

The examination is the same examination, and the standard of recording is higher. 4.1.4 covers the structured approach.

It matters because an unrecorded finding cannot be relied on later, and an imprecisely recorded one is worse than nothing. 4.1.5 covers common examination pitfalls.

How It Is Performed

Establish and record the history from the patient in their own account, and record separately what the records say. 4.2.30 covers previous surgery.

Record the mechanism as described, and record it as the patient's description rather than as an established fact. 4.2.21 covers the dashboard injury.

Examine both knees in full, since the comparison is part of the record. 4.1.4 covers the structured approach.

Record every measurement rather than a summary, including the range in degrees and the side to side differences. 4.7.10 covers the post operative range assessment.

Record the negative findings explicitly, because a silence is read as an omission. 4.1.8 covers examination documentation.

Record anything that limited the examination, and why. 4.23.4 covers the limited examination.

Record the function in the patient's own terms and separately from your assessment of it. 4.18.6 covers functional limitation.

What a Positive Means

A finding in this setting means what it means clinically, and its value depends entirely on how it was recorded.

A measurement is more useful than an impression, because an impression cannot be rechecked. 4.7.10 covers the post operative range assessment.

A recorded negative finding is as valuable as a positive one here. 4.1.8 covers examination documentation.

An inconsistency between the reported limitation and the observed function is recorded as an observation rather than as a conclusion. 4.18.6 covers functional limitation.

A limitation of the examination recorded at the time protects the rest of the record. 4.23.4 covers the limited examination.

MRCS Level

How It Is Performed

In a viva this is the documentation question and the expected answer separates observation from inference throughout.

The expected points are the patient's account and the records kept separate, the mechanism as described, the full bilateral examination, the measurements, the explicit negatives, the recorded limitations and the function in the patient's terms.

Say that you would separate what you observed from what you concluded. 4.1.8 covers examination documentation.

Say that you would record negatives explicitly, and give the reason. 4.1.4 covers the structured approach.

Say that you would record what limited the examination. 4.23.4 covers the limited examination.

What a Positive Means

The reasoning expected is that a report's weight comes from the traceability of its conclusions to recorded observations. 4.1.8 covers examination documentation.

An unrecorded observation cannot be distinguished later from one that was never made, which is why the record rather than the memory is the examination's output.

A measurement can be compared with another examiner's and an impression cannot, which is why the former survives challenge. 4.7.10 covers the post operative range assessment.

Inconsistency between report and observation has several explanations including pain, fear and variation, so recording it without interpreting it is the correct treatment. 4.2.10 covers severity.

How Good It Is

The examination is as good as it is anywhere, and the report is as good as the record.

Its best contribution is a traceable record, which is the only thing that survives into a dispute. 4.1.8 covers examination documentation.

It cannot establish causation, which is the question most often asked of it. 4.2.9 covers the onset.

Imaging and contemporaneous records carry the history, so the examination contributes the current state. 4.1.6 covers that relationship.

No figures appear for any accuracy comparison on this page, under decision 023, and the comparison is the claim being made.

FRCS Level

How Good It Is

At decision level the examination supports an opinion on the current state, and the limits of that opinion are part of it.

A documented current state with measurements supports a durable opinion on impairment. 4.18.6 covers functional limitation.

Causation requires the contemporaneous records as well as the examination, and saying so is part of a competent report. 4.2.9 covers the onset.

Pre existing change is frequently present and is distinguished from the injury's effect only with the earlier records. 4.18.2 covers established disease.

Prognosis is an opinion with a stated basis rather than a finding, and the distinction belongs in the report. 4.2.10 covers severity.

Where It Misleads

The commonest error is recording a conclusion where an observation belongs. 4.1.8 covers examination documentation.

Negatives are omitted, so the report cannot say what was looked for. 4.1.4 covers the structured approach.

A limitation of the examination is not recorded, so a negative looks complete. 4.23.4 covers the limited examination.

Causation is asserted from the examination alone. 4.2.9 covers the onset.

An inconsistency is interpreted as exaggeration rather than recorded as an observation. 4.2.10 covers severity.

Fellowship Level

Where It Misleads

At fellowship level this setting makes explicit a weakness the whole section has been describing, which is how much of an examination is judgement.

Grades, end points and correctability are all judgements by hand, so two competent examiners produce different reports on the same knee and both are honest. 4.7.5 covers the end feel.

The examination cannot date a finding, so causation rests on records the examiner did not make. 4.2.9 covers the onset.

Effort dependent findings are unavoidable in a setting with an incentive, and noting that is more useful than adjudicating it. 4.2.10 covers severity.

A report's reader will test every unqualified statement, which makes the stated uncertainty a strength of the document rather than a weakness. 4.1.8 covers examination documentation.

The examination's limits in this setting are the same limits it has in a clinic, and the only difference is that here they are written down. 4.1.4 covers the structured approach.