Good record-keeping is therefore more than an administrative function. It provides the evidence behind the report, showing what information the expert had, what the claimant said, what the expert observed during the examination and how the expert developed the opinion. Poor records make even a clinically reasonable opinion more difficult to explain.
The examination needs its own record.
The expert should not treat the final report as the only record of the assessment.
GMC Good Medical Practice requires formal records of medical work to be clear, accurate, contemporaneous and legible. Experts should record relevant clinical findings, treatment information, decisions and actions, together with the name of the person who created the record and the date of creation. The GMC explains that contemporaneous recording means making the record at the time of the event or as soon as possible afterwards.
For medico-legal experts, this means retaining an appropriate record of the examination itself. Notes may include the history the claimant provided, relevant examination findings, measurements, medication the claimant reported, functional restrictions and any significant clarification that arose during the assessment.
The level of detail should remain proportionate. There is little benefit in creating pages of notes that merely duplicate information elsewhere, but the expert should retain enough to explain how they produced the report.
This becomes particularly important when the claimant later disputes their account or when further information causes the expert to reconsider an earlier conclusion.
Instructions form part of the evidential history.
The expert should also maintain a clear record of all instructions.
Practice Direction 35 requires an expert report to set out the substance of all facts and instructions that materially affect the opinions expressed. It also requires the report to identify the material on which the expert relied and to distinguish facts within the expert’s own knowledge from information obtained from other sources.
The working file should therefore show what the instructing party asked the expert to consider and what information it provided at that stage.
This is particularly important when instructions change. The instructing party may initially ask an expert to comment on a physical injury and later provide additional instructions concerning prognosis, rehabilitation or new medical evidence. The working file should identify the date and substance of those additional instructions.
Experts should not overlook informal communications. A telephone conversation or email may materially alter the question the expert considers. If it affects the expert’s reasoning, the expert should make a sufficient record of it.
Keep track of the evidence reviewed.
Large medico-legal instructions may contain extensive medical records, imaging reports, employment documents and previous expert evidence. The file should identify the material the expert had when they formed the opinion.
This protects against a common problem: evidence arriving later and influencing the expert as though they had always had it.
If an expert produced an initial prognosis before seeing an MRI report, that chronology may matter. If previous GP records arrived only after the expert completed the first report, the working file should show that any subsequent change of opinion responded to new evidence.
GMC guidance on expert evidence requires medical professionals to ensure their reports are accurate and not misleading, to take reasonable steps to check the information they provide and to include relevant material.
Good records make that process visible. They allow the expert to identify not simply what they know now, but what they knew when they wrote the original opinion.
Amendments should not erase the history.
Reports frequently change for legitimate reasons. An expert may correct a factual error, receive additional records or reconsider an opinion after receiving new clinical information.
The mistake is allowing an amended document to replace the earlier version without retaining a clear history of what changed.
Version control is therefore sensible medico-legal practice. The working file should identify the date of each report and distinguish drafts, final reports, supplementary reports and later amendments. Where a material opinion changes, the records should also establish the reason for that change.
Practice Direction 35 specifically requires an expert whose opinion changes on a material matter after producing a report to communicate that change without delay.
This does not mean every spelling correction requires a detailed explanation. It means that substantive changes should not become invisible.
Digital reporting systems can assist by preserving timestamps and version histories, but only if the system records and preserves that information correctly. A system that lets users overwrite reports without retaining an audit history creates an avoidable weakness.
Experts should write working notes with care.
Experts sometimes regard handwritten notes, internal comments or electronic annotations as private working material and therefore use language they would never place in the finished report.
Working notes should remain professional, factual and clear enough for later review. Abbreviations may save time during an examination, but they should not become so obscure that even the author struggles to interpret them months afterwards.
Comments about credibility also require caution. The expert may properly record an inconsistency between the claimant’s account and examination findings, but informal labels or speculative comments add little and may distract from the clinical issue.
A better record describes what occurred: the claimant reported one level of movement while the expert observed a different degree during another part of the assessment. Interpretation can then follow from the evidence rather than from a premature label.
Security matters as much as accuracy.
Medico-legal files routinely contain information about physical and mental health, which the UK GDPR classifies as special-category data and protects to a higher standard.
Experts should therefore store records securely, whether those records consist of paper notes, electronic documents, recordings or information within a reporting platform. GMC guidance requires medical professionals to keep records containing personal information secure and to follow data-protection requirements.
Experts should know where they store their files, who can access them and how they transfer information. Downloading copies to personal devices, sending them through unsecured channels or retaining them across several systems can make information management increasingly difficult.
Good record-keeping is not simply about retaining information. It is also about controlling it.
There is no universal retention period.
One of the most common record-management mistakes is searching for a single number of years that applies to every medico-legal file.
UK GDPR does not prescribe a universal retention period. ICO guidance requires organisations to keep personal information only for as long as they need it for its original purpose, to justify that period and, where appropriate, to operate documented retention schedules. Organisations should review the information and erase or anonymise it when they no longer have a reason to keep it.
A medico-legal expert or organisation therefore needs a defensible retention policy that considers the purpose of the records, applicable professional requirements, contractual obligations and the possibility that the instruction may still require the material.
Keeping every report and medical record indefinitely “just in case” is not a sound retention policy. Neither is deleting working material immediately after the expert issues a report without considering whether they may still need it.
The policy should explain both retention and disposal.
The record should allow the expert to reconstruct the opinion.
The real test of medico-legal record-keeping is simple. If the expert returned to the file much later, could they understand how they reached the opinion?
The file should show the instructions received, the evidence available, the claimant’s relevant history, examination findings, material correspondence and any subsequent information that altered the assessment. It should also distinguish different versions of the report and preserve an appropriate explanation for material amendments.
This does not require the expert to retain every duplicate document or every administrative email. Data minimisation remains relevant, and the ICO requires personal information to be adequate, relevant and limited to what is necessary for the identified purpose.
Good medico-legal record-keeping is therefore a balance between completeness and unnecessary accumulation. The aim is not to preserve everything. It is to preserve enough to show, accurately and securely, what the expert knew, what they did and why they reached the opinion in their report.
