Victorian Forensic Paediatric Medical Service (VFPMS)

Medical Report Template

Letterhead

Contact numbers phone / fax / email

Code for report (includes Drs and typist initials)

Date (report dictated and date report typed)

Report prepared for

Title, Name
Organisation
Address

RE Name: full name and also-known-as names.

Date of birth
Hospital unit record number

Author of report

Acknowledgement of Code of Conduct

Reason for Medical Assessment

Site and time of assessment(s)

Consent

Observers

Sources of information

Presenting complaint

Past Medical History

Psychosocial information (including genogram and family medical history)

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 Victorian Forensic Paediatric Medical Service (VFPMS)
Medical Report Template

Examination findings

Forensic Specimen Collection

Medical Investigations and interpretation

Medical Management

Information sharing

Limitations to opinion

OPINION

Recommendations

Signature

+/- Jurat

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 Victorian Forensic Paediatric Medical Service (VFPMS)
Medical Report Template

INSTRUCTIONS

INFORMATION TO PROVIDE USING VFPMS REPORT TEMPLATE

Letterhead (use your own letterhead and contact information)

Contact numbers phone / fax / email

Code for report (for your records eg include Drs and typist initials)

Date (report typed)

Report prepared for

Title, Name
Organisation
Address

RE Name: full name and also-known-as names.

(also provide variations in spelling, if any)
Date of birth
Hospital unit record number

Personal details of doctor (author of report)

Full name
Qualifications and medical registration (where registered not the registration number)
Work address
Position title
Employment history as it relates to this case.
Experience relevant to this case
(approximately page maximum)

Reason for Medical Assessment

Who requested the medical evaluation, and why (1-2 sentences)

Acknowledgement of Code of Conduct

In Victoria include as follows (note, modify he to she if you are female)
EXPERT WITNESS CODE OF CONDUCT
This report has been prepared in accordance with the Practice
Direction for Expert Evidence in Criminal Trials as approved by
the judges of the Supreme Court and of the County Court of Victoria.
The author acknowledges that he has read this code and agrees to
be bound by it.

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 Victorian Forensic Paediatric Medical Service (VFPMS)
Medical Report Template

The author declares that, at the time of preparation of this report, he

has made all the inquiries and considered all the issues which the
author believes are desirable and appropriate, and that no matters of
significance which the author regards as relevant have, to the
knowledge of the author, been withheld.

The opinion expressed is based on the sources of information listed

in this report. Should, however, additional information become
available that might have a bearing on the authors conclusions, the
author retains the right to modify the opinion expressed.

Site and time (record information for each event)

Location where service provided
Time and date called out
Time and date assessment commenced
Time and date assessment concluded

Consent
Who provided consent and for what procedures?
Time, date, manner, use of what consent forms (eg VFPMS mature minor consent form)
Details of how consent was obtained and by whom
Note if consent was given to obtain information from other professionals

Observers
Who, for what part of assessment / examination?
Document when and how assistance was provided

Sources of information
Full details of all people who provided information, (face-to-face conversations,
telephone conversations, email and letters, diary entries, drawings, images captured on
mobile phones etc)
Reports medical and others
Medical files and hospital records
Investigations and reports/correspondence/opinions obtained from other professionals

Presenting complaint
Identity of who requested service, time and date, manner of enquiry (who, when, how
and why?)
History of complaint and involvement of person requesting the medical assessment
(chronological order, dot points may be used)

History of complaint from the person being assessed

From whom (may be more than one person, separate section for each person)
Who did what to whom?
Where?
When?
What symptoms occurred at what time(s)?
What symptoms developed between time of alleged assault and now?
Current symptoms physical and mental health

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 Victorian Forensic Paediatric Medical Service (VFPMS)
Medical Report Template

Past Medical History

Birth and neonatal history
Illness and injury
Operations
Development (cognitive and emotional) including milestones
Behaviour (including problems with attachment)
Puberty and menstrual history
Medication (including contraception and immunization)
Allergies

For adolescents use HEADSS structure to enquire about psychosocial factors, alcohol
and drug use, sexuality and other factors relevant in this age group

Psychosocial information (including genogram and family medical history)

Genogram and family history medical and psychosocial information
Medical
Family history of medical conditions
Ask specific questions in relation to trauma if subject has physical injury
Psychosocial
History of subjects transitions between care-givers when, why?
Subjects prior involvement with Child Protection (chronology of past reports,
investigations and outcomes)
Full details of current Childrens Court orders and expiry dates

Specific questions related to alleged assault

Since alleged assault has patient (as appropriate to nature of alleged assault)
Voided?
Defecated?
Eaten?
Drunk?
Changed clothing?
Changed sanitary products?
Showered or bathed?
Had sexual intercourse? (and had sexual intercourse in preceding week)
(if so, what?, when? any additional symptoms?)

Note specific questions about symptoms and signs should be asked in relation to
possible
significant blood loss (including loss into tissues and extravascular spaces)
head injury
strangulation
drug and alcohol use
suspected ingestion of foreign substance

Examination findings

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Medical Report Template

Appearance and demeanour, cooperation, affect, clarity of speech, movements

Odour, state of clothing, cleanliness
Orientation and mentation (mini mental state exam if required), memory
Quality of interpersonal interactions and engagement, eye contact
Measure height, weight and head circumference, plot on growth charts, record
percentiles
Describe clothing, jewellery
Record general exam findings systems and ear, nose, throat, mouth
thoroughly examine skin
CNS
Development
Behaviour

Examination of injuries
Note lighting and magnification
Use of any equipment (magnifying lights, torch, colposcope)
Fully describe individual injuries / pattern of injury
Use Body diagrams
Number injuries and use a format that makes identification / reference easy

Photodocumentation
Video or DVD colposcopic recording
(Note that our MOU with the OPP means that we MUST indicate in each report when a
video or DVD colposcopic recording has been made)
Photographs where? when? what region of patients body? Who took them?
Special photographic techniques?
If possible include information about where the images are located.

Specimen Collection for Forensic analysis

Use proforma to document the full list of all specimens
Drop sheet
Debris
Clothing (one item per bag)
Wet and dry swabs and slides (one site on body per envelope)
Swabs and slides
Swabs alone
Buccal swab for victim DNA (outside of FMEK)
Other (nail scrapings, hair etc)

Chain of evidence
Specimens were given to at (location)
At date and time

Investigations
Serology (Hep B, Hep C, HIV, VDRL)
Swabs in culture medium for microscopy culture and sensitivities
Swabs in viral culture medium (rarely collected these days)
Swabs in special medium (chlamydia, gonococcus)
Full blood examination

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 Victorian Forensic Paediatric Medical Service (VFPMS)
Medical Report Template

Clotting studies (provide information about exact what tests were ordered)
Other blood tests (list)
Radiology (list)

Medical Management
Treatment
Prescriptions and medications prescribed and/or dispensed
Morning after pill / Post coital contraception
Antibiotics as prophylaxis for sexually transmissible infection
Specialist referral (who, where? what opinion and treatment is sought?)
Planned review and medical follow up document your case management plan

Information sharing
Information provided to investigators (Who? When? What?)
Information provided to subjects healthcare provider(s)
Information provided to subject and care-givers

Limitations to opinion
List any omissions or limiting factors

OPINION
This is the most important part of the report and must be very carefully worded!
Comment in terms of likelihood

Recommendations
(This is also REALLY important and must be carefully considered)
For improved safety and well being of this child
For improved safety and well being of siblings
Intervention from Child Protection
Intervention from Vic Police
Intervention from health services
Intervention from community based agencies
Parenting assessments, psychological evaluation of parent(s)
Services/ for parents / carers
Other (including psychological interventions / counselling)

Jurat with witness details (for court report)

I hereby acknowledge that this statement is true and correct and I make it in the belief
that a person making a false statement in the circumstances is liable to the penalties of
perjury.

Signature
Typed name and title
Contact details of author
Date signed

Witnessed by (name) at (place) on (date and time) + stamp

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