How To Read Your Medical Report

A medical report generally has four parts. These are the diagnosis, the treatment you received, your current condition, and the prognosis, which is the doctor’s view of how you are likely to recover. Reading with these in mind makes the wording easier to follow.

The diagnosis section

This states what was found: the injury, where it is, and often a clinical name you may not know. If a term is unclear, ask the doctor or the hospital’s medical records office to explain it in plain language.

The treatment section

This lists what was done, such as surgery, medication or physiotherapy. It shows how serious the injury was and what care it needed.

Your current condition

This describes how you were on the day of the examination. It includes ongoing pain, restricted movement or other lasting effects the doctor noted. If a symptom you still have is missing, raise it with the treating doctor directly.

The prognosis

This is often the most important section for your claim. It looks forward, not just at today. It covers your expected recovery and whether any effects are likely to be permanent.

Compensation for pain and suffering is assessed against a published guide.^[1] The detail in this section is what places your injury within it.

What a report cannot do

A report reflects your condition when it was written. It cannot predict every future change. If your condition changes later, tell your doctor.

What to do next

Note anything unclear or missing and raise it with the treating doctor before the report is relied on further. Getting your medical report for a claim covers what happens once it is finalised.

Once you have the report, an independent lawyer can read it with you and use it in your claim. Send the accident date, where it happened, whether anyone was injured (yes/no) and the police report status.