MEDICAL COUNCIL OF NSW
Medical Council of New South Wales, PO Box 104, Gladesville NSW 1675 AUSTRALIA Telephone (02) 9879-2200 Facsimile (02) 9816-5307. www.mcnsw.org.au
Policy No: GLMED-004 Date of Endorsement: 5 April 2022 Page 1 of 6
Guideline – Medico-Legal Consultations
and Examinations
Document Type
Guideline
TRIM Reference
HP22/9046
Number
GLMED-004
Date of
Endorsement
Endorsed By
Publication Date
Review Date
5 April 2022
Medical Council of
NSW
26 April 2022
April 2027
Summary
This guideline provides clarification on the conduct and administration
requirements of NSW registered practitioners providing medico-legal
consultations and examinations.
Applies to (Scope)
NSW registered practitioners
Medical Council of NSW staff and members
Document Owner
Executive Officer, Medical Council
MEDICAL COUNCIL OF NSW
Medical Council of New South Wales, PO Box 104, Gladesville NSW 1675 AUSTRALIA Telephone (02) 9879-2200 Facsimile (02) 9816-5307. www.mcnsw.org.au
Policy No: GLMED-004 Date of Endorsement: 5 April 2022 Page 2 of 6
Medico-Legal Consultations and Examinations
Guideline
1. Purpose
The Medical Council of NSW receives many complaints about medico-legal
consultations. In these circumstances, the practitioner is not in a therapeutic
relationship with the person being examined (the consumer), and the interview
and examination may need to be more extensive than the consumer might have
been expecting. While some procedures may be simple or routine for the
practitioner, they may not be for the consumer. Effective communication is crucial,
especially when the consumer may be nervous and anxious about the possibility
of receiving an adverse medical report from the practitioner, and the potential
impact on the outcome of the legal or other process for which they are
undertaking the examination.
2. Key Principles
Practitioners are reminded that they have a duty to act in an ethical, professional
and considerate manner when examining people, whether or not they are
responsible for their care. The same level of professional skill is required of a
practitioner acting in a medico-legal capacity as in a therapeutic setting.
Practitioners practising as medico-legal consultants are practising
medicine, and accordingly are subject to the provisions of the Health
Practitioner Regulation National Law (NSW) regarding their conduct, health
and performance and must abide by the Medical Board of Australia’s Good
medical practice: a code of conduct for doctors in Australia.
Practitioners should only undertake medico-legal assessments in their areas of
expertise and should decline a request if:
• they are not adequately qualified or experienced;
• there may be a conflict of interest (personal, work-related, or financial); or
• for any other reason they are unable to complete the task within the terms
stipulated by the third party
At all times, practitioners should treat the consumer with dignity and respect. To
avoid appearing insensitive, rude, or abrupt in their manner or rough in their
examination, practitioners are advised to give particular attention to identifying the
consumer’s concerns, and to adequately explain the reasons for the examination
and how it will be conducted. Adequate time should be allowed for the
consultation to enable a complete assessment to be carried out.
MEDICAL COUNCIL OF NSW
Medical Council of New South Wales, PO Box 104, Gladesville NSW 1675 AUSTRALIA Telephone (02) 9879-2200 Facsimile (02) 9816-5307. www.mcnsw.org.au
Policy No: GLMED-004 Date of Endorsement: 5 April 2022 Page 3 of 6
3. Use of this guideline
THE CONSULTATION
1. At all times, the practitioner should communicate with the consumer in
language that they can understand.
2. The consumer has the option of having an accompanying person present
during the history and/or the examination. This should be explained to the
consumer when the interview is being scheduled. The role of the
accompanying person is to support the consumer, but not to answer questions
or contribute to the assessment. However, should the consumer have an
intellectual or speech difficulty, it is appropriate for the accompanying person
to assist in the communication between practitioner and consumer.
3. A professional interpreter should be used where the consumer has difficulty
with spoken English. Interpretation should not be provided by a support
person or member of the consumer’s family. Interpreters can be organised via
the Translating and Interpreting Service (TIS National); NSW Health Care
Interpreting Services (HCIS) (NSW Health staff); or through Multicultural NSW
Language Services.
4. The practitioner should not make any unnecessary personal remarks,
especially when the consultation involves an intimate examination.
5. The practitioner should be sensitive to cultural diversity, and respectful of the
consumer’s personal circumstances such as possible trauma or mental health
issues, especially when conducting an intimate examination.
6. As an aide memoir or to clarify disputes about assessments some
practitioners choose to video or audio record the examination:
a. The reason for this should be clearly explained to the consumer and
consent must be obtained in advance.
b. In accordance with health and privacy legislation, video and audio
records must be kept secure for
i. an adult 7 years from the date of the recording
ii. a child or young person until the age of 25 years
7. The practitioner should not offer any opinion to the consumer on their claim or
medico-legal circumstances.
8. The practitioner should not offer any opinion on the consumer’s medical or
surgical management by other practitioners.
9. In the majority of cases it is appropriate to advise the consumer of an
incidental clinical finding which has been identified by the examining
practitioner. There may be some situations where it is preferable to notify the
consumer’s treating practitioner.
10. It is not appropriate for the practitioner to undertake any form of treatment in
relation to the consumer.
MEDICAL COUNCIL OF NSW
Medical Council of New South Wales, PO Box 104, Gladesville NSW 1675 AUSTRALIA Telephone (02) 9879-2200 Facsimile (02) 9816-5307. www.mcnsw.org.au
Policy No: GLMED-004 Date of Endorsement: 5 April 2022 Page 4 of 6
THE INTRODUCTION
1. The practitioner should properly introduce themselves and explain their
specialty field of medicine in language which the consumer can understand.
2. The practitioner should explain the purpose and nature of the consultation and
examination and that it is not the practitioner’s role to treat the consumer.
3. The practitioner should be aware that the patient may believe that they are not
independent but are working for the third party. The practitioner should explain
that their role is that of an independent reviewer who is providing an impartial
opinion for use in a court or before another decision-making body and that
there are limitations on the confidentiality of the assessment.
THE INTERVIEW
1. The practitioner should limit their questions to matters that are relevant to the
purpose of the assessment, prefacing personal questions with an explanation
as to why they are necessary.
2. The consumer should be given an opportunity to provide information that they
believe may be relevant to the assessment.
THE PHYSICAL EXAMINATION
1. It is essential that prior to commencing an examination, the practitioner
explains which part of the body is to be examined, why it is to be examined,
and what the examination entails, including the extent to which undressing is
required. The position of the practitioner during the examination should also
be explained, particularly when the practitioner will be standing behind the
consumer.
2. The consumer’s modesty should be preserved by;
• the provision of a screen behind which the consumer can undress and
dress,
• the practitioner excusing themselves from the consulting room whilst
the consumer is undressing,
• the provision of a gown or sheet for modesty
3. The practitioner should examine the consumer in privacy, unless the
consumer has brought a support person to be with them at that time, although
the practitioner may choose to have a chaperone present during the
examination.
4. Examination should be limited to the area relevant to the consumer’s problem.
It is inappropriate for a practitioner to examine any part of the body without the
consumer’s consent. This may limit the scope of the practitioner’s
examination and subsequent report.
5. If an intimate examination is warranted, the reasons and nature of the
examination must be carefully explained to the consumer, and the consumer’s
permission obtained. This should be noted in the report.
MEDICAL COUNCIL OF NSW
Medical Council of New South Wales, PO Box 104, Gladesville NSW 1675 AUSTRALIA Telephone (02) 9879-2200 Facsimile (02) 9816-5307. www.mcnsw.org.au
Policy No: GLMED-004 Date of Endorsement: 5 April 2022 Page 5 of 6
THE REPORT
1. The practitioner should ensure that their report contains both the consumer’s
history and examination findings and that it notes all diagnostic possibilities.
Any limitations to a full assessment should be noted.
2. The report should be impartial and unbiased, and reflect the practitioner’s
consideration of the available opinions of other practitioners and health
professionals who have assessed, treated or provided reports on the
consumer in the past.
3. The practitioner should not offer any opinion on the consumer’s medical or
surgical management by other practitioners.
4. The report should be completed within the timeframe requested by the third
party unless there are foreseeable delays or the deadline is unreasonable, in
which case the practitioner should negotiate a new timeframe.
5. The report should set out the material relied upon and any assumptions made.
6. The report should be comprehensible, easy to read and explain medical
terminology.
7. The practitioner should be aware of the risks inherent in utilising their previous
reports as the basis of a subsequent report without further review of the
consumer.
4. Legislation and References
• The Health Practitioner Regulation National Law (NSW).
• Medical Board of Australia’s Good medical practice: a code of conduct for
doctors in Australia.
• Health Records and Information Privacy Act 2002
• Surveillance Devices Act 2007
5. Related Policies
Nil.
6. Definitions & Abbreviations
Term
Explanation
Ahpra
Australian Health Practitioner Regulation Agency
Council / we / our
relevant Health Professional Council. The Councils
established under section 41B of the Health Practitioner
Regulation National Law (NSW) No 86a.
HCCC
Health Care Complaints Commission
HPCA
Includes the individual health professional Councils and
the support functions and business units. The HPCA is an
administrative unit of the Health Administration
Corporation.
MEDICAL COUNCIL OF NSW
Medical Council of New South Wales, PO Box 104, Gladesville NSW 1675 AUSTRALIA Telephone (02) 9879-2200 Facsimile (02) 9816-5307. www.mcnsw.org.au
Policy No: GLMED-004 Date of Endorsement: 5 April 2022 Page 6 of 6
Registered
practitioner
Includes identified groups of health practitioners
practising in New South Wales whose health,
performance and conduct are regulated by a Health
Professional Council.
Council members
Includes the office holders and members of the individual
Health Professional Councils and their associated
Committees.
The Law
The Health Practitioner Regulation National Law (NSW)
No 86a
Staff
Includes permanent, temporary, casual, contractors or
consultants, working in a full-time or part-time capacity, at
all levels of the HPCA.
7. Revision History
Version
Approved By
Amendment notes
June 1996
September
2001
April 2003
December
2004
December
2005