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Medical documentation, expert reports and expert testimony
The medical record is a legal document written in real time that must not be changed retrospectively, and an expert report is evidence whose first duty is to the court — describing facts, separating them from interpretation, staying within one's expertise and stating the level of certainty.
Why it matters in the exam
The exam asks about the rules of the record, the structure of an expert report and the expert's conduct in court. In the record: write at or near the time, with date, time, name and signature; a correction is made by a dated addition, not by deletion or rewriting; and the Patient's Rights Law requires keeping a record and protecting its confidentiality, with release by consent or court order. A record altered afterwards without marking damages the doctor's credibility more than any error originally written.
In Israel the Evidence Ordinance allows an expert opinion to be submitted in writing, and the expert may be cross-examined on it. A good expert report includes: the expert's details and qualifications, the question asked, the material relied on, the findings, the discussion and the conclusion, with a clear separation between what was seen and what is inferred. The level of certainty is phrased carefully: "consistent with", "likely", "highly likely", "not consistent with" — and not "certain" when there is no certainty.
The expert's duty is to help the court, even when engaged by one side; the expert must present alternative explanations too, acknowledge limitations and change an opinion if new facts are presented. A treating doctor who testifies is a "witness of fact" about what he saw and did, and may also be an expert on interpretation — but must keep the two roles distinct. Points exams like: do not go beyond one's expertise, do not rely on unverified information, and do not alter a record after learning of a claim.
Key points
- Record in real time; correct by dated addition.
- Written expert report under the Evidence Ordinance, with possible cross-examination.
- Separate fact from interpretation and state the level of certainty.
- The expert's duty is to the court.
- Stay within one's field of expertise.
Summary table
| Topic | Rule | Why | Common error |
|---|---|---|---|
| Medical record | Real time, date, time, signature | Credibility and evidence | Completing it afterwards without marking |
| Correction in the record | Dated addition, no deletion | Transparency | Deleting or rewriting |
| Written expert report | Under the Evidence Ordinance; cross-examination possible | Clear structure | Mixing facts and interpretation |
| Level of certainty | "Consistent", "likely", "highly likely" | Accuracy | "Certain" without basis |
| Expert's role | Duty to the court | Objectivity | Acting as the side's advocate |
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Sources
- פקודת הראיות [נוסח חדש], התשל״א-1971, סעיפים 20–25, נוסח עדכני — Expert opinion in writing and cross-examination
- חוק זכויות החולה, התשנ״ו-1996, נוסח עדכני — Medical records and confidentiality
- Academy of Medical Royal Colleges: Medical expert witnesses — guidance, 2019 — Duties of the expert to the court
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.