DIRECT EXAM OF TREATING DOCTOR
We are still in trial so I have limited time to share with you this week, but here is a simple outline I used during the trial for a treating doctor. I’ve omitted a lot of references to the hospital records and exhibits I used during the examination. I revised a portion of it to make it appropriate for sharing. Also, this is for a physician who first saw the plaintiff in the hospital.
DIRECT EXAM OF TREATING DOCTOR
WHY WITNESS (Note: The first question in the juror’s mind is: who is this and why are they being called as a witness? So, I like to get that fact out first)
- ROLE
- HERE TO EXPLAIN
- “REASONABLE MEDICAL CERTAINTY” DEFINED
(Note: if you don’t instruct the witness about the standard of proof in the beginning you need to keep repeating the phrase every time you ask a medical opinion)
QUALIFICATIONS
1. NAME – PROFESSIONAL ADDRESS
2. PROFESSION/SPECIALITY
3. EDUCATION
(1) BOARD CERTIFICATION
4. PROFESIONAL EXPERIENCE
5. QUALIFICATIONS –See bio
EXAMINATION OF PLAINTIFF –
1. WHEN/CIRCUMSTANCES
HISTORY
- HISTORY OBTAINED? HOW?
- SEE ADMITTING HOSPITAL RECORD
PHYSICIAL EXAMINATION
1. FINDINGS
E. DIAGNOSIS
1. WHAT? WHAT BASIS?
HOSPITAL CARE
- REVIW HIGHLIGHTS
(1) Ex 21 p. 16 photo
- PROCEDURES DONE SUMMARY:
(1) See Ex 82
PRESENT CONDITION
1. LAST EXAM – CONCLUSIONS
(1) SEE HOSPITAL DISCHARGE Ex 27 p. 38
PROGNOSIS
1. PERMANENT INJURIES?
2. ABILITY TO WALK
3. LIFE LONG CARE
4. VENTILATOR
4. EFFECT IN FUTURE
(1) DISABILITY
(2) DISFIGUREMENT
(3) PHYSICAL PAIN
(4) MENTAL PAIN
(5) LOSS OF ENJOYMENT OF LIFE
3. FUTURE TREATMENT REQUIRED?
(1) NATURE
4. LIFE EXPECTANCY IMPACTED?
CAUSATION
1. MECHANICS OF HOW ACCIDENT CAUSES THESE INJURIES
2. PROXIMATE CAUSE OF INJURY: REASONABLE PROBABILITY
BILLS
1. HAVE REVIEWED?
2. IN YOUR OPINION THESE WERE MEDICALLY NECESSARY AS A RESULT OF HER INJURIES FROM THE FIRE?