Medical Reports for an RAF Claim: What to Prepare

Key takeaways

• The RAF 1 medical report, ordinary treatment records, medico-legal reports and RAF 4 serve different functions.
• Request the full clinical record, not only a discharge summary or medical certificate.
• Keep radiology reports, images, laboratory results, referrals, prescriptions and rehabilitation records with the related provider entry.
• Match medical evidence to the loss being claimed; medical proof does not replace employment or financial proof for loss of earnings.

1. Start with the purpose of each medical document

A useful RAF medical file has several layers. Mixing them together makes it difficult to see what is present and what is still missing.

Statutory medical report

The current RAF 1 form contains a medical-report section. It asks for information such as when the injured person was first seen, earlier treatment, the injuries and diagnosis, treatment given or planned and the levels of care involved. The form directs that this part be completed by the treating medical practitioner or, for hospital treatment, the hospital superintendent or an authorised representative. It also calls for clinical notes to be attached.

This statutory report is part of the prescribed claim documentation. It is not a substitute for the underlying hospital and medical records.

Treatment records

These are the contemporaneous records created while care was delivered: emergency notes, admission records, progress notes, operation notes, nursing entries, prescriptions, referrals and discharge material. They help establish the treatment history and may reveal details that a later summary leaves out.

Diagnostic and rehabilitation evidence

Radiology reports, image files, laboratory results, specialist tests, physiotherapy notes, occupational-therapy records and other rehabilitation material show how an injury was investigated and managed. A report interpreting a scan and the scan image itself are different items; ask what format is available and keep both where possible.

Medico-legal reports

A medico-legal report is prepared for a legal assessment rather than routine treatment. Depending on the claimed loss and the facts, different experts may address diagnosis, prognosis, functional limits, future care or work capacity. Do not commission reports indiscriminately. Their relevance, timing and scope should be decided against the claim and the available clinical record.

Serious-injury assessment

The RAF 4 is a separate serious-injury assessment used for a claim for general damages where applicable. It is not another name for the RAF 1 medical report, a discharge summary or a treating doctor’s letter.

2. Prepare the RAF 1 medical-report material

Start by confirming that the claim uses the current prescribed form for the accident and intended submission date. The RAF publishes claim forms, but a form or procedure can be amended. Work from the official version rather than an old download saved by someone else.

For the medical-report section, prepare:

• the claimant’s identity details exactly as used in the claim;
• the correct collision date and a concise description of the injuries linked to it;
• the date and place of first treatment;
• details of any earlier provider who treated the injuries;
• the provider’s diagnoses and recorded injury codes, where used;
• treatment already provided and treatment still planned;
• relevant clinical notes for attachment; and
• the practitioner or authorised hospital representative’s correct professional and facility details.

Do not complete the clinical opinion on the provider’s behalf. You can supply accurate identifiers and supporting records, but the authorised person must record and certify the medical information required from them.

Before the document is used, compare names, identity numbers, dates and facility details against the claim file. An administrative mismatch should be raised with the issuing provider through its records process; it should not be silently altered on the document.

3. Request the complete record from every treatment provider

Create one provider list before sending requests. Include the ambulance service, emergency unit, hospital, general practitioner, surgeon, specialist, radiology practice, laboratory, pharmacy and each rehabilitation provider involved in the accident-related care.

For each request, identify the patient, facility or practice, relevant treatment dates and the collision date. Ask for the complete record for that period, including items that apply to the treatment:

• casualty, triage and emergency notes;
• ambulance or transfer records;
• admission and discharge records;
• ward, nursing and progress notes;
• consultation and follow-up notes;
• operation, anaesthetic and procedure records;
• referral letters and specialist correspondence;
• prescriptions and medication charts;
• sick notes or certificates issued during treatment;
• radiology reports and available image files;
• pathology or laboratory results;
• physiotherapy, occupational-therapy and rehabilitation notes; and
• consent forms or disability documentation relevant to the recorded care.

A discharge summary is useful, but it usually summarises an episode. It may not contain the observations, investigations, referrals or treatment sequence recorded elsewhere in the file. Mark the request as complete only after comparing the material received with the provider’s document list or the known course of treatment.

4. Build a treatment chronology that can be checked

Use a spreadsheet or table as an index, not as a replacement for the records. A practical chronology has one line for each material event with these fields:

1. date and, if known, time;
2. provider and facility;
3. reason for attendance;
4. injury, symptom or diagnosis as recorded by the provider;
5. investigation or treatment;
6. referral or follow-up instruction;
7. source document and page or file name; and
8. a gap or query requiring follow-up.

Use the provider’s own wording when recording a diagnosis. Do not turn a symptom into a diagnosis or infer causation from the order of events. If two records differ, record both versions and identify the source of each.

The chronology should make it possible to trace the journey from the collision to first treatment, later treatment, rehabilitation and present status. It should also show missed appointments, periods with no treatment and unrelated prior or later conditions. Those facts may need context, but hiding them makes the pack less reliable.

5. Keep diagnostic evidence linked to the clinical record

Diagnostic material is easiest to understand when the request, report, image and follow-up note are kept together.

For radiology, record the examination date, body area, imaging practice, referring provider and report. If the provider supplies the images through a disc, portal or download link, preserve the original format and note how access can be provided securely. Do not rely on a mobile-phone photograph of a screen when the original digital study is available.

For laboratory or specialist tests, retain the order or referral, result and the note showing how the clinician interpreted or acted on it. A result without its clinical context may be difficult to connect to the accident-related treatment.

Where rehabilitation is relevant, keep the initial assessment, treatment plan, attendance record, progress measures and discharge or outcome note. A bare invoice proves a charge; it does not describe the therapy, response or functional change.

6. Separate medical expenses from medical history

The RAF’s public claim guidance lists an itemised tax invoice from a registered provider or hospital and proof of payment for past medical expenses. Build a separate expense schedule with:

• provider and invoice number;
• service date;
• treatment or service description;
• amount invoiced;
• amount paid and payment date;
• payer, including a medical scheme where relevant;
• proof-of-payment reference; and
• any unpaid balance, reversal, refund or duplicate entry.

Keep the invoice and proof of payment behind the matching schedule line. Do not record an amount as personally paid if it was paid by a medical scheme, employer or another source. The financial trail must reconcile to the supporting documents.

7. Match medico-legal evidence to the loss being claimed

Medical evidence may support the existence, severity, treatment and prognosis of an injury. It does not by itself prove every financial consequence.

For a loss-of-earnings claim, the RAF’s current public guidance refers to medical reports or medico-legal evidence addressing temporary or permanent disability, but it separately lists employment, remuneration, tax, banking, academic and other income evidence. Keep those streams distinct:

• clinicians and appropriate experts address medical and functional issues within their expertise;
• employers and work records address role, attendance, remuneration and employment history;
• tax, banking and accounting records address income where relevant; and
• the legal and actuarial assessment connects admissible evidence to the claimed loss.

Avoid asking a treating clinician to make a legal or financial conclusion outside the purpose of the treatment record. If an expert report is required, the instruction should identify the issue, relevant records and questions without directing the desired outcome.

8. Understand when RAF 4 may be relevant

If general damages are being claimed, the serious-injury process must be considered separately. The RAF’s current guidance says a RAF 4 Serious Injury Assessment Report is required where applicable, and the form is completed by a medical practitioner registered under the Health Professions Act using the prescribed assessment framework.

Do not self-classify an injury as serious from a diagnosis, an operation or time away from work. Do not assume that a RAF 4 replaces the treatment record. The assessor may need the underlying clinical and diagnostic material, and supporting reports may be annexed, but the form has its own legal function.

If the claim may include general damages, obtain advice on the current assessment, timing and submission requirements. This article does not determine whether a particular injury meets the legal test.

9. Resolve missing records and discrepancies truthfully

A useful gap log states what is missing, why it is expected, when it was requested and the provider’s response. Common examples include an emergency visit mentioned in a later note, an imaging report without the images, a referral without the specialist record, or invoices for treatment that has no clinical entry in the pack.

If a record contains an apparent error:

• preserve the record as issued;
• note the exact discrepancy and its page or file reference;
• compare it with independent source documents;
• ask the provider about its formal correction or addendum process; and
• keep the request, response and any authorised addendum together.

Do not pressure a practitioner to change an opinion, backdate a note or remove an inconvenient fact. A transparent explanation supported by source records is safer than a file that appears to have been reconstructed.

10. Protect health information while preparing the pack

Medical records contain sensitive personal information. Limit preliminary circulation to what is reasonably needed, verify the recipient, and use a secure transfer method suitable for health information. Avoid public links, unencrypted messaging groups and shared folders that expose records to unrelated people.

Keep an untouched provider-issued set and a separate working copy. Remove unrelated third-party information before wider use where lawful and appropriate, but do not redact or edit the evidential copy without recording what was done. A lawyer or information-governance professional can advise on disclosure, consent, confidentiality and the handling of another person’s information.

Final preparation checklist

Before the file is reviewed, confirm that:

• every provider and facility appears on the provider list;
• the RAF 1 medical-report section uses the current form and authorised completion route;
• clinical notes accompany the statutory report where required;
• the treatment chronology links each entry to a source file;
• reports and original diagnostic files are both included where available;
• rehabilitation records show attendance and progress, not only charges;
• the expense schedule reconciles invoices and proof of payment;
• medico-legal reports address a defined claim issue;
• RAF 4 has been considered separately if general damages may be claimed;
• gaps and conflicting entries are recorded rather than hidden;
• originals or provider-issued copies remain unchanged; and
• the current RAF lodging rules and material deadlines have been checked.

Next step

Prepare the provider list, treatment chronology, gap log and expense schedule before a consultation. Bring the current RAF forms, every record already obtained and proof of outstanding requests. A qualified RAF lawyer can then identify which documents are required for the claim, which expert evidence may be justified and which formalities or deadlines need immediate attention.

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