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Summary:
Establishing a medical report is a frequent medical act, if not a daily one in some specialized areas. However, its importance is not always well understood and it is not uncommon to come across reports that are either imprecisely delivered or drawn up with too many details, which may depreciate not only their medical validity but also their psychological, social, legal and economic impact. The authors propose to remind the key elements of the establishment of a medical report and to discuss the aftereffects, on the long term, that are sometimes involved.

The medical report is a certificate that must attest the facts. It is a mean for the physician to describe the medical elements in an objective manner and to indicate the non-objective character of some elements that are considered worth mentioning (e.g. the account of the circumstances of the trauma as they are reported by the victim). The medical report belongs to the patient who has requested it and should therefore be handed over to him/her. The patient's motivations may vary : usually, the medical report will be used to support a file for the justice or for an insurance company but it may also be intended to an employer, the army, an institution. For the solicited physician involved in a therapeutic relationship, the temptation is strong to establish a medical report favorable to the patient. However, for its validity not to be suspected, the report should always adhere to a precise scheme. This scheme will be presented in this article along with the pitfalls to be avoided and the elements that should not fail to be reported.

The objective and precise establishment of a medical report constitutes a therapeutic action (that acknowledges the patient's suffering) as much as a legal act (that acknowledges or not the victim as such). The medical report may therefore become the key element of an optimal and diverse management of victims of violence.