The allied health chronology: function, care and work across a medico-legal file.

Medico-legal chronologies are usually discussed as a doctor's job: diagnoses, imaging and surgery set out in date order beneath a medical opinion. Occupational therapists, physiotherapists and other allied health assessors write expert reports from the same files, and they spend the same evenings assembling them. Their question is different, though. An occupational therapist asks what the person could do, who helped them, and how that changed over time, which means the chronology has to record a different set of facts.

Most of those facts are already in the file, scattered across certificates, treating notes, case manager emails and the claimant's own statements. The task is to find them, date them, and keep each one tied to the page it came from, because the report will be read by people whose job is to test it.

The same expert duties apply to every profession that signs a report

The harmonised expert witness code applies to any expert witness engaged to provide a report for use as evidence, with no carve-out by profession.¹ Expert evidence rests on specialised knowledge based on training, study or experience, which describes an occupational therapist assessing care needs as accurately as a surgeon assessing a fracture.¹ The code also requires every report to state the assumptions and material facts on which each opinion is based, and for an allied health report most of those material facts come out of the chronology.¹

Professional obligations run in parallel. The shared Code of conduct used by twelve National Boards, including occupational therapy, physiotherapy, chiropractic and podiatry, has a section on legal, insurance and other assessments. It records that the usual therapeutic relationship does not exist when a third party contracts the assessment, and that the practitioner should provide an impartial report.² The next section asks practitioners to take reasonable steps to verify content before signing, not to omit relevant information deliberately, and to make clear the limits of their knowledge.²

Psychology sits outside that shared code and has its own, but the logic carries across. Whoever signs the report owns the facts in it, and a chronology that cannot be traced back to the records is a weak foundation for any of them.

An allied health chronology tracks function rather than diagnosis

A medical chronology is organised around clinical events: the injury, the scan, the operation, the specialist review. An allied health chronology needs those events as anchors, but the entries that carry the opinion describe what the person could do at each point and what support they needed to do it. The file holds that information in different places, so the chronology has to follow several threads at once.

None of these threads is optional for a care-needs or functional capacity report, and each one tends to be split across documents written by people who were not thinking about the occupational therapist who would read them later. A certificate of capacity records restrictions in one sentence, while the physiotherapy discharge summary written three weeks later may describe the same person quite differently.

Care hours carry a legal threshold, so the chronology has to count them

In New South Wales, the Civil Liability Act sets conditions on damages for gratuitous attendant care, meaning domestic, nursing or other help provided by someone the claimant does not pay. The court must be satisfied that there is a reasonable need for the services, that the need arose solely because of the injury, and that the services would not have been provided but for the injury.³ It also bars damages unless the services are provided for at least 6 hours per week and for a period of at least 6 consecutive months.³

The court decides whether those conditions are met, but the occupational therapist's report is often where the evidence for them is organised. Consider a claimant whose partner drove them to every physiotherapy session, took over the cooking and helped them shower for the first months after a shoulder reconstruction. A report that gives only a current weekly figure leaves the earlier period unanswered, even though that period may be the one that satisfies the threshold.

So the care thread needs dates and intensity, entry by entry. When did the help start, what tasks did it cover, roughly how many hours a week, and when did it taper or stop? Each answer should point to its source, whether that is a statement, a case note or the assessor's own interview, because a figure with no visible source is the first thing the other side will challenge. Other jurisdictions set their own rules, and the assessor should work to the ones in the letter of instruction.

The pre-injury baseline is the entry most often missing

The same statutory conditions explain why the baseline matters so much. Care is only attributable to the injury if the need arose because of it, which means the report has to show what the person needed before. A claimant with long-standing knee osteoarthritis whose son already mowed the lawn and carried the shopping has a pre-injury level of support, and the care attributable to a later back injury is the increase on top of it.

Baseline evidence is usually thin and scattered. It sits in GP notes from years before the claim, in an earlier compensation file, in an employer's record of duties, or only in the claimant's own account given at interview. A chronology that starts on the date of injury hides that problem, because it never shows the reader that the baseline was looked for.

The better practice is to start the chronology before the injury, carry the earliest relevant records into it, and mark which baseline statements rest on documents and which rest on the claimant's recollection alone. Where nothing in the file speaks to pre-injury function, the report should say so plainly rather than infer it, which is exactly the qualification the shared code and the expert code both expect an assessor to state.²¹

Your observations stay yours, and the file work can be delegated

An allied health report has two very different inputs. One is the assessor's own evidence: the interview, the standardised tools, the observed transfers and lifts, the home visit. The other is the history assembled from records the assessor did not write. Only the second is a candidate for software, and the NSW Personal Injury Commission draws its line in the same place.

The Personal Injury Commission's procedural direction on generative AI permits its use to generate chronologies and indexes and to summarise or review documents.⁴ It prohibits generating content intended to reflect a witness's or other person's evidence or opinion, and it requires an expert who uses generative AI for any purpose in preparing a report to disclose that use in the report, including which parts it was used for.⁴ It also restricts entering material produced under compulsion into any generative AI program unless the platform keeps the information within a controlled environment and does not use it to train large language models.⁴

Ahpra's guidance on artificial intelligence applies the same accountability to every registered profession. The practitioner remains responsible for their practice, must apply human judgement to any output of AI, and needs to understand where the data is located, how it is stored and whether it is used to retrain the tool.⁵ In practice, that turns into a short set of questions worth asking of any chronology tool before a claim file goes near it:

• does every chronology entry link to the page it came from, so checking a care-hours figure is a lookup rather than a search;
• are illegible or undated pages flagged in the output, instead of smoothed into fluent entries;
• is the file processed onshore, and does the vendor say plainly whether your files are used to train models;
• does the tool keep a record of its own use, so the disclosure the Commission requires can be written from that record rather than from memory.

We have set out the forum-by-forum rules in more detail in what the rules actually say about AI in medico-legal reports, and they apply to an occupational therapist's report in the same way they apply to a surgeon's.

A functional history is only as strong as its dates

Every opinion an allied health assessor gives about future care, equipment or work capacity is projected forward from a past. If that past is dated, sourced and carried back before the injury, the projection can be tested and defended. If it is a narrative reconstructed from memory of a long file, the most important numbers in the report have nothing underneath them.

The chronology is therefore where an allied health report earns or loses its credibility, well before the assessor writes a single recommendation.

Trenthos IME works on that layer for any assessor who works from records, not only for doctors. It reads every page of the brief, builds a dated chronology with a page reference on each entry, and flags what it could not read instead of filling the gap. An occupational therapist reads the same chronology for function, care and work, while the assessment, the care-needs opinion and the signature stay with them, and the tool records its own use so the disclosure can be written from it.