How to Structure an Independent Medical Evaluation Report

by | Published on May 30, 2016 | Medical Record Review

An independent medical examination or evaluation has medical and legal value and is performed by a medical physician who has received special training and experience in the field. He/she is not involved in the claimant’s care and their evaluation involves review of relevant medical records and diagnostic studies, history and physical examination.

The structure of the IME report may vary from one examiner to another and from one jurisdiction to another. It also depends on the type of examination. The general outline of a report is as follows.

  • Introductory information: This would include the name of the claimant along with identifying data; date of injury; date, time and place of examination; purpose of the examination; referring source; brief synopsis of the report; list of all medical records reviewed; hand dominance, left, right or ambidextrous, in the case of upper extremity evaluation.
  • History: This should include history obtained via medical record review and that obtained via current interview. It is important to carefully identify the source of information, whether claimant, interpreter, records, family member or other.
  • Record review: The review should be complete, thorough and accurate, which can be ensured with the help of reliable medical record review services. The source of information must be carefully identified including all providers by name and the dates of service. It is best to list past medical history record review separately from the record review for the current injury.
  • Subjective current interview or oral history: This section should contain documentation of chief complaint(s) that includes characteristics of symptoms and chronology. Document pain including location, frequency, radiation, duration and components that worsen or alleviate symptoms. Weaknesses and neurologic complaints if any should be described. Other details to include are mechanism of injury, symptoms before and after the treatment, response to treatment, current functional status, occupational history, time off work, review of systems wherein all appropriate psychological symptoms such as depression and chronic pain should be included.
  • Physical examination: All findings should be thoroughly documented. To signify impairment rating, document the findings in a manner consistent with the requirements of the impairment guide being utilized.
  • Other objective data: This section should contain a listing of all the radiologic and other imaging tests reviewed. It is also necessary to clearly identify official written interpretation vs. examiner’s opinions of the tests reviewed. Other things to include are applicable functional tests, and review of ancillary tests.
  • Opinion section: This should include diagnoses and discussion on them. Any inconsistencies in data or history can be noted down and discussed here. In case there is disagreement with another examiner’s opinions, the reason for disagreement must be clearly explained. Examiners can also include their comments on past medical treatment; maximum medical improvement and when this occurred; future medical treatment; causation; apportionment; disability/functional status; prognosis; and answers to specific questions put by the requesting agency, wherein verbatim questions and direct answers should be included.

Ensuring the quality of an IME report is very important because this will help maximize its value to all parties concerned. When evaluating the quality of the report, the following questions can be asked.

  • Whether the report is clearly written and well organized, so that even a non-medical reader can understand it.
  • Whether the report’s length is in keeping with the complexity of the case.
  • Whether the report is objective, fair and unbiased.
  • Whether all questions asked has been effectively addressed.
  • Whether it provides the information the requesting agency needs.

Whether the report complies with the appropriate rating guide in case an impairment rating is required.

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