Best Practices in Medical Record Review

Report review is one of the most crucial aspects of a QME’s practice, so it’s important that it is done right. Even the smallest detail, when left out of a review, can make or break a Workers' Compensation case. This can lead to an unfair outcome on the part of the injured worker, and no one wants that. So how to conduct a thorough record review? Read on for some helpful tips.


There are a few obvious components to QME reports – subjective complaints, objective findings, diagnoses, and so on. But the less obvious components are oftentimes the most crucial to a Workers' Compensation case. Here we will break down the less obvious components so you never miss them again.


Report Sections:


Past Medical History

  • Carefully review this section for injuries that may have preceded the injuries being alleged in the current claim.

Social History

  • If you’re evaluating a psych claim, read this section for things like childhood abuse, crime victimization, prior drug abuse and the like.

Treatment History

  • Strictly an orthopedic claim? You’ll want to pay close attention to this section. If the claimant is denying injury to his lumbar spine prior to his 2019 injury, why did he undergo an LESI in 2013?

Medication

  • This tiny section can be helpful too. If you are an internist evaluating a claimant who is alleging high blood pressure as a result of an industrial injury that occurred in 2015, it’s helpful to know that she has been on blood pressure medication since 2011.

Causation and Apportionment

  • This is a tricky area for QMEs because the defense attorney wants your opinion and not the opinion at which the QMEs before you arrived. So don’t fall into the easy trap of relying on the opinions of previous evaluators. You make this decision based solely on what you saw in the records and in your interview of the claimant. Our suggestion? Read this section for informational purposes only, and not to inform your own decision.

Deposition Transcripts

  • Some QMEs mistakenly overlook deposition transcripts, and here is why this is a mistake. Claimants are understandably nervous when having their deposition taken, and who can blame them? They’re being carefully questioned by the defense attorney, and that is a nerve-wracking experience for anyone. But…when folks are nervous they have a very strong tendency to blurt out the truth. So while a claimant may have told all his treating physicians that he has never suffered a prior injury to his bilateral upper extremities, he may just mention during the deposition that motor vehicle accident in which he was involved 10 years earlier that resulted in traumatic whiplash with pain that radiated down to his shoulders. You need to know this.

Overview

The crux of the matter comes down to this: Information is power, so obviously the more information you have, the better armed you are to arrive at a fair and equitable decision for everyone involved. And yes, such a thing is possible.

I don’t blame you if you’re beginning to feel a bit overwhelmed at this point. As a QME you have a lot on your plate, and now you have to worry about thoroughly conducting record reviews? The good news is, you don’t. Medical-Legal is here to help, to take one hat off your head. Contact us today at mariachild51@gmail.com or 310.678.2270 to find out how we can take record review off your plate, thoroughly and at reasonable rates.

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