How to Conduct a Thorough Record Review
Record review is immensely helpful to Qualified Medical Evaluators, Independent Medical Evaluators, Workers' Compensation attorneys, and personal injury attorneys. For this reason it is essential that it be done correctly. We have put together a short-list of suggestions for conducting high-quality and useful record reviews. Organize the records chronologically before you begin. The entire point of record review is to provide the reader with a chronology of events so he/she can see any patterns within the patient’s records as well as know about injuries and diagnoses that preceded the injury being investigated.
Know what you are looking for. For example, if an applicant is claiming a lumbar injury, look out for records that indicate a prior injury or pre-existing condition to this body region. If an applicant is claiming a psyche injury, look for previous treatment from mental health providers.
For orthopedic claims, thoroughly review all objective (physical examination) notes. This can be time-consuming, but these notes will be of immense benefit to an orthopedic QME. - This includes any tests (ie. Babinski’s, Tinel’s) as well as range of motion testing, strength testing, etc. - Always look for positive Waddell’s signs – both for orthopedic and psyche claims - as these indicate malingering on the part of the applicant. These will usually be bolded in the notes, so they won’t be hard to miss.
Review laboratory test results. For psyche claims, these include Hgb A1c, TSH, AST, ALT, alkaline phosphatase, and total bilirubin. Flagged results for any of these levels are useful to the psyche QME as abnormal levels can affect an applicant’s emotional health (or anyone else’s for that matter).
For orthopedic claims, laboratory test results are not nearly as important, but do review any rheumatologic test results as abnormal levels can be a significant cause of orthopedic pain.
The most important part of any set of medical records are QME, AME, and PQME reports, so review them carefully. These reports are usually extremely thorough and include all of the items your client will need to assist him/her in arriving at a decision.
Use well-ordered formatting as this will make your review easy to read. The following is an example of well-ordered formatting:
Use Times New Roman font, size 13 throughout. Place record titles in bold, underlined, blue font, with the following title format example: Primary Treating Physician's Progress Report (PR-2), signed by John Doe, MD, Orthopedic Surgery, dated December 2, 2020
Separate each record by a double space, as well as each section of a record. Speaking of sections, here is how they should be arranged in the review:
Record review: If the QME has reviewed other providers’ records and reports in preparation for his/her evaluation, they will be listed here. There’s no need to “review the review”; simply list the names and credentials of the providers.
Subjective: The applicant’s complaints, both physical and psychological/psychiatric.
Objective: Physical examination; not necessary for psyche claims.
History of injury: Detailed timeline and description of how the injury occurred, whether or not is was reported promptly, and if the employer responded appropriately, ie. offering a claim form and treatment.
Job description: Both the responsibilities and physical activities involved in the applicant’s job at the time he/she was injured.
Medications: Include any and all medications, even OTC.
Diagnoses: Write this as “The diagnoses were of” rather than “The diagnoses were.” Separate each diagnosis with a semicolon to make for easier reading.
Permanent and stationary/maximum medical improvement status: This is a good indicator of whether or not the applicant is ready to return to the workforce.
Causation: Very important! This is the beginning of the arrival at a decision for or against the applicant.
Apportionment: Also very important! This will assist the attorneys in arriving at a settlement amount.
Whole person impairment rating: Also assists the attorneys in arriving at a settlement amount. List each rating separately by body part, or in the case of psyche claims, mental health diagnosis.
Work status: Is the applicant temporarily totally disabled? Temporarily partially disabled? Or able to return to work at his/her usual and customary duties?
Treatment plan: This will help in determining if recommended treatment options were approved. If they weren’t, this could damage the defense attorney’s case. If they were, it will assist future QMEs in deciding if and when an applicant has reached permanent and stationary/maximum medical improvement status. That’s about it. Sounds easy, but if it’s done properly, record review does require time, diligence, and patience. Stick to it until you get it right and you will become a valued member of any QME’s or Workers' Compensation/personal injury attorney’s team. We hope this helps!