IME Physicians: Proper Disclosing of Documents
One of the most important functions that a physician performing Independent Medical Exams undertakes is the preparation of his/her IME report. These reports are frequently used to evaluate and settle many cases. A crucial element of a persuasive and defensible IME report is the section documenting the medical and other records that the physician read and considered before forming her opinions. An IME report that does not list and precisely describe the records reviewed is less than ideal.
Recommendations for properly disclosing and documenting the records reviewed include:
- Each document should be described precisely, including, where appropriate, date, length, author, and other descriptive information.
- The list should be numbered.
- The documents should be listed chronologically or according to some natural, logical grouping (for example, all medical reports, all diagnostic studies, all depositions).
- To make an IME report truly stand out, the examiner should consider not merely listing the medical records reviewed, but summarizing each record reviewed as well.
- The following descriptives should be avoided: “including,” “including but not limited to,” “relevant portions of,” and “various.”
- Examiners should not make opposing counsel’s job easier by explicitly listing documents that were not available for review.
- Generally, examiners should not produce reports in cases where there were few or no records available for review.
- Surveillance material should be described objectively and without any superfluous language attacking the claimant.
- Illegibility should not be used as an excuse for the wholesale ignoring of records.
- Examiners should expect close questioning regarding the authenticity, accuracy, and completeness of medical records provided by the referral source.