IME Report Writing Checklist

By: Steven Babitsky

Physicians performing IMEs are judged to a large extent on the quality of their reports. As most cases settle prior to hearing or trial the IME report is extremely important to the client.

IME Physicians can use the following checklist to increase the value of their reports.

1. Answer all the questions posed by the client
One of the chief complaints by clients is that IME physicians do not answer all of the questions posed.

Practice Point
Physicians who identify and answer all of the questions posed simply and completely will obtain more IME work than those who miss or avoid questions or offer vague, confusing or ambiguous answers.

2. List all of the medical records and other documents you have reviewed
Physicians who list the records reviewed increase the value of their report. In addition, the list will help the physician when testifying at deposition or hearing.

Practice Point
Physicians should, with the help of their staff, organize and list the medical, hospital, and diagnostic records in a user friendly fashion. The list of records can be organized chronologically, or by body part, injury or condition. Charts and time lines can add value to your IME report.

3. Meeting the Deadlines of the Client
Clients are often under regulatory or company requirements to file IME reports within a certain timeframe.

Practice Point
Find out when the client needs the report by and exceed the client’s expectations by getting the report to them well before their deadline.

4. Properly Format Your Report IME reports that are not properly formatted (with relevant paragraph headings) are difficult to read and understand.

Practice Point
Break up your paragraphs with appropriate headings that are helpful to your readers. For example: • Records Reviewed • History of the present illness per examinee • Present Complaints • Past Medical History • Personal and Social History • Work History • Physical Examination • Diagnostic Study Results • Answers to Specific Questions • Rationale • Additional Comments

5. Take and Include a Detailed History
Your report will be less valuable and subject to questions at deposition/hearing when you do not take a detailed history.

Practice Point
Include in your IME report a well-documented, thorough, well-written and accurate history.

6. Make sure Your Report is Legally Sufficient
IME reports that contain opinions that are not properly expressed may result in the report and opinion being rejected by the judge, commissioner, or fact finder.

Practice Point
Utilize the terms of art in your forum and jurisdiction. For example: “the opinions I have expressed are based upon a reasonable degree of medical certainty (probability).”

7. Avoid Using Problematic Words in Your Report
The value of many IME reports are substantially reduced due to the use of hedge words or words and phrases that are vague or otherwise invite unnecessary scrutiny and cross-examination.

Practice Point
Physicians writing their IME reports should avoid using hedge words or problematic terms that will encourage extensive cross-examination and difficulty. Some of these terms/words are:  Alleged, Apparently, Appears, Authoritative, Clearly,  Complete, Confidential, Could, Credible, Dictated but not read, Draft, Electronic signature, Evidently, Exhaustive, He,  I believe,  Is said, It, It seems, Legal/legally, Malingering,  Meticulous , Obviously , Patient, Possible, Presumably, Privileged, Probable , She, Substantially, We, Work product

8. Have a Rigorous Quality Control Process
One of the reasons that clients do not hire physicians for repeat IME work is due to sloppy reports filled with grammatical and typographical errors.

Practice Point
Read the report carefully to yourself to correct any mistakes you find. In addition, have another intelligent person proof the report by looking for mistakes you may have missed.

9. Avoid Excessive Boilerplate/Standard Language
The more your IME reports resemble “cookie cutter,” reports, the less valuable they are. In addition, standard reports will often result in internal inconsistencies.

Practice Point
IME physicians should avoid excessive reliance on the same standard language in all reports.

10. Avoid Detailed Cover Letters
Many excellent IME reports are ruined by overly friendly or solicitous cover letters.

Practice Point
Have a simple cover letter (if one is needed at all) without any personal or other comments that can be made to imply bias on your part.

Conclusion
IME physicians who scrupulously follow the above 10 suggested points are best positioned to write an excellent, defensible, and valuable IME report.