Medical Transcription: Independent Medical Evaluation

By Anne Martinez from Medical Transcription For Dummies

An independent medical evaluation (IME) is a common report that you will see in medical transcription. An IME is a comprehensive review of a patient’s medical history performed by a physician not previously involved in the patient’s care.

IMEs are usually performed for a legal purpose, such as assessing eligibility for workers’ compensation or disability benefits or for litigation related to an accident or injury. A qualified medical evaluation (QME) is the same thing as an IME. Topics covered in an IME include:

Factors surrounding the onset of the patient’s illness or injury
A detailed description of the patient’s medical course and treatment, including a full review of available records
Consideration of any additional information, such as a report provided by a private investigator
A physical examination
Assessment of the appropriateness of the care already rendered
Whether further medical care is warranted
Determination as to whether the patient has a permanent disability and its exact nature and degree

Standard medical transcription formatting guidelines are largely ignored in favor of customized formatting that fits on letterhead stationery. Section headings, for example, may be centered, transcribed in mixed case instead of uppercase, bolded, underlined, or any combination thereof.

The formatting and organization of IME reports is also more diverse than any other report type. It’s essential to obtain a model report or template to use as a starting point, even though the sections dictated may vary.

Introduction

The first thing an IME does is state the name of the patient, the date of the injury or onset of illness, and the purpose of the report. If the report is related to an insurance or disability claim, a case number is given.

Re: Patient, Unfortunate

DOB: 02/13/1977

Case #: 23159777

Date of Injury: 11/01/2011

Date of Examination: 11/25/2012

The first paragraph summarizes the purpose of the report:

As requested by Verribig Insurance Company, I evaluated Mr. Amos Stake in my office on November 25, 2012, for injuries sustained to his left hand on November 1, 2011, during the course of his employment as a forklift operator at Widget Manufacturing Co. The purpose of this review is to address the issue of long-term disability related to his hand injury.

History and present complaints

The history of the case may be given in a single large section titled History or be divided into subheadings. In either case, it’s usually very extensive. It provides details about who the patient is and how he came to be in his current condition. If the injury is employment related, it will include a work history going back for years.

Many of the subheadings used in the history portion of an H&P also are used here, including past medical and surgical history, social habits, and family history. Each encounter with a medical provider may be listed by date and described.

When compensation is being sought for a disability, a great deal of attention will be focused on the patient’s physical and mental capabilities before and after the incident.

Almost anything can be pulled in; if the report requestor hired a private investigator to follow the patient around and watch for signs of malingering, perhaps going on a ski vacation while allegedly too injured to work, that will be mentioned here as well.

Transcribe exactly as dictated. If you have the slightest doubt about a word or phrase, flag it for dictator review.

Physical findings

Occasionally an IME is based purely on review of records, but more often there’s an in-person examination as well. The exam often is limited to body parts/systems related to the reason for the IME but can go into those in fine detail, resulting in something like this:

Hand grip strength, as measured by Jamar dynamometer, showed left hand at 49, 44, and 51 pounds; right hand at 50, 57, and 45 pounds. Lateral pinch gauge using Jamar pinch gauge showed left hand at 17.1, 17.2, and 16.2 pounds; right hand at 16.2, 16.3, and 17.5 pounds. Circumferential measurements of both upper extremities showed left arm at 25.2 cm, left forearm 21.3 cm; right arm 24.4 cm and right forearm 21.4 cm.

Diagnostic studies

The examiner will review and comment on the results of laboratory tests, MRIs, and other diagnostic studies. The discussion may be under this heading or incorporated into another section.

Records review

An IME often includes an itemized list of documents that the examiner reviewed as part of the evaluation. These reports are from office visits, treatments, and diagnostic procedures the patient received. The records list may be dictated near the beginning of the report as part of the introduction, or just before the examiner renders his conclusions. It should be formatted as a vertical numbered list, like this:

Medical Records Review:

1. January 22, 2011: Annual physical exam by the patient’s primary care. No patient complaints reported.

2. March 15, 2011: First report of injury. X-rays of the left knee were negative.

3. April 12, 2011: MRI of the left knee showed complete tear of the mid to distal ACL.

Diagnosis

The diagnosis section of an IME can stray quite far from other medical documents. Of particular note, diagnoses should be transcribed exactly as dictated without expansion. Diagnoses are usually formatted as a vertical list. So, the diagnoses section of an IME may look like this:

Diagnoses:

It is my opinion that the diagnoses are:

1. Mild residual left shoulder weakness with full range of motion.

2. Residual pain in left medial epicondyle area.

3. Left wrist weakness.

An IME report doesn’t always include a separate diagnosis section. The diagnosis may not be in dispute, or it may be discussed in the introduction or conclusion of the report rather than listed under a distinct heading.

Conclusion

This is where IME reports get wildly divergent. Their purpose is to either answer a question or give a determination regarding degree of disability and prognosis. The resulting conclusion sections commonly take one of three formats:

A simple yes/no opinion and rationale
A series of answers to specific questions
A set of headings related to rating degree of disability

Some dictators will employ a combination of conclusion styles.

Yes/No opinions

If the IME has been requested in order to evaluate the need for or appropriateness of a specific treatment, for example a particular operation, then the conclusion is usually a paragraph or two answering yes or no and rationale behind the answer, similar to this (but longer, of course):

CONCLUSION

It is my professional opinion within a reasonable degree of medical certainty that Mr. Quewl has significant right shoulder adhesive capsulitis consistent with a postsurgical “frozen shoulder.” It is my opinion that a repeat arthroscopy for lysis of adhesions is indicated.

Here’s another example:

ASSESSMENT

My opinion is that she is recovered from these injuries at this time. Her treatment appears to have been appropriate. My opinion is she has reached a medical endpoint for the injuries suffered on 1/20/12 and needs no further treatment.

Question-and-answer format

It’s very common for the requestor of an IME to ask the evaluator to answer very specific questions, especially if the requestor is an insurance company or attorney. In such cases, the questions and answers to them are listed in the conclusion section of the report.

Disability assessment headings

The conclusion portion of an IME related to a workers’ compensation claim is often structured by headings to determination of disability. Typical headings include:

Disability status: Is the patient disabled? Permanently or temporarily?
Impairment rating: Exactly how much permanent impairment has the patient sustained from the injury. This is drawn from a handbook and is very specific, like this:

Based on the AMA Guidelines, 6th Edition, Chapter 16, Mr. Beaderday is entitled to a permanent disability rating of 12% of the lower extremity, which is comparable to 5% whole person.
Causal relationship and apportionment: Was the injury caused or aggravated by the reported workplace event? If partially, to what degree?
Work restrictions or limitations: Can the individual continue working? The answer may be with restrictions, not at all, or perhaps in a new profession with vocational training.
Maximum medical improvement (MMI): Has the patient reached a stable condition that is unlikely to improve further?

Physician certification

A report that is being specifically created for legal use often concludes with a physician certification. This is often a few sentences describing the examiner’s credentials, followed by a place for the examiner to date and sign the report and attest to its accuracy. This may be added to the document after transcription or as part of the transcription process.