Reviewing a 3,000-page record before an IME

A large record production has the same problem as a small one, multiplied. The entry that decides the causation question is on one page, that page is somewhere in the middle, and nothing about the production order tells you where. In a 300-page record you find it by reading. In a 3,000-page record, with an examination on Monday and a clinic schedule in between, reading is not on offer, and the substitutes examiners use have costs. Skimming the specialist notes and skipping the rest is how the nursing assessment with the prior complaint gets missed. Reading the first and last hundred pages is how the treatment gap in the middle gets missed. Trusting the referral letter's summary is how the examiner adopts the retaining party's version of the record, which the other side will point out.

What follows is a method for a large record that keeps the examiner's time on the pages that need a physician.

First pass: inventory, not reading

Before reading anything, build a list of what the production contains: each provider or facility, the date range of its records, the record type, and the page range. A records vendor's index, if there is one, is a start, but check it against the production; indexes are wrong often enough to matter. This inventory becomes the records-reviewed section of the report, and it is where the missing records show up. A referral to physical therapy with no therapy records in the production, a pharmacy history naming a prescriber whose notes are absent, an imaging report that references a comparison study not in the file. Note each one. Ask the retaining party for the missing records now, while there is still time for them to arrive.

Second pass: the records that establish the case

Read, in full and in date order, the records that establish the frame. The first encounter after the incident, usually the emergency department or urgent care visit, for the mechanism and the initial complaints. The first visit with each treating provider, for the history as given to each of them. Every imaging report, and the prior imaging if it exists. Every operative report. The most recent visit with each active provider, for current status. This set is a fraction of the production and it tells you the outline of the case: what was claimed, when, to whom, and what the objective studies show.

Third pass: everything else, in order

This is the pass that examiners skip and should not. The bulk of a large production is routine follow-up notes, therapy visits, nursing documentation, and primary care records, and it is exactly where the entries that change a case are found: the prior complaint mentioned in passing, the pain scores that plateau, the work note that lifts restrictions, the visit where the patient describes a second incident. Reading it in date order is faster than it sounds, because most notes are templated and the eye learns quickly what changed from the prior visit. Keep a running timeline as you go, one line per encounter, with the page number. By the end you have a chronology, and the chronology is the summary section of your report.

What to bring into the examination

A one-page list of the questions the record raised: the discrepancies between histories, the prior complaints to ask about, the findings to re-measure, the second incident to explore. The examination is where the record's questions get tested against the person, and an examiner who walks in with the list uses the hour well. An examiner who walks in having skimmed the record asks the claimant to tell the story, and gets the claimant's version.

When there is no time for the third pass

There often is not, and this is the point at which most examiners either skim or delegate. Skimming is the option with the hidden cost; the report's summary will have gaps, and the gaps will be found. Delegating the reading to a clinician team that reads every page, builds the timeline, and returns it in the examiner's own template is the option that scales. The examiner then does what only the examiner can do: verify the summary against the source where it matters, examine, diagnose, and opine. The summary is complete, the pages are cited, and the examiner's evenings go back to the examiner.

A note on the referral letter's summary

Retaining parties often send a summary of the records with the referral. Read it for the questions it raises and the theory it reflects, and then set it aside. It was written by an advocate, it is incomplete by design, and adopting its characterizations into your report is the fastest way to be shown, in deposition, that you did not form your own view of the record.