An independent medical examination report answers specific questions put by the party that retained you, based on a review of the records and your own examination of the claimant. It is not a consultation note. Nobody will treat the patient from it. It will be read by an adjuster deciding what to pay, by an attorney deciding whether to depose you, and possibly by a jury deciding whether to believe you. Physicians new to this work usually write their first reports too much like a clinic note and too little like the document they will be cross-examined on. The structure below is the one most retaining parties expect, with what each section has to accomplish.
Open with the examinee, the date and place of examination, who retained you, and the questions you were asked to answer, quoted from the referral letter. Stating the questions up front frames everything after it and keeps you from answering questions nobody asked. If you were asked about causation, apportionment, and work capacity, the report should end with those three answers and nothing else.
List every record you reviewed, by provider and date range, with page counts where you have them. This section establishes your credibility. Opposing counsel will compare it to the production and ask about anything you did not see. A list that says "medical records, 1,842 pages, reviewed in full" is defensible. A list that omits the physical therapy notes or the prior imaging invites the question of how you formed an opinion without them. If you were not given records you would expect to exist, say so here.
The history has two sources and the report should keep them separate. What the claimant told you at the examination is one account; what the records say is another. Report both, and note where they diverge. The claimant who tells you the pain began the day of the collision when the emergency department note records no complaint of that region is not necessarily lying, but the discrepancy is a fact and your report has to state it before the deposition does. Include the mechanism of injury as first documented, the course of treatment, prior injuries or complaints involving the same region, occupational history, and current symptoms and function in the claimant's own words where those words matter.
This is the longest section and the one most often done badly. It should be a chronological account of the treatment, provider by provider, with dates and the findings that bear on the questions asked. It should be complete enough that a reader can follow the case without the records, and specific enough that any statement can be traced to a page. Two failure modes are common. The first is the summary that paraphrases from memory and gets dates and findings wrong; each error is a cross-examination question. The second is the summary that quotes selectively, reporting the one visit that supports the conclusion and skipping the five that complicate it. Both are found by anyone who runs the report against a full chronology of the record, and the other side will.
Document what you did and what you found, with measurements. Range of motion in degrees, strength by grade, reflexes, sensation by dermatome, specific provocative tests by name with the result. Note the duration of the examination. Note observations of the claimant outside the formal exam: gait to and from the room, sitting tolerance, movement while dressing. Record nonorganic signs if you tested for them, by the standard names, and state what they do and do not mean. An exam section that reads "full range of motion, no tenderness, neurologically intact" for a claimant whose treating therapist measured lumbar flexion at 35 degrees a week earlier is a discrepancy you will be asked about; measure and record so that your findings can be compared, not just asserted.
List the imaging and other studies with dates and the reported findings. State whether you reviewed the images or only the reports, because they are different evidence and you will be asked. Where you disagree with a radiologist's reading, say so and say why.
State your diagnoses, distinguishing the conditions you attribute to the incident from those you consider pre-existing or unrelated. Each diagnosis should be traceable to findings in the history, the exam, or the studies. A diagnosis that appears in this section without support earlier in the report is the first thing a competent cross-examiner will find.
Answer each question asked, in order, with the reasoning that leads to the answer. The standard in most forums is reasonable medical probability, meaning more likely than not, and your language should meet it: "it is my opinion, to a reasonable degree of medical probability, that" followed by a clear statement. Show the reasoning. If you conclude the disc herniation predates the collision, say which findings support that: the degenerative appearance on the report, the prior complaints in the primary care record, the absence of acute findings. If the records are incomplete in a way that affects the opinion, say what would change it. An opinion that acknowledges its limits is harder to attack than one that claims certainty the record cannot support.
Address causation, apportionment, maximum medical improvement, permanent impairment under whatever guide the jurisdiction uses, work capacity and restrictions, and future treatment, but only where asked. Do not comment on credibility beyond the documented discrepancies, and do not offer legal conclusions.
Close with a statement that the opinions are your own, held to a reasonable degree of medical probability, based on the records listed and your examination, and subject to revision if additional records are provided. Sign it. Attach your curriculum vitae if the retaining party asks.
Read every page of the record before the exam, not after, so the exam tests what the record raises. Cite pages. Keep the claimant's account and the record's account separate. Measure what you can measure. Answer the questions asked and stop. And when the record is large, get the reading done by someone who will do it completely, because the summary section is where most reports are discredited.
As long as the record summary requires and no longer. A report on a 300-page record may run eight pages; one on 3,000 pages may run thirty. Length in the summary section is not a defect. Length in the opinion section usually is.
Where the exact language matters, yes, with the page cited. Direct quotation of a triage note or an intake form is far harder to challenge than paraphrase, and it shows you read the page.
In most United States jurisdictions, reasonable medical probability, meaning more likely than not. Some forums use reasonable medical certainty. Ask the retaining party which language the jurisdiction expects and use it consistently.
Yes, and many examining physicians have the summary prepared by a nurse or a review service, then verify it against the source and adopt it. The examination, diagnoses, and opinions must be your own. The NaviCase Record Summary before the exam and IME Report Prep after it are built for exactly that division of labor.
Say so in the records-reviewed section and again in the opinion where it matters, with a statement that your opinion is subject to revision if those records are produced. Saying nothing about a missing record reads as either not noticing or not caring.
Send the records and your dictation. The record review and your history and exam come back drafted; the conclusions stay blank for you.
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