Writing a Decent Med-Legal Report - Part 3

Sunday, July 6, 2003 | 0

This is the third in a series on writing decent medical-legal reports. Part 1 reviewed some of the basics necessary for a medical-legal report, including the required elements specified by Regulation Section 10606.

Part 2 began a review some of these required elements in more detail, and specifically, prior medical history. This article will finish the required elements discussion.

FINDINGS OF THE EXAMINATION

This is the part of the report where your observations of the injured workers are to be set forth, including your findings on the clinical examination and the results of diagnostic tests that are administered.

Many physicians get technical in this section of the reports, which is fine in order to support your conclusions, but remember that non-medical people will read your report, and it needs to make sense to them. The reader probably won't be familiar with all of the technical jargon, so where technical jargon would normally be used by a medical professional, it would be appropriate to define or otherwise give the reader a brief explanation of what the jargon describes and how it may be relevant. Try to present your findings as simply and directly as you can.

The Industrial Medical Council (IMC) has adopted guidelines for the evaluation of certain physical disabilities. For links to the guidelines, go to the Physician's segment page on this site. These guidelines set forth more specific areas of an examination that should (or in some cases, must) be reviewed and commented on relative to your findings on examination. The IMC Physicians Guide says that you should follow the guidelines presented in Evaluation of Industrial Disability by Packard Thurber for any disability that is not covered by IMC guidelines.

The American Medical Association Guide to the Evaluation of Permanent Impairment, used in most other states, is inappropriate for California. In most other states, the physician "rates" the disability. In California, the physician describes the disability, and a rating specialist determines what the rating is.

Describe the purpose of clinical tests rather than referring to the test only by name. In addition, discussions of diagnostic tests are appropriate in this section. The need, purpose and findings of x-rays, EMGs, etc., should summarize the findings in this section. This not only assists non-physicians in understanding the case, but will also assist in getting your bill - or the bill of the diagnostician - paid because it will assist in determining the reasonableness and necessity of the test.

DIAGNOSIS

The diagnosis section of your medical report is relatively straight-forward. You should give a specific diagnosis for each condition you are asked to evaluate. If a specific diagnosis cannot be made, then it is appropriate to provide your impression or a differential diagnosis.

CAUSE OF THE DISABILITY

The part of your report that describes the cause of the disability may be simple, or it may be complex, depending on the facts of the case, whether the injury was a specific injury or a cumulative trauma, and whether or not apportionment is a factor.

In simple situations this part of the report is relatively basic. In more complex situations, however, the physician must be careful to describe each contributing factor to the disability thoroughly so that the reader clearly can see that you understand all relevant factors pertaining to the ultimate disability determination.

Care must be taken with factors that would indicate whether or not apportionment is a consideration. One of the biggest defects seen in medical reports relative to apportionment discussions is a lack of understanding between medical apportionment and legal apportionment. There may be conditions that pre-existed the injury that may have contributed to the disability, but they cannot legally be apportioned. If the physician cannot, with a degree of medical certainty, estimate the level of disability that would have existed absent the injury, then the physician cannot apportion the disability.

In addition, apportionment cannot be discussed out of the context of the principle that the employer "takes the employee as he finds him." This means that compensation will not be denied even though the worker was "predisposed" to injury or a previous condition made it more difficult for the worker to heal from the injury. In other words, there must be some functional disability pre-existing the injury that created some impairment in work ability. Failures in understanding apportionment principles, or failure to delineate appropriately factors of apportionment are frequently the downfall of otherwise fine medical-legal reports. Care must be taken by the physician to ensure that apportionment discussions are proper.

Our next article will discuss describing permanent disability, and how the physician can either make or break a case with a good, rateable, permanent disability description.