Setting the Stage: What You Can Learn (and Not) from the Medical Records and How to Use Them

Abstract

A requesting party who has asked a physician to perform an IME should send a cover letter that briefly introduces the medical issues that are either in dispute or for which need clarification. This cover letter should contain specific questions that the IME physician is asked to address.

The independent medical evaluation requires that the IME physician review prior medical records in advance of the examination. This allows the physician to understand the medical issues of the examinee and allows them to craft additional questions that will be asked during the history-taking portion of the evaluation. IME physicians should note where there are discrepancies in the medical record and attempt to rectify them. In some instances, nonmedical records such as surveillance information will also be presented for review. The IME physician should always base medical opinions on medical information, but ancillary information can provide a flavor for the overall claim context.