How to Document an IME

You may find it unnerving and insurmountable to take notes the first time you are asked to document an IME. This is called an independent medical exam, insurance medical exam or a defense medical exam. Here are tips on how to document an IME.

The exam is required by the insurance company to prove or disprove a patient has been injured. You attend the exam to support the patient and to record everything that is said or done. Many states do not permit audio or videotaping an exam. You can provide a valuable service to your clients by offering the service of attending these exams. When you learn how to document an IME, the whole process becomes easier.

Speed: the challenge to documenting an IME

It just doesn’t seem possible that you can look at your watch to figure out what time the history starts and what time the history ends, how long the doctor is out of the office, if he leaves the office as well as listening, watching and writing.

But every time you do it you’ll get better at it. At first, when it seems overwhelming, the best thing to do is listen and watch and just write very short notes to yourself so that you can fill in the blanks at the end of the exam, You’re not there to be a stenographer.

How to Document an IME: Start With Taking Notes

This is what worked for me. I brought a clipboard with prenumbered paper. I divided my paper into two columns. On the left, I wrote the doctor’s question. On the right, I wrote the patient’s response.

Here is another shortcut: Don’t write down the doctor’s questions if they are normal questions. Write down the patient’s answers. You can almost always figure out what the doctor asked based on the plaintiff’s answers. If you can’t, then you can jot down a part of the question enough to get you started.

Range of Motion Testing During an IME

When you’re watching the exam itself, you can make drawings to indicate the patient’s range of motion. It is difficult to judge angles by just watching the exam. Most times if the doctor is testing the patient’s back, she will say to the plaintiff, “Okay, bend over now, lean back now, lean to the right, lean to the left.” You can draw angles on your paper so that you’re just copying the angle you observe. You can estimate the angle.

If the exam is too rapid and you cannot capture the angles, write, “The doctor asked the patient to bend forward, backward and side to side so quickly that it was not possible to tell how far the patient was able to go.”

Critical Timing at an IME
It is very important to the lawyers that you keep track of time. They like to see how long the exam took.

• Start timing when you’re called to the examining room with the plaintiff.
• Note what time the doctor actually comes in to the examining room.
• Note the time when he actually starts the history portion.
• If he gets interrupted and leaves, note the time he leaves the room and the time he returns to the room.
• Note what time the history portion ends and what time the physical examination starts. Sometimes that’s impossible because the doctor combines the history and physical. The doctor will ask questions during the physical at which point you just note the start time and the end time. You’ll make a point that it was all done at the same time.
• Note the time that the physical ends and the time that you left the office with the patient.

How to document an IME: Writing Tips

1. Write your report as soon as soon as possible after the exam – preferably the same day. Although you think you’ve taken good notes, there are always things you’ve missed. If you write the report the same day, you can fill in those blanks from recall.

2. Write the report in chronologic order because that way as you write it things will come back to you. Your report should show that you took contemporaneous notes, that you didn’t just make it up, that there is a flow to it.

3. Hold onto your notes until you finish the report. Then have a plan – either you throw out all your notes or you keep all your notes. The reason this gets to be important is if you are called to testify, which rarely happens, the opposing counsel will ask to see your notes.

You want to be in a position to honestly say, “It is my policy to keep all my notes” or “it is my policy to throw out my notes after I finish the report.” Your reports will need to have everything that your notes have because if there is one remark written on your notes that somehow contradicts your reports, you’re going to questioned when you testify. Keep your reports in computer files that are backed up. Follow these tips on how to document an IME to be able to produce a polished report.

Pat Iyer MSN RN LNCC is president of The Pat Iyer Group. She has attended IMEs involving neuropsychological, orthopaedic, neurological and other types of injuries.
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