Steven Babitsky, Esq.

Introduction

For physicians performing IMEs, their report is their work product. Physicians who write high quality IME reports are successful and attract higher fees and more work. Let’s look at some common language used by IME physicians and how more precise artful language can improve these reports.  For each example, the reader should look at the sample language and the suggestion and note how the phrase is improved.

Example #1:    “I have reviewed the provided documentation to formulate my opinion.”

Suggestion:     “I reviewed the following medical and other records.” (list them)

Example #2: “I informed the patient.”

Suggestion:     “I informed the examinee.” (or Mr./Mrs. Jones)

Example #3: “I informed the patient that during the process of the physical examination he may experience increased discomfort.”

Suggestion:     “I asked the examinee to inform me if he is experiencing any increased discomfort and that portion of the examination would be stopped immediately.”

Example #4: “He stepped off a lift and injured…”

Suggestion:     “He stepped off a 6 inch lift and injured…”

Example #5: “Medical records reviewed – a copy of an email from Sharon Jones…”

Suggestion:     “Medical and other records reviewed a copy of an email dated 11/30/2015 from Sharon Jones…”

Example #6: “Discussion/Conclusions: specifically in response to your questions…”

Suggestion:     List the questions and the answers directly after them; e.g.

Q.

A.

Example #7: “I do not believe that this patient can be released to full duty work at this time.”

Suggestion:     “It is my opinion that the examinee cannot be released to full duty work at this time.”

Example #8: “It is certainly possible that the chondromalacia was pre-existing.”

Suggestion:     “I do not have an opinion as to whether the chondromalacia was pre-existing.”

Example #9: “The opinions rendered in this case are the opinions of the evaluator.”

Suggestion:     Delete this.

Example #10: “… is a pleasant 55 year-old female.”

Suggestion:     “… is a 55 year-old female.”

Example #11: “She is well-kempt.”

Suggestion:     “She is neatly dressed.”

Example #12: Physical exam – no height or weight.

Suggestion:     “The examinee is 5 feet 5 inches and weighs 150 pounds.

Example #13: “I feel that the patient…”

Suggestion:     “It is my opinion that the examinee…”

Example #14: “If you were to have any question or concerns in regards to this patient’s treatment, please do not hesitate to contact me.”

Suggestion:     Delete this.

Example #15: “He started to develop a recurrence of pain in his arm.”

Suggestion:     “He started to develop a recurrence of pain in his right arm.”

Example #16: “I personally saw and evaluated the patient today.”

Suggestion:     “I saw and evaluated the examinee today.”

Example #17: “… there is good literature to support adjacent segment degeneration which can occur in about 20 percent of people adjacent to a fusion.”

Suggestion:     “The following literature supports…”

Example #18: “It could be debated…”

Suggestion:     Delete this.

Example #19: “It is very likely…”

Suggestion:     “It is my opinion…”

Example #20: “I have dictated and seen this patient and I have done it to the best of my ability…”

Suggestion:     Delete this.

Example #21: “Medications: were as listed.”

Suggestion:     List them in report.

Example #22: “I do not believe so…”

Suggestion:     “It is my opinion…”

Example #23: “It is my impression…”

Suggestion:     “It is my opinion…”

Example #24: “That patient’s back is abnormal.”

Suggestion:     Delete this.

Example #25: “I do think…”

Suggestion:     “It is my opinion…”

Example #26: “It is explained to the examinee.”

Suggestion:     I explained to the examinee.

Example #27: “Accident and treatment history.”

Suggestion:     Accident and treatment history per the examinee.

Example #28: “No mention of medications.”

Suggestion:     “The claimant took the following medications today prior to his/her examination.”

Example #29: “It has been emphasized to the examinee that he should not attempt…”

Suggestion:     “I emphasized to the examinee…”

Example #30: “No height and weight listed.”

Suggestion:     “The claimant is 6 feet and weights 240lbs.”

Example #31: “I have been provided with the following authenticated medical records.”

Suggestion:     “I have been provided with the following medical records.”

Example #32: “The following medical records were reviewed in detail.”

Suggestion:     “The following medical records were reviewed.”

Example #33: “The mechanism of injury as described would not have resulted in a meniscal injury.”

Suggestion:     Add footnote citing medical literature.

Example #34: “This was a self-limited examination with symptom magnification.”

Suggestion:     “This was a self-limited examination with symptom magnification as the claimant…”

Example #35: “Findings are non-psychologic with evidence of symptom magnification.”

Suggestion:     “Findings are non-psychologic with the following evidence of symptom magnification.”

Example #36: “I can conclude that the claimant…”

Suggestion:     “It is my opinion, to a reasonable degree of medical certainty that the claimant…”

Example #37: “I can conclude…”

Suggestion:     “I conclude…”

Example #38: “There is no medical necessity for the proposed decompression of the tibia nerve CPT code 28035, and the request should be denied.”

Suggestion:     “There is no medical necessity for the proposed decompression of the tibia nerve CPT code 28035.”

Example #39: “The physical examination of the lumbar spine, combined with the claimant’s history indicates that this injury is the result of the incident on 12/1/2015.”

Suggestion:     “Based on the results of the physical of the lumbar spine, combined with the claimant’s history, it is my opinion to a reasonable degree of medical certainty that the lumbar injury is a result of the incident on December 1, 2015.”

Example #40: “Is the proposed treatment palliative?”

  1. “The treatment rendered and proposed by the treating physician is appropriate,
    medically necessary, and relatable to the incident on December 1, 2015.

Suggestion:     “The treatment rendered and proposed by the treating physician is not palliative and is appropriate and medically necessary.”

Conclusion

IME physicians who write clear, complete, and high-quality IME reports are the most sought-after physicians.

About the Author

Steven Babitsky, Esq. is the President of SEAK Inc and was a workers’ compensation litigator for 20 years. He is the co-author of Writing and Defending Your IME Report and is the creator and faculty of How to Start, Building, and Run a Successful IME Practice, and IME Skills for Physicians The Master’s Program. He can be reached at stevenbabitsky@seak.com and 508-548-9443.