Are Record Review Summary Services Legal for IMEs?

The short answer is:  Yes, record review summary services are a legal and viable option for use in your independent medical examination reports.

In most situations, you will still be required to personally review the documents (especially if your report includes an attestation to that effect, or if the laws of your state require it).  However, there is generally no specific requirement that you personally dictate a summary of the records reviewed.  Thus, a record review summary (regardless of its source) becomes a permanent component of your work product for the case.

Cornell Law School defines “work product” as “material prepared in anticipation of litigation” and “the result of gathering basic facts or conducting interviews with witnesses.”  When describing an attorney’s work product, often such materials have been collected, reviewed, and/or summarized by third parties, such as paralegals.  However, the final collective body of information (the work product) is unquestionably accepted as that of the attorney working on the case.  This principle applies equally to any documents (including record review summaries) utilized in producing your IME reports.

What is the Record Review Summary Process?

When you request a record review summary from Independent Medical Transcription, Inc. (IMT), you will first transmit any available electronic records (normally in scanned PDF format) via one of several secure, HIPAA-compliant file transfer methods. From there, we begin with a report template that has been designed and formatted according to your preferences.

One of our trained and experienced record reviewers will carefully examine every page of the records and produce a detailed summary, according to your requested specifications and medical specialty. When complete, the draft report is returned to you. You then perform your personal review of the records and either edit the draft yourself or dictate a list of additions or changes that you would like to include in the final record review, which we will then use to complete the record review summary based on your input.

Many of our clients prefer to complete this step well in advance of any examination(s) to be performed on the claimant, and we are happy to accommodate. After the examination takes place, you can dictate any further details for your report (history, examination, opinions/conclusions, etc.), which we will then transcribe according to our typical medical transcription process. You then review your final report and submit it to your client.

How Does This Help Me?

The primary benefit is that you are relieved of the need to dictate a lengthy review of records, especially when many of the records that must be reviewed are irrelevant to the case or do not pertain to your medical specialty. By performing your own personal review, you are still intimately familiar with the details of the case and with the claimant’s medical history, but you can concentrate your time and attention on aspects of the records that matter the most to you.

What If I’m Questioned About the Content of My Chart Review?

It is widely accepted (and even expected) in the medical community that doctors do not personally type or transcribe their own notes and reports.  Although EHR systems have made it more commonplace for doctors to double as typists, the use of scribes and transcriptionists in producing medical documents remains a common practice that few will be able to argue against.

A clear and irrefutable line of reasoning might be:  “Did I type the report myself?  No, most doctors don’t.  Are the findings and conclusions in the report my own?  Yes, absolutely.”  Given that you have personally reviewed the records, provided direction to IMT on what to include in the RR summary, and confirmed that all information necessary to support your conclusions can be found in the chart review, then it can clearly be said that the report is 100 percent your own work, and your signature and attestation on the report are proof of that.

Common Attestations and References

“I declare under penalty of perjury that the information contained within this document was prepared by and is the work product of the undersigned and is true to the best of my knowledge and information.”

“I declare that the attached forensic medical evaluation of [claimant name] was prepared by me and is true and correct to the best of my knowledge.”

– Attestations such as these do not in any way preclude the use of a third-party record review summary service, again based on the definition of “work product” and based on the fact that you, as the physician or expert, have provided all necessary input and have personally reviewed the medical records as well as the content of your report.

“The independent medical examiner shall prepare a complete and accurate report following an independent medical examination or review of records that at least shall contain: … (b) a list of all of the information, such as documents, reports, records, and/or test results, received and reviewed in preparation for the independent medical examination …, (d)the independent medical examiner’s professional opinion, and (e) a signed statement certifying:  (1) that the report is a full and truthful representation of the independent medical examiner’s professional opinion with respect to the claimant’s condition …; (2) that no person or entity has caused, directed or encouraged the independent medical examiner to submit a report that differs substantially from the professional opinion of the independent medical examiner; and (3) that the independent medical examiner has reviewed the report and attests to its accuracy.”

Request for Proposals for Independent Medical Examination Services for the New York State Insurance Fund, June 13, 2018, page 30; section 4.6.5, “The IME Report,” subparagraph (i). 

“Sign the IME report after you have reviewed the report to be submitted.  Your signature on the report indicates that you have reviewed and approved the content of the report.  You will be held accountable for the content of your report.”

Washington State Medical Examiners’ Handbook, July 2021, page 30;  chapter 4, “The IME Report,” subsection “When to Sign the IME Report.”

Why Choose IMT for your Record Review Summaries?

  • Our record review summary service saves significant effort in your forensic and IME workload, allowing you to focus more on the aspects of your reports that truly require expert attention – your findings and conclusions.
  • We will thoroughly summarize voluminous and unrelated medical records that would otherwise eat up your valuable time and energy.
  • Every document we transcribe undergoes a careful quality check before being returned to you, ensuring the accuracy, completeness, and readability of your reports.

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Independent Medical Transcription, Inc., is based in Marathon, FL, and provides top-quality and 100% remote medico-legal transcription services, primarily for independent medical exams, medical record reviews, and other forensic reports, for clients throughout the United States.

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