Washington L&I publishes this Word template as a standard structure for independent medical examination reports. It takes the examiner from identifying information and history through record review, physical examination, diagnostic studies and pain inventories to conclusions on diagnoses, work-relatedness, prognosis, restrictions and recommendations, an impairment rating report and answers to the claim manager's specific questions.
The L&I-approved independent medical examiner writes the report on the template; it has signature blocks for two examiners, each with name, specialty and date, for exams with more than one examiner.
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Independent Medical Exam Template
This form is a Word template, not a PDF. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
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L&I offers it as the standard structure for IME reports, and its payment policy requires IME reports to contain the elements in the Medical Examiners' Handbook. Following the template's headings, from history and record review to impairment rating and the claim manager's questions, helps make sure none is missed.
The template lists accepted conditions from the assignment letter, diagnoses with pre-existing and post-injury conditions separated, discussion of work-relatedness, prognosis, physical restrictions, review of job analyses, diagnostic, therapeutic and follow-up recommendations, and findings unrelated to the accepted condition.