Are you finding it difficult to prepare reports from medical records?
As a medical evaluator, one of the most crucial aspects of your job is thoroughly and accurately reviewing medical records. These records form the foundation of your opinion and final report.
Even experienced Independent Medical Examiners (IMEs) can make mistakes when handling medical records. These errors can lead to delays, misinterpretations, and even harm your professional credibility.
Here’s what you should know: Most of these mistakes are avoidable if you know what to watch for.
In this blog, we’ll look at five of the most common mistakes IMEs make when working with medical records and share tips to help you avoid them.
Ignoring the Power of Outsourcing Medical Records
Many IMEs try to do everything themselves, including organizing and reviewing huge stacks of medical records. They don’t consider outsourcing this work to experts who can do it more efficiently and effectively. When you have multiple case files, reviewing records is time-consuming and overwhelming.
How to avoid:
Outsource your IME medical record review to trained professionals. There are medical record review companies and individuals who specialize in organizing, summarizing, and flagging key points in medical records. If you outsource this task to professionals, you can spend your valuable time on the actual examination and report writing.
Ignoring Inconsistencies in the Records
Sometimes, the timeline in a patient’s records doesn’t make sense. There may be a six-month gap between visits, or a note may say “pain resolved,” but the next page shows the patient still receiving treatment. Ignoring these inconsistencies is a serious mistake.
How to avoid:
Look for gaps, sudden changes, or contradictions in the report. If something seems off, mention it in your report.
Not Reviewing Complete Medical Records
One of the most common mistakes IMEs make is not reviewing the full set of records. Sometimes, IMEs receive hundreds or even thousands of pages. It’s tempting to skim through them or only read what seems relevant. But doing that can lead to missing important details.
How to avoid:
Always ask for a complete set of records. If you think anything is missing, like lab reports, imaging studies, or specialist visits, request them to provide it. Don’t presume you have been given everything you need. Make sure you go through each section carefully. Use tabs or digital bookmarks to highlight important parts of your report. It takes time, but it’s worth it.
Not Taking a Detailed, Accurate History
IMEs sometimes rush through the patient’s medical history or don’t write it down clearly. They might skip important details about how the injury happened when symptoms started, or what treatments the patient has tried.
How to avoid:
Spend some time with patients. Ask lots of questions and write everything down. Make sure your reports are clear and have an accurate history that matches what the patient says and what the records show.
Reviewing Records Out of Order
Reading records in a random order can cause confusion. You can easily miss timelines. You will not understand what happened first. You will receive documents from different providers, each with their own format. Sometimes they are scanned in upside down or sideways. Records do not always come in date order. So it’s easy to get lost.
How to avoid:
Always begin the IME medical record review process by organizing the records chronologically. Use the date of service to sort them. This lets you clearly follow the patient’s journey from injury to recovery.
If you don’t have time to organize them yourself, don’t worry. Trained medical record review teams can do it for you accurately and quickly.
How to Sort Out the Mistakes Easily?
If you make these 5 mistakes in your report, your report could be ignored, and the judges might not trust your findings.
The best solution for all these issues is outsourcing your medical records. This means handing the difficult task to a team that can handle tough cases with an easy blow. When you outsource, you gain time, clarity, and confidence, and most importantly, your stress level drops.
Conclusion
An IME’s work comes with a great responsibility. Managing medical records is a tough job, but it is one of the most important parts of being an IME. A thorough and organized medical record review for IMEs ensures that all relevant details are considered before forming an opinion. If you avoid the above mentioned mistakes, your report will be accurate and trustworthy. You will be like a professional who cares about getting the facts right.
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