Not only do Independent Medical Evaluation (IME) reports come with a lot of pressure, they also require meticulousness. While you may want to serve your client, it’s never a good idea to sacrifice the integrity of your IME report by making mistakes. Here’s some of the do’s and don’ts of a good IME report.
The 5 Do’s of a Good IME Report
An independent medical evaluation report can play a significant role in the life of a person or the viability of a business. Those who perform independent medical examinations are often in a position to affect change. Because of the weight an IME report can carry, it’s imperative you get it right.
1. Do Keep Your Report Clear, Concise, and Uncomplicated
While you may find yourself dealing with a very complicated situation, your report must remain clear in all aspects. Don’t waffle, or use vagueness. By doing so, you run the risk of invalidating your report due to a perceived lack of confidence and understanding of the issues at hand.
Keep your words clear, and your findings brief. Brevity doesn’t mean you must dumb down your statements or sacrifice the integrity of your words.
2. Do Back Up Your Statements with Facts, Data, and Documentation
Don’t assume everyone will understand some of the information your present. To avoid ambiguity and misunderstandings, you should always including supporting documentation.
This will all go towards establishing the veracity of your own statements. It will also show that you’re findings aren’t based on your opinion alone. Supporting data clears up any possibility of someone claiming there’s bias in the report.
3. Do Define Terms and Nomenclature for Non-Medical Personnel
Your report will contain many technical and medical words, phrases, shorthand, abbreviations, and jargon. When you can’t find simpler words for these things, you should define them the first time they show up with references. This will all help to make your report clear and accessible.
4. Do Strive for a Measured and Objective Tone or Voice
Refrain from filling your report with emotion or aggressive language. The moment your report veers into that kind of territory, readers will view it as biased and even antagonistic. Not only can that destroy your credibility as an examiner, it can also taint the case it’s applied to in several negative ways.
5. Do Focus on Quality Over All Else
The quality of your reports will earn you more credibility and more work. You want to produce effective reports that elevate you above others who continually make mistakes. While these suggestions may seem like a lot, they’re very easy to incorporate once you get the hang of them. In fact, you can start from a professional IME template to make it even easier to create consistent, high-quality reports.
The 5 Don’ts of a Good IME Report
From the “do’s,” it’s easy to see a few of the things you should not do when it comes to creating your IME reports. However, there’s always room to clarify some of the “don’ts” more clearly. Here are a few things you should not do.
1. Don’t Use Uncertain, Vague, Ambiguous, or Unclear Terms
Your report must show absolute confidence. Where you cannot professionally assert confidence over your statements, you should clearly document it. Generally, you should avoid any statement that sounds like you’re making a guess.
Always, your report should state what is and what’s known. Your report should not contain statements that start with uncertainty. For example, avoid starting statements with what you believe, what you suspect, or how something seems. Avoid ambiguity by steering clear of words like “may,” “perhaps,” “could,” and the like.
2. Don’t Use Absolutes or Contradictions in Your Report
An easy mistake for an examiner to make is to pepper their statements with absolutes. You can, and should, only use absolute phrasing if there’s an absolute certainty in your field that something only has one answer.
Rarely is something applicable to all people at all times. It’s best to omit absolute wording altogether. Never say something is always a certain way, or symptoms must occur in a certain sequence. Nothing affects everybody similarly, and nothing only affects a certain person, group, or populace.
This also applies to contradictions. Don’t contradict your statements. You may think to do it to add some clarity, but it only adds confusion. If anyone finds just one example where your absolute statement isn’t so absolute, it can invalidate your statement altogether. It can also call your credibility into question.
3. Don’t Include Any Form of Bias in Your Report
Your IME report isn’t a soapbox or venue for you to express non-medical opinions or personal feelings on the situation. Your own beliefs or lifestyle should have no bearing on your report in any way, shape, or form. You must remain impartial in every way.
If your examination findings clash with another examiner’s, don’t attack the other examiner. Your findings and statements should speak for themselves. The moment anyone suspects the possibility of bias on your part, it can call your report, credibility, and judgment into question.
You should not put emphasis on your statements. For example, avoid placing quotations around a statement to call it into question. Avoid using exclamation marks to make a point. These types of things draw attention to themselves and stand out as bias.
4. Don’t Embellish, Veer From, or Add Anything Extra to Your Report
Your independent medical examination serves a specific purpose. Stay on topic. Don’t veer or add in irrelevant data from unrelated things. This also goes back to staying clear and concise. Whether it’s a personal injury, disability, workers comp, or other insurance claims, make sure you only address what you’re hired to address.
5. Don’t Sacrifice Your Credibility
Keep it simple and avoid the more common pitfalls. Produce relevant reports that serve their function as intended. If your IMEs represent a good source of income for you, it’s important you remain credible and professional when reporting.
Following these suggestions can also help when the time comes for the review and transcription part of your IME report. Clear, concise language makes it easier for transcriptionists to finish the job on time with no mistakes in the copy.
Nathaniel Smathers, is contributor to the DataMatrix Medical blog with a background in healthcare content creation for over a decade. Nathaniel has a passion for exploring the intersections of healthcare, data analysis, and digital innovation.