Q&A: Lack of Medical Records

Abstract

QUESTION: A client refers individuals for impairment ratings without sending any of the individuals' health-care records. It is felt that adequate impairment evaluations cannot be performed without this information. Therefore, these appointments were canceled with the indication that neither the maximum medical improvement (MMI) nor impairment can be assessed without the medical records. What are your thoughts on this scenario?ANSWER: You are correct. The referral source is wrong in referring individuals without sending along their healthcare records, including medical, psychological, physical therapy, occupational therapy, applicable deposition transcripts, and other associated documents. The need for having these records applies both to direct examinations and to performing an assessment based on document review.The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Section 2.7a, Clinical Evaluations, explains that record review is the first part of any such evaluation (6th ed, 28):This passage from the AMA Guides repeatedly emphasizes the importance of healthcare record review for developing an adequate understanding of the examinee's history. A premise that an accurate history can be obtained from an examinee (instead of reviewing the examinee's healthcare records) has extensively failed scientific scrutiny.1Section 2.3 of the AMA Guides specifies the importance of diagnosis in the impairment evaluation methodology (6th ed, 23): “The Guides is of value only if the medical diagnosis is correct; an incorrect diagnosis leads to an incorrect impairment rating. The most important element of the Guides remains the physician's accurate diagnosis.” In fact, in the AMA Guides Section 1.3d, the impairment rating methodology requires the evaluator “fix the diagnosis” (6th ed, 6) (the relevant definition of fix from the Oxford English Dictionary is “to make firm or stable”), and that the fixed diagnosis must be of a “specific” nature.Healthcare records can be invaluable for the process of “fixing” a “specific” diagnosis. Obvious examples include records of previous diagnostic conclusions from other clinicians (with those records hopefully detailing the methods and findings that led to the previous diagnoses), records of results from clinical testing (eg, laboratory tests, imaging, psychological testing), and records of any potentially confounding factors.Evaluators may be asked to limit impairment ratings to aspects of the clinical presentation that can be credibly attributed to a specific injury or disease. Consequently, use of the standard method for causation analysis2–4 is often a necessary part of the impairment rating evaluation. The value of healthcare record review for the standard method for causation analysis has been discussed in a previous AMA Guides® Newsletter?3 in the following terms:The Practice Guidelines from the American College of Occupational and Environmental Medicine5 (ACOEM) emphasize that, for the standard method for causation analysis, the review of medical records often needs to go beyond healthcare records. For example, passages from the ACOEM guidelines include5:Of relevance to the third step of causation analysis (“Evidence of individual exposure. What objective evidence is there that the level of the patient's exposure is of the frequency, intensity, duration, and temporal pattern of exposure associated with work-relatedness?”5), the ACOEM guidelines5 call for consideration of “exposure records” and “any further information that is available for exposure assessment, such as job records (job positions and times held in relationship to timing of disease development), video of job tasks, and monitoring data (work sampling, personal dosimetry, air monitoring, etc).”The need for the review of an extensive set of medical records has been further emphasized in publications and formal continuing medical education programming from the American Academy of Orthopaedic Surgeons.4 For example, such documentation specifies that the necessity of a review of medical records is an inherent theme of the standard method for causation analysis, and explains4:The evaluator must determine whether the clinical presentation has reached a point of MMI. In Section 2.7b, Analysis of the Findings (6th ed, 28), the AMA Guides states, “Discuss (in their documentation) how specific findings relate to the conclusion of diagnoses and MMI status.” A review of medical records is the only credible method for determining if a clinical presentation has plateaued; this is a state that would be consistent with a conclusion of MMI.There are potential reasons for a referral source to request an impairment rating evaluation without providing an opportunity to review medical records. Some reasons are malignant; for example, a referral source who benefits financially from higher impairment ratings might be attempting to hide issues that lead to lower impairment ratings. Other potential reasons are benign. For example, a referral source who is trying to minimize the cost of the evaluation might honestly believe that it is legitimate to base an impairment rating on an evaluation in the absence of any medical record review. Under either scenario, an evaluation that does not include a medical record review is at risk of producing an erroneous impairment rating.Evaluators are advised to do the following: