Guide for independent impairment assessment reports

Introduction

Under Victoria's workers compensation legislation, a worker may need to attend an independent impairment examination.

After the examination, the IIA writes a medical report. This report helps agents and self-insurers make decisions about a worker’s claim.

All medical reports have to meet WorkSafe Victoria's (WorkSafe) service standards. This includes format, content, accuracy, consistency and absence of bias.

Once an IIA submits a report, it can be audited for quality at any time against these standards by peer review. If reports do not meet the standards, an IIA's approval to accept referrals may be revoked.

WorkSafe sets service standards and expectations for all IIAs to ensure positive outcomes for workers in Victoria.

Writing for your audience

Why good writing matters

You have to know who the audience is and what information they are likely to understand. This can be a challenge because the audiences for an independent medical report differ in background knowledge, literacy skills and other characteristics. These affect how easy it is to understand the information and the opinion you provide.

The audience can be agents and self-insurers, conciliation/arbitration officers, lawyers and the courts, as well as other doctors and medical panels.

Be consistent and clear

A consistent report format ensures the information you provide is useful and clear across all audiences. This is particularly important if this information is later reviewed at conciliation, by a medical panel or by a court.

A clear report should be structured and written in a manner easily understood by its readers.

While it may be necessary to use relevant medical terminology to record examination findings and diagnoses, plain English is encouraged for commentary, explanations, summaries and conclusions. Keeping your language and writing style consistent will help the reader follow and understand the material.

Use familiar words

It is important to use words that are familiar to the reader. Where possible, use words that your readers would use themselves.

Format of the report

A consistent report format is key to making sure the content is easy to understand. The following structure will help with your report.

Introduction

• Purpose of the examination and name of requestor.
• Worker information including, name, claim number, employer, date of injury and date of birth.
• A list of all materials given to you and seen by you in preparing your report.

Body

• A concise yet comprehensive history of events leading up to and including the injury/ies. Note the difference between what the worker told you and what you learned from the materials provided to you.
• Symptoms and restrictions reported by the worker.
• Subsequent work and medical history, other relevant personal and occupational history.
• Your clinical examination findings and general observations, both positive and negative.
• Results of any diagnostic investigations provided by the requestor and your recommendation for any additional investigations.
• The significance of any other opinions/reports/assessments made available to you.
• Answers to all of the questions asked by the requestor.

Note: A short explanation should be provided if a question is not answered or considered inappropriate or irrelevant.

Conclusion

You should include a concise summary or make concluding comments that highlight the most important issues in your report, particularly in the case of extensive and/or complex reports. You should ensure that your impairment assessment has accurately been reached using the American Medical Association's Guides to the Evaluation of Permanent Impairment, fourth edition (the Guides).

Your personal signature is essential to verify that you have read and checked your report and certified its accuracy.

Content of the report

The following information will help you meet WorkSafe’s expectations when writing the content of your report. More information on consistency of content and answering questions asked by the requestor is set out in later sections of this handbook.

The history

The history available to you is from materials provided by the requestor and the worker's answers during the examination. If these are inconsistent, this should be noted in the report.

For most reports, the following details are essential:

• the events leading up to and causing the reported injury
• the injury itself – diagnosis, mechanism/aetiology, severity and prognosis, etc
• confirmation that the injury has stabilised
• history of symptoms and restrictions, including effects on activities of daily living
• history of medical treatment and any complications
• effects of the injury/ies on capacity for work, including any past return to work attempts, if asked by the requestor

Additional relevant details can include:

• pre-existing and subsequent non-work related factors that impact the worker's injury and overall health, including personal issues and other medical issues
• handedness (usually in the event of limb or shoulder girdle injuries)
• level of education, formal qualifications and skills, other training, etc
• occupational history, including pre-injury employment and work capacity

Worker's current condition

This will mainly be provided by the worker but might also be available from materials provided by the requestor.

For most reports, the following details are essential:

• the current treatment plan
• current effects of the injury/ies on capacity for work and current work status
• current symptoms and/or restrictions, including effects on activities of daily living
• any planned and recommended treatment
• pre-existing and subsequent non-work related factors that currently impact the worker's injury and overall health, including personal issues and other medical issues

Investigations

A review of investigations undertaken, if any. Note if further investigations are required.

The examination

Every independent medical report must be based on an actual medical and impairment assessment of the worker. The impairment assessment must be based on the Guides.

Your physical and/or mental state examination of a worker has a number of purposes:

• to document the diagnosis and consequences of the injury
• to help assess the functional capacity
• to identify the nature and magnitude of any impairment/disability

Evidence-based findings and opinion

Findings and opinion

It is important to ensure that your findings are evidence-based and that the report shows the reasoning behind your opinion.

Your clinical examination findings should be set out clearly in the report to help the requestor understand how and why your arrived at your opinion. It should provide a reliable point of comparison against findings in past and future reports.

Include negative findings as well as positive in the report.

For psychiatric injuries (primary or secondary), every medical report must contain the findings of a mental state examination.

Inconsistent or incomplete information in the report can cause readers to misinterpret your opinion or prompt unnecessary supplementary requests. It also reduces the value of your opinion in the report when scrutinised.

Your report should show that you have performed a forensic and targeted examination by capturing a thorough and relevant history. Apply your expertise and experience to form an understanding of the worker, the injury and its aetiology. Note any consequential impairment before performing an impairment assessment.

Your report should show that you have correlated your clinical findings to the relevant tables/references in the Guides.

Your answers should be consistent with your evidence-based findings. You should refer to the relevant findings based on the appropriate evidence. This will support the conclusion and recommendations in your answers.

Not enough evidence to make a clinical opinion

If it is difficult to:

• make a diagnosis
• answer a medical question
• conduct an impairment assessment because of unreliable examination findings or incomplete information

then you should make this clear in your report.

It is better to note in your report that you can't answer the question or conduct a reliable impairment assessment, rather than give an unqualified opinion.

Symptoms that are outside your area of expertise

Sometimes a referral may be made that is not in your speciality, or the worker presents with symptoms you are not qualified to provide advice on.

If symptoms or signs are outside your area of expertise, then you should not include an opinion on that matter in your report. You should note this and state that you are unable to provide an independent medical opinion on that matter as it is outside your area of expertise.

Symptoms not related to the referral

If, during an examination, you find a condition that doesn’t relate to the request, ethical requirements still apply. You can raise the matter with the worker and encourage them to speak with their treating health practitioner.

You should not discuss the condition with the report requestor or include it in your report.

For example: During a shoulder examination a potential cancerous skin lesion was found. The doctor should advise the patient to discuss this with their treating health practitioner as a matter of urgency.

Answer the questions asked

The purpose of your report is to answer, to the best of your ability, the specific questions asked by the requestor.

For example: What is the worker's level of impairment for the lower back injury and is it stable?

Answer: "Based only on my clinical findings and the background medical information available to me, the worker has a DRE II, lumbosacral minor impairment in accordance with the AmA4 Guides, page 3/102, Table 79 and 72. This represents a 5% whole person impairment and I consider the injury stable."

Providing unasked answers or opinions

You should only answer the questions the requestor asked and not provide any unasked assessments, opinions or conclusions.

There may be circumstances in which one or more unsolicited responses are appropriate or necessary. For example, if you think the questions asked are insufficient or inadequate in a particular case because they do not adequately reflect the complexities of the case or the breadth of the situation.

Depending on your personal approach and experience, you can either provide unsolicited conclusions or recommendations, or contact the requestor seeking direction.

You should be mindful that once you have examined a worker, all communications with the requestor form part of your report. That means that you should keep a record of any communications with the requestor, whether by email or telephone. A copy of that record should be provided with the report.

Responding to inappropriate, irrelevant or repetitive questions

In some cases the requestor's questions may seem inappropriate, irrelevant, or repetitive. This can be a difficult situation, and has the potential for misunderstandings.

Attempting to answer questions which you have little confidence in, or are outside your area of expertise can feel frustrating, irritating, and pointless.

It would be ideal if you can clarify the situation with the requestor before finalising your report. However, this may not always be possible. There may be situations where it is reasonable to list the question, explain your concerns regarding that question, and indicate how you have chosen to proceed.

Avoiding bias

As an IIA, you are being engaged by the requestor to provide an independent impairment assessment of the worker's injuries. Not as their representative or to act as the worker's treating doctor.

It is important that the independent impairment assessment and the corresponding report are independent and impartial. It is not the role of an IIA to determine or comment on liability or entitlement to compensation. The IIA's role is to provide a medical opinion to help others determine liability and compensation entitlements.

Bias, either conscious or unconscious, most commonly arises in one of the 3 ways below.

Taking the worker's side

This could happen because:

• you feel sympathetic towards the worker and their circumstances
• you accept at face value what the worker tells you about their workplace, their accident and its consequences disregarding other conflicting material
• of a professional commitment to "act in the best interests" of a patient

The worker's account of their injury and symptoms is important but you should consider it in the context of any conflicting information or material. This is because a worker's memory can be unreliable, or the worker stands to gain something from not disclosing all information.

Taking the requestor's side

IIAs should not feel the need to provide a 'favourable' opinion just because WorkSafe and self-insurers are paying for the examination and report. IIAs are only expected and required to provide impartial and independent medical opinions to the requestor.

You have an obligation to protect this independent status. Notify WorkSafe immediately in case of a real or perceived attempt to influence your opinion by an employee of WorkSafe, an agent, a self-insurer, a worker or their representative.

Professional bias

This may be demonstrated through certain diagnoses, models of causation, and/or treatments, either as a result of one's particular specialty training, or from a personal view of some aspect/s of medical practice.

The best defence against unconscious bias is a deliberate, conscious awareness of the issue of bias, its types and its origins, and a determination to minimise its effects on your work.

The best defence against conscious or potential bias is to write your report and subsequently re-read it and ask yourself the following questions:

• Could what I have written be biased in any way?
• Could what I have written create a belief or perception of bias in others who might read it, even if no such bias exists?

If the answer to either question is 'yes', or 'maybe', you should rewrite your report in a way that removes that bias or perception of bias.

Writing high-quality reports

Writing a high quality report involves timeliness, efficiency, presentation standards, accuracy and more.

The following tips can help you deliver a well-written, well presented, accurate report on time.

Use a checklist

If you regularly perform impairment assessments, you might want to use a report checklist. This includes all the components which are more or less standard in each report. It can include your usual preamble, section headings, signature, even basic history and examination proformas which can be tailored to each case.

Ensure all provided documentation is available

Make sure that all relevant documentation is available before starting the interview and examination of the worker. You should read these documents before the examination so you can get an initial understanding of the case.

It is not acceptable to make contact with the worker after an examination to ask for further information.

Read the requestor's questions

Before you start (and if necessary again during the interview and/or examination) make sure you have the information you need to answer the specific questions.

Make concise notes

You should make notes of your findings as you go. Note key positive and negative findings on both history and examination, and any contradictory findings which could influence your assessment and conclusions. This will help you write your report at the end of the examination with the worker. It also ensures that if you can't write your report immediately, or if the report is mislaid or lost, you have a record of your key findings for later use.

Recording the examination

Some assessors prefer to record the interview and examination to prepare their report. Some workers also want to record the interview for their own records. If a recording is made, it must be done with the agreement of both parties and made available to either party on request.

Decide your own drafting strategy

Decide on your own strategy to prepare the first and final drafts of your reports. Quality results are generally achieved by preparing an initial draft, then revising or editing to a final draft, while ensuring the right formatting (and use of a spell-check to detect typos).

Re-read your report

Ensure your report accurately reflects your findings and conclusions and ask yourself:

• Is my report accurate? Does it include a medical diagnosis based on an appropriate clinical examination using an evidence-based approach to evaluate the symptoms and findings?
• Is my report independent, impartial, limited to relevant information and does not disclose personal information except where it concerns the work injury?
• Are you satisfied that the medical opinion you provided is consistent with and agrees with your clinical findings?

Personally sign the report

Ensure you have signed the report and record that you have signed it on your own copy. If the report is forwarded without your signature, record why it is not signed and ensure that a signed copy is forwarded as soon as possible.

Transparency

As per WorkSafe's IIA process, a copy of your report will be made available to the treating health practitioners. The detailed information and opinions you provide may support them in the management of their patients. Your report is also likely to read by the worker.