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What Is IME Transcription? Some DO’s and DON’Ts Of an IME Report

April 12, 2019


IME Transcription stands for Independent Medical Evolution transcription. It is a comprehensive review of the medical report of a patient performed by a doctor not earlier involved in the patient’s care.
     It is usually performed for a legal purpose, such as evaluating eligibility for the worker’s compensation or benefits or disability benefits related to an accident or an injury. The qualified medical evolution is the same thing as an IME.

IME transcription covers the following topics:
– Entire description of the patient’s medical treatment including a full review of available records,
– Physical examination,
– Consider the additional report reported by the private investigator,

– Determining as to whether the patient is going through the permanent disability or it’s nature and degree.

The format of IME report is very different than any other report type. It becomes very essential to obtain a model report or template to use as a starting point, even though the sections dictated may vary.
If we talk in brief that what is the exact process through which it goes. It includes the following sections:
1) Introduction:
The first that an IME does is to mention the full name of the patient, the exact date of injury or the onset of the report, and the purpose of the report. If it is related to any insurance or disability claim, a case number is given.
Re: Patient, Unfortunate
DOB: DD/MM/YEAR
Case#: 12345678
Date of Injury: DD/MM/YEAR
Date of Checkup: DD/MM/YEAR
The first paragraph of the report compiles the purpose of the report.
2) History and Current Complaints:
The case history can be given in the single large section titled history or be classified in the subheadings. It provides detail about who the patient is and how he reached to be in his current situation. If the injury is employment related, it will definitely include the work history going back for years.
   There are many subheading used in the history portion including past medical and surgical history, family history, and social habits. Each and every encounter with the medical transcription provider may be listed by date and time.
 When the compensation is sought for the disability, a great deal of attention is focused on the patient’s physical and mental capabilities before and after the incident.
Almost anything can be included, if the requestor hired a private investigator to follow the patient around the watch.
If anyone has the slightest doubt about a word or phrase, can flag it for the dictator review.

3) Physical Findings:
IME is purely based on the review of the records, but many times  there’s an in-person examination as well. This exam is limited to body parts/systems related to the reason for IME but can go on to detail, resulting like Hand grip strength, circumferential measurements of both upper extremities showed left arm, left forearm, right arm, and right forearm.

4) Diagnostic Studies:
The examiner reviews and comments on the results of laboratory tests, MRIs, and other diagnostic studies. This discussion may be under such kinds of headings or also can be incorporated into another section.

5) Medical Records Review:
An IME often includes the documents that the examiner reviews as a part of the evaluation. Such documents contains the reports from workplace visit, treatments, and diagnostic procedures the
patient received. The record list may be dictated near the starting of the report as part of the introduction or just before the examiner renders the conclusion.

Conclusion:
This is the place where IME reports get widely divergent. The resulting conclusion consist one of three formats.
– Simple Yes/No
– A series of answers to specific questions
– A series of subheading related to rating degree of disability.

Physician Certification:
A report that is especially created for the legal use often conclude with a physician certification. It consists of a few lines that explains the examiner’s credentials, followed by a place for the examiner to date and sign the report and attest to its accuracy. It can be added to the document after the transcription or as part of the transcription.

An Independent Medical Evaluation (IME) reports doesn’t come only with a lot of pressure, it also requires meticulousness. While we want to serve our clients. it’s never a good idea to sacrifice the integrity of your IME report by making mistakes.



Here are some of the DO’s and DON’Ts of a good IME Transcription report.
5 DO’s Of A Good IME Report:
1)Make Your Report concise and uncomplicated:
While you feel yourself dealing with a very complicated situation, your report must remain clear in all aspects. Keep your words always clear, and your conclusion brief.

Doing IME Transcription WIth Mobile

2) Define Terms properly for Non-Medical Personnel
The IME report contains so many typical and technical words used in medical, shorthand, abbreviations etc. When you don’t find the simpler words for such kinds of words, you should define them at the first time. It will all help to make your report more clear and accessible.

3) Focus on Quality over All:
The most important thing, in the client servicing, is customer satisfaction. You should start from a professional IME templates to make it easier to create consistent, high-quality reports.

4) Back Up Your Statements With Facts and Documentations:
Many times, everyone is not able to understand some of the information you present. To avoid ambiguity and misunderstandings, you should always include the supporting documents.


5) Strive For A Measured and Objective Tone:
Keep your report out from emotion or aggressive language. If your report veers into that kind of languages, readers will view it as biased and it won’t be a good sign for your business.

5 DON’Ts Of A Good IME Transcription Report:
1) Do Not Sacrifice Your Credibility:
If IME transcription brings a good source of income for you, it’s very essential you remain credible and professional with reporting. Clear and concise language makes it easier for the transcriptionists to finish the job with no errors in the copy.

2) Don’t Use Absolutes Or Contradictions In Report:
If an examiner makes an easy mistake to pepper their statement with absolutes. You should only use absolute phrase at that place where there is only one answer. Rarely is something applicable to all people at all times.
 This also applies to contradictions. 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.

3) Don’t Add Any Kind Of Prejudice in Your Report:
The IME report should not contain any types of non-medical opinions or personal feelings on the situation. It should not show your own belief or lifestyle. You must remain impartial in each and every way.


4) Don’t Add Anything Extra To Your Report:
The independent medical examination serves a purpose. Don’t deviate from the topic. Always keep yourself focused. Never try add in irrelevant data from unrelated things.

5) Don’t Use Uncertain, Vague, Ambiguous terms:
The IME report must show the confidence. You should avoid the statement that sounds like you are making a guess. Always try to keep your report states what is and what’s known. Your report should not contain statements that contain uncertainty.

You can always contact Eyered Transcription for EMR Transcription and all types of transcriptions for the transparent and satisfactory services. We have been doing this for 20 years and we have more than 100 satisfied clients. You are always welcome here with your every types of queries through our email or call.




By: Anna williams Category: blog

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