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...
