Guidelines to Accurately Document Medical-Legal Reports

Guidelines to Accurately Document Medical-Legal Reports Medical-legal reports are vital in personal injury cases and their recordings can be accurately transcribed by a reliable medical transcription company.

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Medical-legal reports are very important in personal injury and workers’ compensation cases and if you have recordings of these reports, you need to have them documented properly using a medical transcription company. A medico-legal report should be objective; the content should be confined to relevant professional matter and include information that will support the patient or healthcare professionals in seeking his or her entitlements. These reports are typically dictated by physicians in private practice to law firms for accident/personal injury insurance purposes, and since the transcription process is both time and labor intensive, medical transcription services come as a boon for various medical specialties such as occupational therapy, vocational rehabilitation, orthopaedic, physiotherapy, psychology, neuropsychology, speech therapy and so on.

If the practitioners intend to be accurate in presenting a medicolegal report for personal injury then it is important to address those issues which the patient’s attorney is concerned about such as pain, suffering, inconvenience and alteration of lifestyle. The PI (personal injury) report should include: 

Pain

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Inconvenience

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Resulting impairments

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Embarrassment

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Prognosis

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Occupational effects

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Restriction on lifestyle

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Treatment needs in future

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Suffering

When patients reach maximum medical improvement (MMI) they are asked to complete a questionnaire including the above-listed components. The patient-provided information is combined with the findings from the final exam to prepare the final assessments of the doctor for the personal injury medical legal report.

The medico-legal report the evaluating doctor prepares should contain the following details: 

Date of examination

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History of injury

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Patient’s complaint

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Information from the partiesreviewed in preparations of the report or relied upon for the formulation of physician’s opinion

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Findings on examination

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

Diagnosis

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Opinions as to the extent of disability and work limitations

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Cause of the disability

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Medical treatment indicated

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Opinion whether or not the permanent disability has resulted from the injury and whether or not it is stationary. It if is stationary, a description of the disability should be included with complete evaluation.

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Appointment of disability, if any

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Reasons for the opinion

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Signature of the physician

A medical-legal report thus prepared must be accurate, objective and clearlyillustrate the true capacity/incapacity of the injured worker. To ensure clarity, and expert, organized and consistent evaluation reports, specialized medical transcription services can prove to be a great support.

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