Your examination report will consist of one or more completed documentation protocols. Your documentation should reference the evidence you reviewed, the history you and the claimant discussed, evidence gathered from the examination, and the findings of any tests you performed or ordered.

Here are guidelines used by experienced examiners as they finish and check their examination reports:

• Determining the diagnosis should be the final step in completing each documentation protocol. Complete the other components of the form, interpret any test results, and consider the weight of all evidence in confirming a diagnosis.
• For each condition evaluated, identify and explain any discrepancies in diagnosis, history, medical records, clinical testing, or descriptions of functional impairment.
• Your documentation must use appropriate and ethical language for the audience who will read it. It is evidence that will be reviewed by VBA adjudicators and if a decision is appealed, judges. The audience for your report can also include the claimant, who may read it on the VA-DoD eBenefits website or MyHealtheVet, the VA's Personal Health Record system.
• Check the Request for Examination to make sure you addressed all claimed conditions and any questions asked by VBA.
• Once you have applied these guidelines, sign each documentation protocol.