The information in each section is based on the C&P medical examination clinical quality review tool. Each item would be checked as excellent, good, average, needs improvement, or not applicable for role in this encounter. Any average or below average findings would be explained in a comments section on the form.
- Date of onset/injury
- Description of onset/injury
- Treatment and response, clinical course
- Current health status
- Appropriate in scope for impairment evaluation of claimed condition and review of systems
- Documentation of pertinent positive findings
- Documentation of pertinent negative findings
- Testing, if utilized, appropriate test(s), interpreted/reported properly in exam
- Were any lab tests, psychological tests, and/or imaging tests required?
- Did not provide or order unnecessary testing (e.g., duplication, already of record)
- Abnormal testing/diagnostics: notification provided and documented
- Excerpts or references to records provides objective evidence of records review.
- Listing of primary diagnostic source verification (especially important for malignancies, conditions requiring pathology report or specific testing).
- Prior C&P type exam available and if so, reviewed (background/baseline info)
- Clinically accurate diagnosis, concurs with ICD-10 and/or DSM-5
- Precise Diagnosis (A precise diagnosis is one that identifies the disease process for the noted signs and symptoms. No rule-outs or non-committals.)
- No Diagnosis rendered: this finding is supported and explained
- Diagnosis validated by primary source documentation (Especially important for neoplasms, conditions associated with a pathology report or requirement of specific testing.)
- Supported by history, physical exam, diagnostic studies, and other medical evidence
- If applicable, explanation of discrepancies or changes from diagnoses of record
- Clinically significant changed or new diagnosis notification provided and documented
- Appropriate discussion of disease or body-part specific limitations
- Appropriate discussion of limitations on employment related activities
- Appropriate discussion of limitations on personal/social activities
- Addresses Activities of Daily Life if indicated
Were discrepancies addressed (to include, but not limited to, those pertaining to diagnosis, history, medical records, clinical testing and functional status)?
- Performed and signed by appropriate clinician / certification for type of exam
- Document reporting is appropriate (to include, but not limited to, professional and ethical language and within the examiner's scope of practice)
- Medical opinion is well-supported, clear, and a sound rationale is provided.
- Did the provider include a discussion of the relevant findings as needed, including medical records and referenced medical and scientific literature?
This Review Tool also has a requirement for dentists: If the dentist believes that a trauma rating is required to allow treatment, there is notation that a request was submitted to the enrollment or business office to complete the 10-7131 form.