Medical record review prompts for IME and QME physicians

Run before the examination. The flag on post-referral records matters because those may not have been part of what you were asked to consider.

The second sentence is the valuable one. A question the record cannot answer is worth identifying before the examination, when it can still be fixed, rather than in the report.

Run after the examination, against your own history-taking.

This is the mirror prompt and the most important one in the lane. Failure mode 5.6 is the specific risk to a neutral evaluator, because the referral itself carries a framing. Run I6 with the same specificity you ran I2, and if the contrary column is thin, the prompt is at fault before the record is.

Lane failure mode: inherited framing, and substitution. Two risks, and the second is the graver one.

The referral arrives with a theory attached, and it is easy to run prompts that test that theory rather than the record. I6 exists to correct this and only works if it is run honestly.

The second is substitution: letting a digest stand in for the review the statute assigns to you. Every prompt in this lane produces an aid to review, never the review. See the responsibility note below, which is the only place in this library where a specific statute makes the boundary explicit.

Professional responsibility. Neutrality is the product, and in at least one jurisdiction the division of labor is set by statute.

California Labor Code section 4628 governs who may do what on a medical-legal report. Subsection (a) reserves to the signing physician the taking of a complete history, the reviewing and summarizing of prior medical records, and the composing and drafting of conclusions. Subsection (c) then carves out a narrow exception: another person may prepare an initial history outline or excerpt prior records, but the physician must review the excerpts and the entire outline and make such additional inquiries and examinations as are necessary. Subsection (e) supplies the consequence. Failure to comply makes the report inadmissible as evidence and eliminates any liability for payment of the medical-legal expense.

Read that carefully, because it locates AI-assisted extraction precisely. Output from the prompts in this lane sits in the 4628(c) position: excerpts and an outline, prepared by something other than the physician. It does not sit in the 4628(a) position, and treating it as though it does is the failure mode the statute is written against. The physician reviews the excerpts and the underlying records, not the summary alone. A QME report built on a summary in place of a review is not a quality problem, it is an admissibility problem, and it takes the fee with it.

That is California workers' compensation. Other jurisdictions and other systems differ, and IME practice outside workers' compensation is governed differently again. Treat 4628 as the clearest published statement of a principle that applies more broadly rather than as the rule everywhere, and settle your own jurisdiction with your board and counsel.

Two further questions worth settling in advance: whether AI-assisted review requires disclosure in your report or on cross, and whether the systems you use are consistent with the confidentiality terms of the referral. The conservative practice is to describe your review methodology plainly and to verify at Tier 1, since everything in the report is sworn or subject to challenge.