Everything a California QME report must contain, in one checklist.
QME report requirements in California come from the Division of Workers' Compensation: the exam date and street address, every record reviewed with its declaration, the §35.5 non-discrimination attestation, opinions on every disputed issue, and a signature. This checklist turns the DWC Medical-Legal Quality Assurance Checklist into a pre-report review list. Informational, not legal advice.
Completeness is a checklist. Substantial evidence is a trail.
Every requirement in the checklist traces to the record: the declaration of pages received, the dates and pages cited, the wrong-patient page that never belonged in the file. A report built on an incomplete record fails the first review, no matter how clean the prose.
Twelve items the DWC looks for in a QME report.
Condensed from Title 8 of the California Code of Regulations §§35.5, 36, and 38 and the DWC Medical-Legal Quality Assurance Checklist (updated 2026-04-29). Confirm against the current regulations and your own counsel.
Report header
Date, recipients, and worker identifiers: RE, date of birth, date of injury, employer, claim number, WCAB number, and date of evaluation.
Advocacy letters
Acknowledge each party's cover letter and list the specific questions asked, so every disputed issue in scope gets answered (§35.5(c)(1)).
Exam details
State the date the examination was completed and its street address in the body of the report; note the sign date if it differs (§35.5(b)).
Telehealth
For telehealth evaluations, require written agreement of all parties and state that no physical exam was required (8 CCR §46.3).
Evaluator status and assistance
Identify the role (QME, AME, IME, PTP) and anyone who assisted; if AI was used, disclose the application and its purpose per the DWC checklist.
Records declaration
Attest the number of pages received and reviewed; flag missing records and follow the §35(i) 10-day procedure if they do not arrive.
Review the record, not a summary
Labor Code §4628(a)(2) and 8 CCR §41(c)(2) require reviewing the available records; a party-provided summary alone does not satisfy the standard.
History and medical summary
Injury history, the records reviewed, current treatment, symptoms, medications, review of systems, and past and personal history.
Physical examination
Perform and document the examination per AMA Guides 5th Edition protocols, including the face-to-face time with the injured worker.
Diagnosis and analysis
Impression, causation, and apportionment (Labor Code §§4663, 4664 and the Escobedo how and why), stated at reasonable medical probability.
P&S reporting
If permanent and stationary with permanent partial disability, complete DWC-AD Form 10133.36 and serve it with the report (§35.5(c)(2)).
Attestation, signature, service
Include the §35.5(h) non-discrimination declaration under penalty of perjury and the §40 disclosure; sign and date, then serve per §36 (QME Form 122) within 30 days (§38).
Three steps between the exam and the signature.
Upload the packet and your findings
The records you already have, plus dictation or notes from the exam. In the demo case, 342 pages across 2 packets and a 14-minute dictation.
The AI drafts the report body, every line cited
Your template fills field by field from the findings and the record; every factual statement links to its source page, and suspect pages are quarantined, not quietly used.
You complete the attestations, write the opinion, and sign
The checklist sections are organized for your review: verify citations, add the required declarations, write the opinion, and export on your letterhead.
A report you can defend line by line.
A QME report is reviewed for completeness first: declarations, page counts, and dates the draft cannot invent. Medrecords AI keeps the record the single source. Every factual statement links to its page, and the pages that do not belong are quarantined and logged.
In the demo case, a prior-injury reference on p.140 belonged to a different patient. It was quarantined and logged, not folded into the history. When someone asks how the report was produced, the audit trail answers for you.
The rules the platform never breaks.
EVERY LINE CITED
HIPAA, under a signed BAA
Every file is handled under our Business Associate Agreement, from the first byte.
Never trains a model
Your records are never used to train any AI model — ours or anyone else's.
Every line cited
If we can't cite it, we don't say it. Every sentence links to its source page.
Deleted after delivery
Files are deleted 30 days after delivery, with a full audit log of every access.
Four capabilities behind every draft.
The QME report is one deliverable of the same platform that reads, sorts, and cites the whole record.
Medical chronology
The record behind the report, in date order: every visit, image, and gap, each entry synced to its source page.
Custom report builder
Your jurisdiction's template, your client's format, your letterhead. The draft fills the fields; the structure stays yours.
AI medical dictation & transcription
Dictate the exam the way you always have. Transcription built for medical vocabulary feeds the draft directly.
Document sorting & packet builder
Duplicates out, wrong-patient pages quarantined, and a clean exam packet assembled before you ever open the file.
QME report requirements, answered.
Walk into the exam with the checklist already drafted.
AI drafts. You decide, attest, and sign.