A client’s expectation regarding the work product provided by Dr. Zünkeler may vary, e.g. a telephone call or video conference, a record review report, an IME report, or a life care plan (i.e. a detailed clinical assessment of a catastrophically injured patient with a dynamic projection of future health-care costs). In some cases, sworn testimony in depositions, at court, or in administrative hearings is required to explain the opinions and conclusions reached in a case and their underlying basis to the finder of fact (typically a judge or a jury).
A telephone call to discuss the important aspects of a case may be sufficient. If the diagnostic imaging studies in a case are of particular importance, a video conference with screen sharing may be helpful. Sometimes, important clinical findings and conclusions are best summarized and presented on slides. We use Microsoft Teams for secure and private video conferences. The client can easily join by downloading the Microsoft Teams app or by using a web browser on a camera/microphone-equipped desktop or laptop computer or a handheld device (e.g. iPhone or iPad). A reliable high-speed internet connection is helpful.
A record review reportquotes and summarizes the important records in a case and, if available, discusses the diagnostic studies, including imaging studies. A list of diagnoses is established. An attempt is made to structure the diagnoses according to pre-existing, causally related, and subsequent factors in relation to the date of injury. In the “Discussion” section, the case and its key features are briefly summarized, and opinions and conclusions based on the available medical records are presented. Any record or diagnostic deficiencies are listed, and the client’s questions (if any) are answered.
In cases in which the treatment records of several individuals who were treated by a single health-care provider are reviewed (e.g. in the setting of an external peer review), the findings and opinions can be documented in a peer review report, a slide presentation (to be used at a hearing), or both.
An IME reporthas the same elements as a record review report, except that the examinee’s verbal history and physical examination findings are included. Although an IME report requires additional time, meeting with and physically examining the examinee are often very helpful. Dr. Zünkeler also offerstelemedicine IMEs to examinees who are physically located in Maryland at the time of the IME.
A life care plan or health-care cost projectionis sometimes requested when a person is severely disabled after a catastrophic injury or illness to establish a needs-based estimate of future health-care costs. In many cases, the examiner will visit the examinee’s home or long-term care facility. To document the examinee’s ability to perform specific activities and to use necessary adaptive equipment (e.g. braces, crutches, walker, or wheelchair), photographs or videos may be obtained after authorization by the examinee. The presence of the examinee’s spouse or partner, parent or guardian, or legal representative is sometimes necessary to obtain a complete history of the impairment and resulting disability. In some cases, a traditional life care plan is not necessary, and a projection of expected future costs for specific health-care services (e.g. future surgical or medical care) is requested. Case management has additional information on life care plans, which are considered a dynamic document and a form of case management.