A record review report quotes 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.