Psychiatric Specialist

20-25 minutes

Independent Medical Evaluation Template

The Independent Medical Examination (IME) template by s10.ai is an all-encompassing resource designed for psychiatrists to evaluate the psychological effects of workplace injuries. This template meticulously guides healthcare professionals in documenting referral details, comprehensive descriptions of workplace injuries, and the patient's psychiatric and medical history, alongside a detailed mental status examination. Essential for legal and insurance contexts, it offers a structured approach to assess the mental health implications of physical injuries. When integrated with s10.ai, this template guarantees a precise and thorough evaluation, facilitating the development of treatment plans and risk assessments, thereby encouraging clinicians to adopt and implement this advanced tool in their practice.

3,436 uses

4.6/5.0

Aarav Patel

Template Structure

Organized sections for comprehensive clinical documentation

Independent Medical Examination Evaluation:

Referral Details:

Referring Entity: [referring agency or law firm name] (include name of referring agency or law firm it has been explicitly mentioned in the transcript, contextual notes or clinical note.)

Purpose of Referral: [reason for referral] (only include reason for referral if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)

Current Complaint History:

[describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (only include describe current issues, reasons for visit, discussion topics, history of presenting complaints etc if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)

Occupational Injury:

[describe the workplace injury] (please include a very detailed description of the workplace injury, its mechanism, severity, impact on work, investigations done for that, management and follow up for the treatment of the injury as mentioned in the transcript, contextual notes or clinical note. Please try to describe this in a chronological manner if possible. Please include verbatim description of features of the injury, the severity of this and the impact it has on the person.)

Previous Psychiatric History:

[describe past psychiatric treatment, episodes of admission, psychologist sessions as mentioned in the transcript, contextual notes, or clinical note. Please use as much detail as has been described in the transcript including dates, duration of treatment, and any other associated information]

Developmental Background:

[describe developmental history] (please include details of place of birth, details of early childhood, upbringing, attachment to parents, any history of speech or motor delays, or developmental delays and schooling explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)

Medical History:

[describe past medical history, previous surgeries] (only include describe past medical history, previous surgeries if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)

Current Medications:

[mention medications and herbal supplements] (please include all mentioned medications and herbal supplements, both current and past, if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)

Known Allergies:

[mention allergies] (only include mention allergies if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)

Lifestyle and Social History:

[describe social history] (only include describe social history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)

Substance Use Background:

[describe history of smoking, alcohol use and drug use] (please include all described details related to smoking, alcohol and drug use mentioned in the transcript, contextual notes or clinical note.)

Legal and Forensic History:

[describe forensic history] (please included ongoing or past charges, warrants, involvement with the Police or justice system, prison sentences or other legal matters mentioned in the transcript, contextual notes or clinical note.)

Family Background:

[describe family history] (only include describe family history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)

System Review:

[describe review of systems] (only include describe review of systems if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)

Diagnostic Tests:

[mention diagnostic studies and results] (only include mention diagnostic studies and results if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)

Mental Status Evaluation:

- Appearance: [Describe the patient's clothing, hygiene, and any notable physical characteristics.] (Only include appearance details if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)

- Behaviour: [Observe the patient's activity level, interaction with their surroundings, and any unique or notable behaviors.] (Only include behaviour details if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)

- Speech: [Note the rate, volume, clarity, and coherence of the patient's speech.] (Only include speech characteristics if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)

- Mood: [Record the patient's self-described emotional state, using their own words if possible.] (Only include self-described emotional state if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)

- Affect: [Describe the range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood.] (Only include [emotional response] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)

- Thoughts: [Assess the patient's thought process and thought content, noting any distortions, delusions, or preoccupations.] (Only include thought process and content if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)

- Perceptions: [Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient.] (Only include perception details if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)

- Cognition: [Describe the patient's memory, orientation to time/place/person, concentration, and comprehension.] (Only include cognitive observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)

- Insight: [Describe the patient's understanding of their own condition and symptoms, noting any lack of awareness or denial.] (Only include insight observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)

- Judgment: [Describe the patient's decision-making ability and understanding of the consequences of their actions.] (Only include judgement observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)

Risk Evaluation:

[Assessment of suicidality, homicidality, and other risks.] (Only include [Assessment of suicidality, homicidality, other risks] if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)

Summary:

[summarize conclusions and opinions] (only include summarize conclusions and opinions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)

Sample Clinical Note

Example of completed documentation using this template

Independent Medical Examination Assessment:
Referral Information:
Referring Agency: Smith & Associates Law Firm  
Reason for Referral: Evaluation of psychological effects following workplace injury  
History of Presenting Complaint:
The patient, a 45-year-old male, experiences persistent anxiety and depressive symptoms after a workplace accident. He reports sleep disturbances, ongoing worry, and decreased motivation since the event.
Workplace Injury:
The patient suffered a significant back injury on 15 March 2024 while lifting heavy equipment at work. The injury led to a herniated disc, confirmed by MRI, resulting in chronic pain and restricted mobility. He has been unable to resume work since the incident and has participated in physical therapy and pain management with limited improvement.
Past Psychiatric History:
The patient has a history of depression, managed with cognitive behavioural therapy in 2018 for six months. No hospitalizations or psychiatric medications were noted.
Developmental History:
Born in London, the patient had a stable childhood with no reported developmental delays. He completed secondary education and maintained consistent employment until the recent injury.
Past Medical History:
The patient had an appendectomy in 2010 without complications.
Medications:
Currently using ibuprofen for pain relief. No herbal supplements reported.
Allergies:
No known allergies.
Social History:
The patient resides with his wife and two children. He describes a supportive family environment.
Substance Use History:
The patient does not smoke, drinks alcohol socially, and denies any illicit drug use.
Forensic History:
No history of legal issues or involvement with the justice system.
Family History:
The patient's father has a history of hypertension. No psychiatric conditions reported in the family.
Review of Systems:
The patient reports chronic back pain and occasional headaches. No other systemic issues noted.
Investigations:
MRI scan on 20 March 2024 revealed a herniated disc at L4-L5.
Mental Status Examination:
- Appearance: The patient appeared well-groomed and appropriately dressed.
- Behaviour: Cooperative and engaged during the examination.
- Speech: Normal rate and volume, coherent.
- Mood: Describes feeling "down and anxious."
- Affect: Restricted, consistent with mood.
- Thoughts: Logical and goal-directed, no delusions.
- Perceptions: No hallucinations reported.
- Cognition: Alert and oriented to time, place, and person.
- Insight: Acknowledges the impact of injury on mental health.
- Judgment: Demonstrates understanding of the need for ongoing treatment.
Risk Assessment:
No current suicidal or homicidal ideation. Low risk of self-harm.
Conclusion:
The patient exhibits symptoms consistent with an adjustment disorder with anxiety and depression secondary to the workplace injury. Continued psychological support and pain management are recommended.

Clinical Benefits

Key advantages of using this template in clinical practice

The Independent Medical Examination Assessment template is an essential tool for clinicians seeking a comprehensive evaluation of patients referred for legal or insurance purposes. This template is meticulously designed to capture detailed referral information, including the referring agency and the specific reason for referral, ensuring clarity and precision in documentation. It facilitates a thorough exploration of the patient's history, encompassing presenting complaints, workplace injuries, and past psychiatric and medical histories. Clinicians can document developmental, social, and substance use histories, providing a holistic view of the patient's background. The template also includes sections for forensic and family histories, review of systems, and detailed mental status examinations, allowing for a nuanced understanding of the patient's mental and physical health. With dedicated areas for risk assessment and conclusions, this template supports clinicians in delivering well-rounded, evidence-based evaluations. By adopting this template, healthcare professionals can enhance their documentation efficiency, improve patient care outcomes, and ensure compliance with legal and clinical standards.

Frequently Asked Questions

Common questions about this template and its usage

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