Medical record review, report writing, and deposition testimony
What this domain tests
This domain tests whether you can build a defensible record review, write a clear report, and give testimony that is consistent with the records and opinions. The focus is accuracy, organization, and transparency about gaps.
Core rules and concepts
- Record review: obtain complete records, create a chronology, identify each author and source, note missing or illegible records, and separate facts from assumptions. Review prior imaging, operative notes, medication lists, and functional reports. Do not rely on a summary when the primary record is available.
- Report structure: identifying information, scope and records reviewed, history, examination, test results, diagnoses, causation analysis, impairment or apportionment, limitations, and signature with date. State the degree of certainty and the basis for each opinion. Use addenda to correct errors; do not silently alter a signed report.
- Distinguish factual statements from opinions. A report that says the worker was injured at work without explaining the medical reasoning is vulnerable. A report that says the findings are consistent with a work-related strain to a reasonable degree of medical probability is stronger.
- Deposition: testify under oath, answer the question asked, do not guess, ask for clarification when needed, and correct errors promptly. Explaining a basis is appropriate; volunteering unrelated opinions is not. Producing documents may be required.
Worked example
A report states that a back injury was caused by a work lift, but the records show identical symptoms and treatment two years earlier. In deposition, counsel asks whether the opinion is still valid. The examiner should acknowledge the prior symptoms, explain what new findings or temporal evidence support the current opinion, and revise the opinion if the prior records undercut it. Defending the original wording without analysis damages credibility more than a candid correction.
Traps that cost marks
Copying records without analysis; failing to date or sign; overstating certainty; ignoring contrary records; arguing with counsel; volunteering opinions; changing an opinion without a documented basis; and submitting an altered report without an addendum.