Scar Evaluation Report

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

I was first introduced to assessing a scar for a medico-legal report during my plastic surgery residency. We would see the patient who had been referred by his/her lawyer. These were patients we had never seen or treated in the past. We would ask the history of the scar (cause, treatment, etc). We would discuss the ways the scar, if any, might be improved. Then my staff physician would write the letter. I wish he had allowed us to read those letters and taught us how to write them. I have never felt comfortable writing them.

I did a "search" this morning looking for tips/suggestions on how to write a medico-legal report. I put in different tags--scar evaluation, scar assessment, medico-legal scar evaluation, etc. My best results were from the tag--writing a medico-legal assessment. It is called an Independent Medical Examination (IME) of a scar (or some other issue--likelihood of a chemical causing a disease) not a scar evaluation report. Here are some tips:

• Even though only one side (either sides lawyer or the insurance company) pays for the report, you should take extra care to maintain a truly independent viewpoint.
• Ask for all the medical information the requesting person has. This will help inform your conclusions and prevent surprises while on the witness stand if asked to testify.
• Write the report based on your findings. Draw your own conclusions.
• You must have consent from the patient in writing to release their medical information. Try to determine how the report will be used. Get clear instructions and a list of questions from the lawyer. A verbal explanation of what's expected can also be helpful.
• Cover the basics first. For a scar evaluation--what accident or injury caused the injury that resulted in the scar? Was it work related? Give a brief description of what happened and when, and don't get into the question of who was at fault. Most of the time, we only have the patient's version of the story. Make a note that your report is based on this version.
• For scars, the initial treatment is often important in the outcome. So the next thing to address is: How was the laceration/wound treated? Where was the treatment carried out? What was the follow up?
• What is the patient's history of past health that might contribute to the scar? Is the patient a known keloid former? Does the patient smoke or a diabetic (impaired wound healing)?
• Mention what the physical findings were initially after the injury, and on (preferably all) future visits. How did they change over time, with or without treatment?
• Lastly, is the patient suffering from an impairment or disability? Is the scar causing a joint contracture (for example)? An impairment is defined as an anatomic or functional abnormality or loss. This is a medical diagnosis, which we're well suited and expected to make. Your report should cover whether an impairment is temporary or expected to be permanent. In other words, is the condition stable and has maximum medical rehabilitation been achieved?
• The question whether an impairment constitutes a disability is settled by a decision-maker; the conclusion is based upon the patient's age, education, training, social situation, job requirements and other factors, including medical impairments.
• You may indeed be asked to give a prognosis. It's understood that no one can predict a patient's future, but a physician can draw conclusions from experience with others and also from information on how the patient in question has coped with adversity in the past. Try to state whether or not an injury/impairment is likely to be long lasting (usually classified as > 1 year) and/or whether it'll have a severe impact on the person's life.
• Decision-makers may also want to know what treatment the patient will need in the future. For example, if the scar has caused a contracture of a joint, the person may require surgery to correct the contracture and /or physical therapy, etc.
• If asked to assess the patient's ability to return to work, don't fall into the trap of making this decision without a full description of his or her work duties.
• For scar evaluation, I am often asked the cost of future treatment. I can only give them the best estimates on the treatments or procedures I would recommend. I do this based on procedure codes and current fees.

Patients may not be familiar with the type of relationship they will have with someone carrying out an IME. So you should be extra cautious in explaining the purpose of the assessment, how it will be performed, what body systems will be involved (usually only those relevant to the questions asked, not a full/total physical exam), what other tests may be required, where the report will be sent and how you will be paid. Make sure the patient understands that the report you write will be based on the examination and/or interview, any observations made during the meeting as well as other medical reports received. It's also important that the person is aware that no treatment or medication prescriptions will result from this assessment. You should document this discussion, as well as the times you start and finish the assessment.

References
Pain-free Medico-legal Reports, Taking the edge off a tedious task an interview with Michael Zitney, MD