STATE OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Workers’ Compensation Division Medical Impairment Rating Program 220 French Landing Drive Nashville, TN 37243-1002 (615) 253-1613; (615) 253-5263 fax Medical Impairment Rating (MIR) Report AMA Guides, 6th Edition [For Dates of injury on or after January 1, 2008] PATIENT INFORMATION (please type all responses) Claimant Name ____________________________________________________________________________ Address ___________________________________________________________________________________ City ______________________________________________ State __________ ZIP ____________________ Phone # ___________________________________________________________________________________ State File # __________________________________ MIR case # ____________________________________ Social security # _____________________________ Date of Birth ___________________________________ Date of Injury ____________________________ Date of MIR Evaluation ____________________________ MIR PHYSICIAN INFORMATION MIR Physician Name _______________________________________________________________________ Address __________________________________________________________________________________ City _____________________________________________ State __________ ZIP _____________________ Phone #______________________________________ Fax _________________________________________ Location of evaluation if different than above) __________________________________________________ __________________________________________________________________________________________ LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 1 of 18 American LegalNet, Inc. www.FormsWorkFlow.com LIST THE FINAL WHOLE PERSON IMPAIRMENT: In NUMBERS __________ % WPI AND In WORDS _______________________________________________ whole person impairment. [This is the FINAL rating legally presumed to be the correct impairment rating.] PHYSICIAN CERTIFICATION AND QUALIFICATIONS “It is my opinion, both within and to a reasonable degree of medical certainty that, based upon all information available to me at the time of the MIR impairment evaluation and th by utilizing the AMA Guides 6 Edition with its Errata, or other appropriate method as noted that the claimant has the permanent impairment so described in this report. I certify that the opinion furnished is my own, that this document accurately reflects my opinion, and that I am aware that my signature attests to its truthfulness. I further certify that my statement of qualifications to serve on the MIR Registry is both current and completely accurate.” Signature: __________________________________________ Dated: _______________ Printed full name of physician _______________________________________________ LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 2 of 18 American LegalNet, Inc. www.FormsWorkFlow.com STEP ONE—Clinical Evaluation PATIENT HISTORY INTRODUCTION AND OVERVIEW (brief description of the injury/illness, prior treatment received, and any periods the claimant was unable to work) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 3 of 18 American LegalNet, Inc. www.FormsWorkFlow.com PHYSICAL EXAMINATION __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 4 of 18 American LegalNet, Inc. www.FormsWorkFlow.com CLAIMANT’S CHRONOLOGICAL MEDICAL HISTORY FOR THIS INJURY Name & Address of All treatment Providers Date Treatment Received Nature of the injury or illness? Part of the body affected? _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ Make additional copies if necessary. LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 5 of 18 American LegalNet, Inc. www.FormsWorkFlow.com MEDICAL RECORD REVIEW (Use additional pages as required) check the applicable blocks next to any test results which you reviewed and relied upon to base your medical assessments or conclusions. Be sure to indicate whether you review imaging reports, OR, both the imaging reports and the actual images. Be sure to show the date of each test and summarize results. Please attach copy(ies) of the report(s) . In the space below, DATE(S) PERFORMED SUMMARY OF RESULTS Please note whether it was the actual images reviewed or if the paper report was reviewed. [ ] X-RAY # Reviewed [ ] X-RAY Reports # Reviewed [ ] EMG/NCS # Reviewed [ ] If radiculopathy exists, state abnormal findings that are consistent with radiculopathy: [ ] If a peripheral nerve entrapment exists, state any abnormal findings, and state whether they meet Guides criteria for conduction delay, conduction block, or axon loss: [ ] If an acute traumatic peripheral nerve injury occurred, state findings that are consistent with permanent nerve dysfunction: [ ] CT SCAN # Reviewed [ ] MYELOGRAM # Reviewed LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 6 of 18 American LegalNet, Inc. www.FormsWorkFlow.com [ ] MRI # Reviewed [ ] OTHERS (Describe) # Reviewed SURGICAL PROCEDURES Please list all operative procedures performed in chronological order with the operation title noted. copy(ies) of report(s) if surgery was performed. LB-0931A (REV 10/10) Attach List operative findings: MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 7 of 18 American LegalNet, Inc. www.FormsWorkFlow.com STEP TWO—Analysis of the Findings 1. Does the claimant have a permanent impairment? YES _____ NO _____ 2. Has the claimant reached maximum medical improvement (MMI)? YES _____ NO _____ If YES, date MMI was reached ____________________ If NO, state why the examinee is NOT at MMI, and what will be needed for the examinee to be at MMI. Do NOT rate the impairment. [Note: If you feel the patient is not at MMI because an additional treatment is required, you MUST document that the patient wants the additional treatment performed.] 3. Do the AMA Guides, 6TH EDITION with its ERRATA adequately assess the medical impairment rating of the claimant? 4. Yes _____ NO _____ If NO, state why they do not. List ALL diagnoses for which there is a ratable permanent impairment causally related to the work injury or exposure in question: 1. 2. 3. 4. 5. 6. 5. Are there diagnoses which the AMA Guides, 6th Edition does not include in impairment tables or for which the Guides does not provide a methodology, so that rating “by analogy” to a condition that is covered in the Guides must be used for impairment rating? (Pages 385, 495, 559, etc.) YES _____ NO _____ list the diagnosis in question and express an impairment percentage that you think is appropriate, explain the analogy utilized to determine it, and explain in detail how you arrived at If YES, please the percentage of impairment chosen. Calculated total whole person impairment: _____%. LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 8 of 18 American LegalNet, Inc. www.FormsWorkFlow.com STEP THREE—Discussion 1. th Using the AMA’s Physicians Guide to the Evaluation of Permanent Impairment, 6 Edition, please translate each of the claimant’s diagnoses as documented above to a percentage of impairment. If there are more than 6 ratable diagnoses, photocopy this page and submit this table for each additional diagnosis. Diagnosis Diagnosis # 1 Diagnosis # 2 Diagnosis # 3 ________________ ________________ ________________ ________________ ________________ ________________ Body part/system ________________ ________________ ________________ ________________ ________________ ________________ Chapter # ________________ ________________ ________________ ________________ ________________ ________________ Table #/page # ________________ ________________ ________________ ________________ ________________ ________________ Key factor ________________ ________________ ________________ ________________ ________________ ________________ Diagnosis line used ________________ ________________ ________________ ________________ ________________ ________________ Class ________________ ________________ ________________ ________________ ________________ ________________ Grade Modifier FH ________________ ________________ ________________ ________________ ________________ ________________ Grade Modifier PE ________________ ________________ ________________ ________________ ________________ ________________ Grade Modifier CS ________________ ________________ ________________ ________________ ________________ ________________ BOTC (if applicable) ________________ ________________ ________________ ________________ ________________ ________________ Final Class and Grade Used ________________ ________________ ________________ ________________ ________________ ________________ Regional impairment ________________ ________________ ________________ ________________ ________________ ________________ Whole person impairment ________________ ________________ ________________ ________________ ________________ ________________ LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 9 of 18 American LegalNet, Inc. www.FormsWorkFlow.com Diagnosis # 4 Diagnosis # 5 Diagnosis # 6 Diagnosis ________________ ________________ ________________ ________________ ________________ ________________ Body part/system ________________ ________________ ________________ ________________ ________________ ________________ Chapter # ________________ ________________ ________________ ________________ ________________ ________________ Table #/page # ________________ ________________ ________________ ________________ ________________ ________________ Key factor ________________ ________________ ________________ ________________ ________________ ________________ Diagnosis line used ________________ ________________ ________________ ________________ ________________ ________________ Class ________________ ________________ ________________ ________________ ________________ ________________ Grade Modifier FH ________________ ________________ ________________ ________________ ________________ ________________ Grade Modifier PE ________________ ________________ ________________ ________________ ________________ ________________ Grade Modifier CS ________________ ________________ ________________ ________________ ________________ ________________ BOTC (if applicable) ________________ ________________ ________________ ________________ ________________ ________________ Final Class and Grade Used ________________ ________________ ________________ ________________ ________________ ________________ Regional impairment ________________ ________________ ________________ ________________ ________________ ________________ Whole person impairment ________________ ________________ ________________ ________________ ________________ ________________ LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 10 of 18 American LegalNet, Inc. www.FormsWorkFlow.com Submit this page for each ratable diagnosis. Diagnosis # 1. Please restate diagnosis: Criteria that support this diagnosis as present: Class _____. Criteria that support choice of Class for this diagnosis: Functional History, Grade modifier _____ Criteria that support choice of this Grade Modifier, or reason this Modifier is not used: Physical Exam, Grade Modifier ______ Criteria that support choice of this Grade Modifier, or reason this Modifier is not used: Clinical Studies, Grade Modifier_____ Criteria that support choice of this Grade Modifier, or reason this Modifier is not used: Burden of Treatment Compliance Grade Modifier (if Chapter 9 or 10 was used) _____. Criteria that support choice of this Grade Modifier, or reason this Modifier is not used: LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 11 of 18 American LegalNet, Inc. www.FormsWorkFlow.com Submit this page for each ratable diagnosis. Diagnosis # 2. Please restate diagnosis: Criteria that support this diagnosis as present: Class _____. Criteria that support choice of Class for this diagnosis: Functional History, Grade modifier _____ Criteria that support choice of this Grade Modifier, or reason this Modifier is not used: Physical Exam, Grade Modifier ______ Criteria that support choice of this Grade Modifier, or reason this Modifier is not used. Clinical Studies, Grade Modifier_____ Criteria that support choice of this Grade Modifier, or reason this Modifier is not used. Burden of Treatment Compliance Grade Modifier (if Chapter 9 or 10 was used) _____. Criteria that support choice of this Grade Modifier, or reason this Modifier is not used: LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 12 of 18 American LegalNet, Inc. www.FormsWorkFlow.com Submit this page for each ratable diagnosis (photocopy for additional diagnoses) Diagnosis # ____ Please restate diagnosis: Criteria that support this diagnosis as present: Class _____. Criteria that support choice of Class for this diagnosis: Functional History, Grade modifier _____ Criteria that support choice of this Grade Modifier, or reason this Modifier is not used: Physical Exam, Grade Modifier ______ Criteria that support choice of this Grade Modifier, or reason this Modifier is not used: Clinical Studies, Grade Modifier_____ Criteria that support choice of this Grade Modifier, or reason this Modifier is not used. Burden of Treatment Compliance Grade Modifier (if Chapter 9 or 10 was used) _____. Criteria that support choice of this Grade Modifier, or reason this Modifier is not used: LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 13 of 18 American LegalNet, Inc. www.FormsWorkFlow.com Use this table for any Central Nervous System injury, condition, or diagnosis to be rated: Chapter 13 Central Nervous System Diagnosis or Condition Table Number/ Page Number Rationale for Impairment % Chosen % Impairment of the Scheduled Member % Impairment of the Whole Person If appropriate a.____________________ _______ _______ _________________________ _________________________ _______ _______ ________ ________ _______ _______ _________________________ _________________________ _______ _______ ________ ________ _______ _______ _________________________ _________________________ _______ _______ ________ ________ ____________________ b.____________________ ____________________ c.____________________ ____________________ Use this section and table for any mental or behavioral disorder or diagnosis to be rated: Are you a Psychiatrist? YES _____ NO _____ If YES, continue. If NO, do not complete this section. Diagnosis: Axis I: [Please remember—this is the only diagnosis that potentially could be ratable] Axis II: Axis III: Axis IV: Axis V: (GAF) BPRS impairment score GAF impairment score PIRS impairment score Median or middle value of these 3 – Impairment (WPI) Subtract impairment for pre-existing mental disorder or borderline intellectual function FINAL IMPAIRMENT RATING FROM CHAPTER 14 LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 14 of 18 American LegalNet, Inc. www.FormsWorkFlow.com Submit photocopy of Table 14-8 of the Guides with score for each BPRS item circled. Narrative report must contain documentation for each BPRS Symptom Construct. Your narrative report must also contain documentation for choice of GAF Scale and must contain documentation for choice of each score from Tables 1412 through 14-16. Use this section for any ratable Pain Related Impairment [Chapter 3] Diagnosis that is ratable from Chapter 3: Explain why this condition/injury was not ratable by Chapters 4-17: [Note: The Guides Errata specifies that “zero is a rating.”] PDQ score ________ [Submit a copy of the PDQ attached to this report that is signed by the examinee.] Final pain related impairment: ________ % whole person impairment. Use this table if there are multiple ratable impairments. List the mathematically highest impairment first, then in order of decreasing numerical impairment. Diagnoses #1 Whole Person Impairment #2 #3 #4 #5 #6 Final Whole Person Impairment from Combined Values LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 15 of 18 American LegalNet, Inc. www.FormsWorkFlow.com Is there a prior, work-related medical impairment rating that should be considered for subtraction from the impairment(s) described above? YES ____ NO _____ If YES, state the prior medical impairment rating and in the following section, “COMMENTS ON IMPAIRMENT RATING,” calculate the final rating both WITH AND WITHOUT subtraction of this pre-existing, work-related impairment rating. COMMENTS ON IMPAIRMENT RATING (including a discussion on subtracting prior, work-related, impairment ratings, if applicable). If a QuickDASH Form, AAOS Lower Limb Outcome Form, a Pain Disability Questionnaire Form or any other questionnaire was completed by the examinee, please include a copy with your report. Complete and return with all required attachments via overnight delivery to: Tennessee Department of Labor and Workforce Development Workers’ Compensation Division ATTN: J. Edward Blaisdell, MIR Program Coordinator 220 French Landing Drive Nashville, Tennessee 37243-0661 LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 16 of 18 American LegalNet, Inc. www.FormsWorkFlow.com QuickDASH—Disabilities of the Arm, Shoulder and Hand Instructions: This questionnaire asks about your symptoms as well as your ability to perform certain activities. Please answer every question, based on your condition in the last week, by circling the appropriate number. If you did not have the opportunity to perform an activity in the past week, please make your best estimate on which response would be the most accurate. (1 is not difficult, not limited, or none; 2 is mild difficulty, slightly limited, or mild; 3 is moderate difficulty, moderately limited, or moderate; 4 is severe difficulty, very limited, or severe; and 5 is unable, extremely, or extreme.) 1. Open a tight or new jar. 1 2 3 4 5 2. Do heavy household chores (e.g., wash walls, floors). 1 2 3 4 5 3. Carry a shopping bag or briefcase. 1 2 3 4 5 4. Wash your back. 1 2 3 4 5 5. Use a knife to cut food. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 9. Arm, shoulder or hand pain. 1 2 3 4 5 10. Tingling (pins and needles) in your arm, shoulder or hand. 1 2 3 4 5 11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? 1 2 3 4 5 6. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.). 7. During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbours or group? 8. During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand problem? LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 17 of 18 American LegalNet, Inc. www.FormsWorkFlow.com Pain Disability Questionnaire Instructions: These questions ask your view about how your pain now affects how you function in everyday activities. Please answer every question and mark the ONE number on EACH scale that best describes how you feel. 1. Does your pain interfere with your normal work inside and outside the home? Work normally Unable to work at all 0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10 2. Does your pain interfere with personal care (such as washing, dressing, etc.)? Take care of myself completely Need help with all my personal care 0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10 3. Does your pain interfere with your traveling? Travel anywhere I like Only travel to see doctors 0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10 4. Does your pain affect your ability to sit or stand? No problems Cannot sit/stand at all 0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10 5. Does your pain affect your ability to lift overhead, grasp objects, or reach for things? No problems Cannot do at all 0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10 6. Does your pain affect your ability to lift objects off the floor, bend, stoop, or squat? No problems Cannot do at all 0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10 7. Does your pain affect your ability to walk or run? No problems Cannot walk/run at all 0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10 8. Has your income declined since your pain began? No decline Lost all income 0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10 9. Do you have to take pain medication every day to control your pain? No medication needed On pain medication throughout the day 0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10 10. Does your pain force you to see doctors much more often than before your pain began? Never see doctors See doctors regularly 0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10 11. Does your pain interfere with your ability to see the people who are important to you as much as you would like? No problem Never see them 0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10 12. Does your pain interfere with recreational activities and hobbies that are important to you? No interference Total interference 0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10 13. Do you need the help of your family and friends to complete everyday tasks (including both work outside the home and housework) because of your pain? Never need help Need help all the time 0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10 14. Do you now feel more depressed, tense, or anxious than before your pain began? No depression/tension Severe depression/tension 0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10 15. Are there emotional problems caused by your pain that interfere with your family, social and or work activities? No problems Severe problems 0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10 LB-0931A (REV 10/10) MEDICAL IMPARIMENT RATING (MIR) REPORT AMA GUIDES, 6TH EDITION RDA 10183 Pg 18 of 18 American LegalNet, Inc. www.FormsWorkFlow.com