Medical Record Review in a QME Report: What to List, What to Summarize, and What You Can Bill

Short answer: in a California medical-legal report, the review of records is a regulated section, not a courtesy. Labor Code 4062.3 and 8 CCR 10682 require the evaluator to identify every record received and every record relied on. Labor Code 4628 requires the signing physician to do the reviewing and summarizing, or, if someone else excerpts the records, to review the excerpts and the whole outline personally. The fee schedule pays for record review by the page: 200 pages are included in a comprehensive evaluation, 50 in a supplemental, and every page beyond that is $3.00, provided the records arrived with a declaration attesting to the page count. A report that lists the records without summarizing them is technically compliant and practically useless, because the parties cannot tell what the physician took from the file.

Perry J. Carpenter, DC, QME's report writing course returns to the records in Session 5 (video), where he covers listing and summarizing everything received, and Session 8 (video), where he builds the records section of an actual template and tracks the time it takes. The section is the largest input to the report and the least glamorous, and most of what goes wrong in impairment and apportionment opinions goes wrong here first.

What the law requires the review of records to contain

Four provisions govern the section, and each adds a requirement.

Labor Code 4062.3 controls what the parties may send and what the evaluator must do with it. Either party may provide the treating physician's records and "medical and nonmedical records relevant to determination of the medical issue." Everything must be served on the opposing party 20 days before it goes to the evaluator, and non-medical records can be blocked by an objection within 10 days. The evaluator, in turn, must "identify all information received from the parties" and "all information relied upon in the formulation of his or her opinion."

8 CCR 35 adds the mechanics. The party sending records must "attach a log to the front of the records and information being sent to the opposing party that identifies each record or other information to be sent to the evaluator and lists each item in the order it is attached." If records arrive after the evaluation, the evaluator notes in the report that they were not received in time, and can address them in a supplemental report without re-examining the worker if the records alone are enough to do so.

8 CCR 10682 lists the required contents of the report, including "a listing of all information received in preparation of the report or relied upon for the formulation of the physician's opinion." The full list of required elements is covered separately.

Labor Code 4628 decides who may do the work. Subdivision (a) says no one other than the signing physician may take the complete history, review and summarize prior medical records, or compose and draft the conclusions of the report. Subdivision (c) opens a narrow door: if someone else outlines the history or excerpts the records, the physician "shall review the excerpts and the entire outline" and make additional inquiries and examinations as needed. Subdivision (j) closes it with the declaration under penalty of perjury that information provided by others is accurately described. The consequences for getting this wrong, inadmissibility and non-payment under 4628(e), are explained here.

Put together: everything received gets listed, everything relied on gets identified, the physician personally reviews it, and the physician swears to the accuracy of the description.

Why a list is not enough

A report can satisfy every provision above with a table that says "Kaiser Permanente records, 3/2/2021 to 11/14/2023, 412 pages" and still be a bad report. Dr. Carpenter's point in Session 5 is that the parties need to know what each record contributed. A claims examiner reading the apportionment section wants to see that the physician noticed the 2019 primary care note documenting low back complaints before the industrial injury. Applicant's counsel wants to see that the physician noticed the negative pre-injury lumbar film. A list of providers and page ranges tells neither of them anything.

The summary also protects the physician. When the opinion cites a fact from the records, the review of records section is where the reader goes to confirm the physician actually saw it. If the fact is not in the summary, the opinion looks like it came from somewhere else, and the deposition question writes itself.

So the section has two layers. The list, which proves receipt and satisfies 4062.3 and 10682. And the summaries, which show what was pertinent and set up every opinion that follows.

How to structure the section

The method Dr. Carpenter teaches, and the one that survives depositions, is chronological. A chronological review reads as the history of the injury, which is what the evaluator is being asked to reconstruct. Grouping by provider is easier to assemble from a production that arrived sorted by provider, but it forces the reader to do the sequencing, and it hides the gaps.

For each entry, record:

The date of service, not the date the record was printed or received.
The provider or source, including the facility and, where it matters, the individual.
The document type: office visit, operative report, imaging report, physical therapy note, deposition transcript, claim form, job description.
The pertinent findings, in a sentence or two. Pertinent means bearing on a disputed issue: mechanism, complaints, objective findings, diagnosis, treatment, work status, prior injuries, non-industrial conditions.
Where it sits in the production, so that both the physician and the reader can find the page again.

Not every page gets a summary. A production of 900 pages will contain pharmacy printouts, billing ledgers, duplicate copies of the same MRI report, and authorization correspondence. Those are listed, because they were received, and passed over, because they are not pertinent. The section should say so: "Pages 612 to 688 consist of billing records and duplicate copies of records summarized above." That sentence is the difference between a physician who reviewed the file and one who did not, and it takes ten seconds to write.

Dr. Carpenter's own practice, stated plainly in the course, is to read every page himself. His reasons: what is relevant is a medical judgment; a reviewer without clinical training will miss the incidental finding that changes the case; and if the report goes to deposition he will have to re-read the file anyway. He is not wrong about any of that. The statute permits excerpting by others under 4628(c), and it requires the physician to review the excerpts and the entire outline. The word "entire" is doing work. A physician who reads a two-page summary of a 900-page production and signs the 4628(j) declaration has not reviewed the entire outline of anything.

Reconciling the file against the log

The claims administrator's production comes with a log under 8 CCR 35, and since 2021 it also comes with a declaration under penalty of perjury attesting to the total page count. Dr. Carpenter's advice, which is worth taking literally, is to reconcile three things before the report is finalized: what the log says was sent, what actually arrived, and what the report lists.

Mismatches are common. A log lists an MRI report that is not in the packet. A packet contains a deposition transcript that is not on the log and was never served on the other party. Two productions from the same adjuster overlap by 200 pages. Each of those has a consequence. A missing record is a gap the report should name. An unserved non-medical record is one the evaluator may not be able to consider, and considering it anyway invites an ex parte dispute. Duplicated pages cannot be billed twice.

The reconciliation is also the physician's best defense on the 4628(j) declaration. The declaration says the information provided by others is accurately described. A report whose list matches the log, and whose summaries cover everything on the list, is accurate on its face. A report that lists 380 pages when the declaration says 412 is going to be asked what happened to the other 32.

What to do when records are missing

Records are late or missing in a large fraction of evaluations. The cover letter references an EMG that was never produced. The worker mentions a prior claim with a different employer and no one sent those records. The surgery happened three weeks ago and the operative report is not in the file.

The regulation is unforgiving on this point. 8 CCR 38(h) says extensions of the 30-day report deadline "shall not be granted because relevant medical information/records have not been received." The evaluator completes the report with what is available, states what is missing, and notes that the opinions may change if the missing records are later provided. That sentence should be specific: which records, from which source, for which period, and which opinions depend on them. When the records arrive, they can be addressed in a supplemental report, which under 8 CCR 35 does not require a re-examination if the records alone are sufficient.

The evaluator should not go get the records. The regulations route everything through the parties, with service on the opposing side, and an evaluator who calls the prior treating office directly has stepped outside that process.

How record review is paid

Under the 2021 medical-legal fee schedule, 8 CCR 9795, record review is priced by the page rather than by the hour.

Code	Evaluation	Base fee	Pages included
ML-201	Comprehensive medical-legal evaluation	$2,015.00	200
ML-202	Follow-up evaluation within 18 months	$1,316.25	200 not previously reviewed
ML-203	Supplemental report	$650.00	50

Pages beyond the included count are reimbursed at $3.00 per page. A page is "an 8 1/2 by 11 single-sided document, chart or paper, whether in physical or electronic form," and "multiple condensed pages or documents displayed on a single page shall be charged as separate pages," so a four-up printout of progress notes counts as four pages.

The records must arrive with a declaration under penalty of perjury that the provider complied with Labor Code 4062.3, including "an attestation as to the total page count of the documents provided." The regulation is explicit: "A physician may not bill for review of documents that are not provided with this accompanying required declaration from the document provider." And the report itself must include verification under penalty of perjury of the total number of pages reviewed.

The billing consequence of the reconciliation described above is direct. If 412 pages arrived and the report verifies 412 pages, the evaluation bills at $2,015.00 plus 212 pages at $3.00, or $636.00. If the declaration says 412 and the report says 380, the physician is either under-billing or has misdescribed the review, and either way the number in the report is the one that controls.

The time it takes

Dr. Carpenter's Session 8 template includes a running account of time spent identifying, reviewing, and summarizing records, and his reason for tracking it is that Labor Code 4628(b) requires the report to disclose whether the evaluation and the time spent on it complied with the administrative director's guidelines. Time is no longer the billing unit for record review, but it remains part of the disclosure framework, and a physician who cannot say how long the review took will have trouble answering the deposition question about whether it was adequate.

The honest number for a careful chronological review of a 400-page comp file, with summaries, is measured in hours, not minutes. That is the origin of the late-report problem described elsewhere: the exam takes an hour, the records take an afternoon, and the 30-day clock does not distinguish between them.

The mistakes that reach depositions

A short list of failures that come up repeatedly.

Listing without summarizing. Compliant, unhelpful, and a signal to both attorneys that the file was not read closely.
Summarizing without listing. An opinion that cites a record the list omits looks like it came from an ex parte source.
Relying on records not served on the other side. The evaluator may not know, which is why the log matters.
Missing the pre-injury complaint. The apportionment opinion depends on the primary care note from 2019 that mentions back pain. It is on page 347 of a production that was sorted by provider. A chronological review would have put it in sequence with the injury.
Missing the incidental finding. A chest film read for rib fractures that also reports a pulmonary nodule. Under the AMA Guides the evaluator has a duty to tell the examinee and the requesting party.
Counting duplicates. The page count in the report should reflect pages reviewed, and reviewing the same MRI report three times is one review.
Treating the summary service's output as the review. The excerpts are the starting point under 4628(c). The physician's review of the excerpts and the outline, with follow-up where the excerpts raise questions, is the review.

Where AI-assisted record review fits

The interest in AI medical record review is real, and the 4628 framework is the right lens for it. The statute does not prohibit assistance with excerpting and outlining. It prohibits the physician from signing off on excerpts without reviewing them and the entire outline, and it makes the physician swear that the description is accurate.

That sets the standard for what useful output looks like. A summary that says "the applicant had prior back complaints" is worthless to a physician who has to defend the apportionment, because it cannot be checked. A chronology entry that says the applicant reported low back pain of two months' duration to a primary care physician on March 14, 2019, with a page citation to the production, is something the physician can open, read, and either adopt or reject. The first is a substitute for review. The second is a tool for it.

Lexamed produces the second kind. It reads the full production and builds a dated, page-cited chronology with the causation, prior injury, and treatment evidence flagged, and it reconciles what it read against the page count that came with the declaration. The physician reviews the chronology against the pages, judges what is pertinent, and writes the review of records section and the opinions that depend on it. The review is still the physician's. The afternoon of sorting is not.

Frequently asked questions

What is a medical record review in a QME report? The section of a California medical-legal report that lists every record the evaluator received and summarizes the records the evaluator relied on. Labor Code 4062.3 and 8 CCR 10682 require the listing; the summaries are what make the opinions that follow verifiable.

Who is allowed to review the records for a QME report? Under Labor Code 4628, only the signing physician may review and summarize prior medical records as part of preparing the report. If someone else excerpts the records, the physician must personally review the excerpts and the entire outline and make any additional inquiries needed, then declare under penalty of perjury that the information is accurately described.

How many pages of records are included in a QME evaluation fee? Under 8 CCR 9795, a comprehensive evaluation (ML-201, $2,015.00) includes review of 200 pages, a follow-up evaluation (ML-202, $1,316.25) includes 200 pages not previously reviewed, and a supplemental report (ML-203, $650.00) includes 50 pages.

How much does a QME get paid for record review beyond the included pages? $3.00 per page. A page is an 8 1/2 by 11 single-sided document, physical or electronic, and condensed pages printed several to a sheet count separately.

What declaration has to accompany records sent to a QME? A declaration under penalty of perjury that the provider complied with Labor Code 4062.3 before sending the records, with an attestation of the total page count. A physician may not bill for review of records that arrive without it.

What should a QME do if records are missing? Complete the report with the records available, state specifically which records are missing, and note that the opinions may change if they are provided. 8 CCR 38(h) does not allow the 30-day report deadline to be extended for missing records. Late records can be addressed in a supplemental report.

Should the review of records be organized by date or by provider? By date. A chronological review reconstructs the course of the injury, exposes gaps, and places pre-injury complaints in sequence with the industrial injury, which is what causation and apportionment opinions depend on.

Can a QME use an AI summary of the medical records? Labor Code 4628(c) allows others to excerpt or outline the records, provided the physician reviews the excerpts and the entire outline and makes additional inquiries as needed. A page-cited chronology the physician can verify against the production fits that framework. A summary that cannot be checked against the pages does not.