What Goes in a California QME Report: Every Required Element, in Order
Short answer: a California medical-legal report has to contain the elements listed in 8 CCR §10682 and laid out in Chapter 12 of the DWC's 2016 Physician's Guide: identifying information, an opening statement, sources of information, history of the injury, current complaints, a history section with social history, review of systems and relevant medical history, the physical examination, diagnosis, causation, permanent and stationary status, impairment, apportionment, treatment to date, future treatment, reasons for opinion, and the mandatory disclosures and declaration. Because California rates impairment under the AMA Guides 5th Edition, a good report also carries the sections the Guides expect: activities of daily living, diagnostic study results, the rating criteria, and the rating calculation.
That is the list. The rest of this piece explains where it comes from, why the two sources do not quite line up, and how experienced evaluators combine them into one template. It draws on Session 2 of Perry J. Carpenter, DC, QME's 16-hour report writing course, which spends about two hours on exactly this question.
Why there are three references instead of one
New QMEs expect a single official template. There is not one. What exists is three documents that each say something about what a medical-legal report should contain, written for different purposes.
8 CCR §10682 is the regulation. It lists the contents a medical-legal report must have to be considered by the Appeals Board. It was numbered §10606 for years and was renumbered in the 2020 rules overhaul, so older guides and templates still cite the old number.
The 2016 Physician's Guide is the DWC's own handbook for physicians in the comp system. Chapter 12 covers writing the medical-legal report, and Table 12-1 turns the regulation into a list of headings a rater can work through.
The AMA Guides to the Evaluation of Permanent Impairment, 5th Edition is not a California document and has nothing to say about workers' compensation. It is the book California adopted in 2005 for rating impairment on injuries after January 1 of that year, and it has its own opinion, in Chapter 2, about what a permanent impairment report should contain.
The mismatch has a history. When the AMA Guides came in with the 2004 reforms, the Physician's Guide in circulation was the 2001 edition, written around the 1997 rating schedule. The report regulation at the time was written for that schedule too. For about a decade, physicians rated under one system using a report structure designed for another. The 2016 Physician's Guide and the current regulation closed most of that gap, but the AMA Guides still ask for things the California documents never mention.
The elements the Physician's Guide requires
Table 12-1 of the Physician's Guide gives the headings in order. Each one has a job.
- Identifying information. Who the examinee is, the claim number, the date of injury, the employer, the parties, and the date and street address of the examination. The address matters more than it looks; more on that below.
- Opening statement. What kind of evaluation this is, who requested it, and what issues it addresses. This is where you set the scope for the reader.
- Sources of information. Everything you relied on: the records you received, the cover letters, the questionnaires, the studies, the interview.
- History of present illness or injury. How the injury happened, in the examinee's account and in the records.
- Present complaints. The current symptoms the examinee attributes to the injury.
- History. Three subsections at minimum: social history, review of systems, and relevant medical history. The relevant medical history is where prior injuries to the same body parts get documented, which feeds directly into apportionment.
- Physical examination.
- Diagnosis.
- Causation. Whether the injury arose out of and in the course of employment.
- Permanent and stationary status.
- Factors of disability, which for injuries after January 1, 2005 means permanent impairment under the AMA Guides.
- Apportionment.
- Medical treatment to date.
- Further or future medical treatment.
- Reasons for opinion. The how and why behind every conclusion. This section is what turns an opinion into substantial medical evidence, which gets its own post.
- Disclosures and declarations. The signature, the disclosure of financial interest, the penalty-of-perjury declaration under Labor Code §4628(j), the date the report was served, and the county it was signed in.
The Guide's stated goal for this structure is a report that is ratable the first time through. A report that forces one of the parties to request a supplemental report to clarify an omission has already failed, and the supplemental costs them money.
What the AMA Guides add
Chapter 2 of the Guides describes a leaner report: a narrative history with an optional work history, current clinical status (chief complaint, review of systems, physical examination), diagnostic study results, maximum medical improvement, diagnoses and the impairments that go with them, the impairment rating criteria, the rating itself, and the calculation.
Most of that overlaps the Physician's Guide. Three things do not, and they are worth building into a California template even though no California regulation requires them.
Activities of daily living. The Physician's Guide only mentions ADLs to the extent pain interferes with them. The AMA Guides are built on ADLs. The entire concept of impairment in the 5th Edition is the effect of a condition on a person's ability to perform activities of daily living. An evaluator who does not document ADLs in a structured way has a rating with no foundation under the very book the rating comes from.
A real review of systems. The Guides say the physician has a duty to tell the examinee and the requesting party about any new condition found during the evaluation and to recommend further assessment. Dr. Carpenter's example from his own practice is an examinee whose symptoms he traced to early Parkinson's disease rather than the industrial injury. The evaluation was not for that, and the condition was not industrial, but a review of systems caught it and the examinee got treatment. Many evaluators skip this section or reduce it to a line. A system-by-system checklist for the medical-legal setting is in a separate post.
Diagnoses that match the impairments. The Guides want the diagnosis list and the impairment list to correspond. Reports that list a diagnosis and then rate something unrelated, or rate an impairment with no diagnosis behind it, read as internally inconsistent, and inconsistency is what opposing counsel looks for.
The hybrid template experienced evaluators use
Put the two lists together, drop the duplication, and you get a structure that covers every date of injury and satisfies both references. In the order Dr. Carpenter teaches it:
| Section | Source |
|---|---|
| Identifying information | Physician's Guide |
| Opening statement | Physician's Guide |
| Sources of information | Physician's Guide |
| History of the present injury | Both |
| Relevant medical history | Physician's Guide |
| Review of records | Physician's Guide, LC §4628 |
| Occupational history | AMA Guides (work history) |
| Review of systems | Both |
| Claimant's report of symptoms | Both (present complaints / chief complaint) |
| Activities of daily living and symptom questionnaires | AMA Guides |
| Physical examination | Both |
| Diagnostic studies | AMA Guides |
| Medical research, if any | Practice |
| Diagnosis | Both |
| Causation (AOE/COE) | Physician's Guide |
| Permanent and stationary / MMI status | Both, combined |
| Permanent impairment (or factors of disability, pre-2005) | Both |
| Impairment rating calculation and method | AMA Guides |
| Causation and apportionment of the impairment | Physician's Guide |
| Further or future medical care | Physician's Guide |
| Work status and restrictions | Physician's Guide |
| Disclosures and declarations | LC §4628, 8 CCR §35.5 |
Two details in that table are deliberate.
The work history is split out from the history of the injury, even though the AMA Guides fold them together, because occupational exposure and the mechanism of a specific injury are different questions in a comp case and get argued separately.
Causation appears twice on purpose. The first causation section answers whether there was a compensable injury at all. The second, after the impairment rating, answers what caused the impairment, which is the apportionment analysis under Labor Code §§4663 and 4664. In an admitted claim the first section is short. The second is where the money is.
Two rules that shape the identifying information
The date and street address of the examination look like boilerplate. They are not.
8 CCR §35.5(b) requires the report to state in the body the date the examination was completed and the street address where it was performed, and Labor Code §4628(b) repeats the requirement. Separately, DWC regulations require the initial evaluation to take place at the office listed on the panel. Moving an examinee to a satellite office for the first visit, even one down the street, is a discipline issue, and stating an address you did not actually use is worse. If the panel office cannot accommodate the appointment, the evaluation has to be rescheduled, not relocated.
The second rule is the signature date. If you sign the report on a date other than the examination date, §35.5(b) requires the signing date to appear next to the signature. Small, easy to miss, and a defect opposing counsel can point at.
The deadline, and the deadline that matters
By regulation, a QME has 30 days from the face-to-face evaluation to serve the report. Past that it is overdue, and the parties can object to it.
Dr. Carpenter's advice is to treat 30 days as the failure point rather than the target and aim for 14. His reasoning is simple: on the other end of the report is an injured worker whose benefits may be waiting on it. High-volume evaluators who get reports out in two weeks also get more panels, because attorneys on both sides notice.
The section that eats the calendar is the review of records. Comp files run to hundreds or thousands of pages, and Labor Code §4628(c) says that if someone other than the physician excerpts them, the physician still has to review the excerpts and make whatever further inquiry is needed to identify the relevant issues. The report deadline does not move because the file was thick.
That is the step Lexamed is built for. It reads the full production and produces a dated, page-cited chronology with the causation and MMI evidence flagged, so the review of records section is drafted from the actual pages, the physician's review is real rather than nominal, and the 30-day clock stops being the constraint.
Frequently asked questions
What regulation lists the required contents of a California medical-legal report? 8 CCR §10682, formerly numbered §10606. The DWC's 2016 Physician's Guide, Chapter 12, Table 12-1, translates it into a list of report headings.
Does a QME report have to follow the AMA Guides report format? No California regulation requires the AMA Guides format. Because impairment for post-2005 injuries is rated under the Guides 5th Edition, experienced evaluators add the sections the Guides expect, particularly activities of daily living, diagnostic study results, and the rating calculation, so the rating has a documented foundation.
What is the difference between permanent and stationary and maximum medical improvement? Permanent and stationary is the California workers' compensation term for a condition that has stabilized and is not expected to change substantially with or without treatment. Maximum medical improvement is the AMA Guides' term for essentially the same point. California reports typically address both in one section.
Why does the report state the examination address? 8 CCR §35.5(b) and Labor Code §4628(b) both require it. The initial QME evaluation must take place at the office listed on the panel, and the stated address is how the DWC verifies that.
How long does a QME have to write the report? 30 days from the face-to-face evaluation under DWC regulations. Many experienced evaluators set an internal target of 14 days.
Can someone else review the medical records for a QME? Labor Code §4628(c) permits another person to outline the history or excerpt the records, but the physician must review the excerpts and the entire outline and make additional inquiries as needed. The physician remains responsible for the review.
Where should activities of daily living appear in a QME report? In a dedicated section after the report of symptoms and before the physical examination, typically supported by a structured ADL questionnaire. The AMA Guides define impairment in terms of ADL impact, so the rating depends on it.