Review of Systems and ADL Assessment in a QME Evaluation: The Two Sections Most Reports Skimp On
Short answer: a review of systems is a structured set of questions, organ system by organ system, about symptoms the examinee has or has not experienced. It is subjective, it is separate from the physical examination, and in a medical-legal evaluation it does two jobs a clinical note never asks of it: it finds conditions outside the claim that the evaluator has a duty to report, and it finds issues outside the evaluator's specialty that trigger a referral to another panel. The activities of daily living assessment is different in kind. Under the AMA Guides 5th Edition, impairment is defined by its effect on ADLs, so the ADL section is not background. It is the evidence the rating stands on.
Both sections are routinely reduced to a line. "ROS negative except as above." "Patient reports difficulty with daily activities." A report that does that has a physical examination with nothing underneath it and a rating with nothing behind it.
Why these two sections matter more in a medical-legal report
A treating physician's review of systems screens for things that need treatment. A QME is not there to treat, and the AMA Guides say so directly: the evaluation is a medical assessment, not medical care, and the examinee should understand that. In the same passage the Guides add the obligation that makes the ROS matter: if new diagnoses are discovered during the evaluation, the physician is obliged to inform the examinee and the requesting party and recommend further assessment.
The ADL section has a different root. The Guides describe impairment percentages as estimates of the degree to which a condition interferes with activities of daily living. That is the whole concept. When an evaluator rates a lumbar condition at a given whole person impairment, the number is a claim about how much that condition limits what the person can do day to day. Without a documented ADL assessment, the claim has no support, and on cross-examination it has no answer.
Review of systems vs. physical examination
The two get confused, and the confusion shows up in reports where ROS findings are written as if they were examination findings.
The review of systems is what the examinee reports. It is subjective by definition: a history of symptoms, taken by asking. The physical examination is what the evaluator observes and measures. It is objective. A report that says "no neurological deficits" under review of systems has recorded the wrong thing. The ROS entry is "denies numbness, tingling, or weakness." The examination entry is the reflex, sensory, and motor findings.
The distinction matters legally because substantial medical evidence requires an adequate history and an adequate examination, and the parties will look for each separately.
A review of systems checklist for medical-legal evaluations
The list below is a standard ROS with the prompts that matter most in a workers' compensation context marked. It is written for a neuromusculoskeletal evaluation; a psychiatric or internal medicine QME will weight it differently.
| System | Ask about | Why it matters in a comp evaluation |
|---|---|---|
| Constitutional | Fatigue, fever, weight change, night sweats | Unexplained weight loss or night sweats with back pain is a red flag for a non-industrial process |
| Skin | Rashes, lesions, healing, scarring | Surgical scars are ratable; skin findings can point to systemic disease |
| Eyes, ears, nose, throat | Vision change, hearing loss, tinnitus, dizziness | Vestibular symptoms after head or neck injury; hearing claims need audiometry, not a checkbox |
| Cardiovascular | Chest pain, palpitations, edema, claudication | Leg pain on walking that resolves with rest is vascular, not radicular, and the distinction decides causation |
| Respiratory | Shortness of breath, cough, wheeze, exposures | Occupational exposure history belongs here as well as in the work history |
| Gastrointestinal | Bowel changes, incontinence, reflux, NSAID use | Bowel incontinence with spine complaints is an emergency finding and a referral trigger |
| Genitourinary | Urinary frequency, urgency, retention, incontinence, sexual dysfunction | Cauda equina signs; sexual dysfunction is an ADL category under the Guides and often goes unasked |
| Musculoskeletal | Pain, stiffness, swelling, instability in every region, not only the claimed one | Unclaimed body parts with symptoms may be in scope, or may need a written question to the parties |
| Neurological | Numbness, tingling, weakness, tremor, gait change, headache, memory | Tremor and gait change found here are how non-industrial neurological disease surfaces |
| Psychiatric | Mood, anxiety, sleep, concentration, irritability | Depression or anxiety attributed to the injury is a psychiatric issue outside a musculoskeletal evaluator's scope |
| Endocrine | Diabetes, thyroid symptoms, heat or cold intolerance | Diabetes is a documented pre-existing condition that may bear on neuropathy and apportionment |
| Hematologic and lymphatic | Easy bruising, bleeding, swollen nodes | Anticoagulation affects surgical recommendations |
| Allergic and immunologic | Allergies, autoimmune history | Inflammatory arthritis is a competing explanation for joint findings |
Record pertinent positives and pertinent negatives in the words used. "Denies bowel or bladder dysfunction" is a documented negative; a blank is not.
When the review of systems finds something: the duty to inform
Perry J. Carpenter, DC, QME describes an examinee whose symptoms he traced, during the review of systems and examination, to early Parkinson's disease rather than the industrial injury the examinee attributed them to. The condition was not industrial and was not what the evaluation was for. He reported it, the examinee was assessed under the claim for the symptoms, and the man was treated for a condition that mattered more to his life than the claim did.
That is the obligation the Guides describe, and it is why a perfunctory ROS is a professional failure as well as a reporting one.
The second consequence is procedural. Under 8 CCR §35.5(d), when a disputed issue is outside the evaluator's scope of practice, the evaluator must notify the parties in writing, no later than the report's service date, so they can obtain an evaluation in the right specialty, with a copy to the DWC Medical Director. The review of systems is where those issues surface: depression in a musculoskeletal case, urinary symptoms that need urology, a cardiac history behind exertional complaints. The written notice is not a courtesy. Without it, the Medical Director will not issue the additional panel and the case stalls.
Why activities of daily living decide the rating
Table 1-2 of the AMA Guides 5th Edition lists the activities of daily living commonly measured:
| Category | Examples in the Guides |
|---|---|
| Self-care, personal hygiene | Urinating, defecating, brushing teeth, combing hair, bathing, dressing, eating |
| Communication | Writing, typing, seeing, hearing, speaking |
| Physical activity | Standing, sitting, reclining, walking, climbing stairs |
| Sensory function | Hearing, seeing, tactile feeling, tasting, smelling |
| Nonspecialized hand activities | Grasping, lifting, tactile discrimination |
| Travel | Riding, driving, flying |
| Sexual function | Orgasm, ejaculation, lubrication, erection |
| Sleep | Restful, nocturnal sleep pattern |
Use these categories and not others. They are what the Guides rate against, and a rating that cites them is defensible in a way that an improvised list is not.
Three places the ADL evidence does specific work:
Impairment class. Many chapters of the Guides assign a class or a range based on how much a condition interferes with ADLs. The physical findings establish the diagnosis; the ADL findings place it within the range.
The pain add-on. Chapter 18 allows up to 3 percent whole person impairment for pain where pain-related limitation increases the burden of the condition beyond what the conventional rating captures. The basis for that add-on is ADL interference, and the QME exam tests whether candidates apply it correctly.
Rebuttal ratings. Under Almaraz/Guzman, an evaluator may depart from the obvious chapter to a method within the four corners of the Guides that more accurately reflects the impairment. The argument that another method is more accurate is almost always an argument about ADL impact, and it needs documented ADL findings to make it.
California's own Physician's Guide barely mentions ADLs, so an evaluator working from the state documents alone will under-document them. The Guides are built on them. That mismatch is why so many California reports have thin ADL sections.
An ADL assessment framework for the face-to-face evaluation
The workable method is a structured questionnaire completed by the examinee before the encounter, then walked through with them in the room. For each Table 1-2 category:
- Ask about the specific activities, not the category. "Can you put on socks and shoes without help?" gets an answer. "Any problems with self-care?" gets a shrug.
- Establish the baseline. What could they do before the injury? An examinee who never climbed stairs because of a prior knee has a different starting point, and that difference is apportionment evidence.
- Grade the limitation. Able without difficulty, able with difficulty, able with assistance or modification, unable. Record frequency and duration where it matters: how long they can sit, how far they can walk, how many hours they sleep and how often they wake.
- Attribute. Which limitations does the examinee attribute to the industrial injury, and which to something else? Their attribution is not the evaluator's conclusion, but it is part of the history.
- Check against the record. Physical therapy intake forms, functional capacity evaluations, disability questionnaires, and treating notes all contain earlier ADL statements. Where today's account differs from an account given eighteen months ago, note both. Consistency across time supports the rating; unexplained drift undermines it.
The questionnaire itself goes in the sources of information. The findings go in a dedicated ADL section, placed after the report of symptoms and before the physical examination, so the reader moves from what the examinee reports, to how it affects function, to what the examination shows.
How the two sections read in the finished report
The test for both is whether the rating section can point back to them.
Every impairment rated should trace to a diagnosis, to examination findings, and to specific ADL limitations. A 5 percent whole person impairment for a lumbar condition should be able to say: these findings on examination, this diagnosis, and these documented limitations in physical activity, sleep, and travel. When the pain add-on is applied, the report should identify which ADLs the pain burdens beyond the base rating.
Where the ROS turned up something outside the claim, the report should record it, state whether it bears on the industrial condition, and document the notice sent to the parties if it was outside the evaluator's scope.
The common failures are recognizable:
- A one-line ROS with no pertinent negatives, so the absence of red flags is unproven
- An ADL section that restates the complaints instead of describing function
- No pre-injury baseline, so nothing can be apportioned and nothing can be compared
- An ADL questionnaire attached but never reconciled with the narrative, so the two disagree
- Ratings that cite the examination but never the ADL findings, leaving the class assignment unexplained
Each of these is a line of deposition questioning waiting to happen.
Where the baseline comes from
The ADL assessment in the room captures today. The baseline, and the trajectory, are in the records: the first physical therapy intake with its function questionnaire, the pre-injury primary care note mentioning the bad knee, the functional capacity evaluation from a year ago, the deposition where the examinee described their day. Those are what make an ADL section evidence rather than a transcript.
Lexamed reads the full production and returns a dated, page-cited chronology with the functional statements and prior complaints flagged, so when the report says the examinee could climb stairs without difficulty before the injury and reported difficulty by the third month after it, both statements point to the pages they came from.
Frequently asked questions
What is a review of systems? A structured inquiry, organ system by organ system, into symptoms the patient has or has not experienced. It is part of the history, taken by asking, and is distinct from the physical examination.
What is the difference between a review of systems and a physical exam? The review of systems records what the examinee reports and is subjective. The physical examination records what the evaluator observes and measures and is objective. Findings from one should not be written under the other.
Is the review of systems subjective or objective? Subjective. It documents the examinee's reported symptoms. Objective findings belong in the physical examination section.
Why does a QME need a thorough review of systems? The AMA Guides oblige the evaluator to inform the examinee and the requesting party of any new condition found during the evaluation and to recommend assessment. The review of systems is also where issues outside the evaluator's specialty surface, which under 8 CCR §35.5(d) require written notice to the parties so another panel can be obtained.
What are activities of daily living under the AMA Guides? Table 1-2 of the 5th Edition lists eight categories: self-care and personal hygiene, communication, physical activity, sensory function, nonspecialized hand activities, travel, sexual function, and sleep. Impairment percentages estimate how much a condition interferes with these activities.
Why does the ADL assessment affect the impairment rating? The Guides define impairment by its effect on activities of daily living. ADL findings place a condition within its impairment class, support the Chapter 18 pain add-on of up to 3 percent, and supply the evidence for any rating by analogy or rebuttal under Almaraz/Guzman.
What should a QME do if the review of systems reveals a condition outside their specialty? Record it, state whether it bears on the industrial condition, and notify the parties in writing no later than the report's service date, with a copy to the DWC Medical Director, so an evaluation in the appropriate specialty can be obtained.