{ "source_packet_sha256": "dd1176ffc4278ca2236d935f4326b7b4a9314c1ca03265fd37eba7ca3a232713", "documents": [ { "key": "original", "label": "Original chronology wording", "word_url": "/evaluation/generated/original-chronology.docx", "word_sha256": "b8853cec6d7c43898fcff818321f6a33ddd730bb8e1ec42aedd2ac26179de276", "pdf_url": "/evaluation/previews/original.pdf", "pdf_sha256": "77e3e02b2eb644aac912935266106bcfb2f9b0033c25ce266d26f9d31b22dfc0", "pages": [ { "src": "/evaluation/previews/original-1.webp", "width": 1160, "height": 1501, "page": 1, "text": "Fictional chronology example\nAlex Testcase. Historical generated wording from October 20, 2026, rendered with the \ncurrent application Word renderer. Before the demonstrated edit. This is not a completed \nphysician review or a report approved for service.\nThe records submitted for review are summarized below in chronological sequence.\nTypes of encounter: M=Medical visit, N=Non-operative procedure, R=Report or letter, \nX=Imaging study, *=Other\n02/01/2024 \u2014 R. Nguyen, M.D. \u2014 Sunrise Spine & Pain Clinic \u2014 [*] \u00b7 low back, left \nleg: The 03/12/2024 progress note records a reported lifting incident at work on \n02/01/2024 [3]. The chief complaint was low back pain radiating to the left leg after that \nincident [3]. (Bates LEX000101)\n03/12/2024 \u2014 R. Nguyen, M.D. \u2014 Sunrise Spine & Pain Clinic \u2014 [M] \u00b7 low back, left \nleg: At the 03/12/2024 visit, the patient reported persistent lumbar pain rated 7/10, worse \nwith prolonged standing, and denied prior back injury [3]. Lumbar spine MRI was \nordered, and the plan was to continue NSAIDs [3]. Modified duty was directed with no \nlifting over 10 pounds [3]. (Bates LEX000101)\n03/28/2024 \u2014 S. Patel, M.D. \u2014 Bayview Imaging Center \u2014 [X] \u00b7 lumbar spine, left \nlower extremity: MRI of the lumbar spine without contrast documented a clinical history \nof low back pain with left lower extremity radiculopathy. [4] Findings included an L4-L5 \ndisc protrusion contacting the left L5 nerve root and mild degenerative disc disease at L5-\nS1. [4] The impression was left paracentral disc protrusion at L4-L5 and mild lumbar \nspondylosis. [4] (Bates LEX000102)\n05/06/2024 \u2014 R. Nguyen, M.D. \u2014 Sunrise Spine & Pain Clinic \u2014 [N] \u00b7 L4-L5, left L5: \nR. Nguyen, M.D., performed a LEFT L4-L5 transforaminal epidural steroid injection on \n05/06/2024 [5]. The documented indication was L4-L5 disc protrusion with left L5 \nradiculopathy and failed conservative management [5]. The patient tolerated the \nprocedure well without complications, and post-procedure pain decreased from 7/10 to \n3/10 [5]. (Bates LEX000103; Bates LEX000104)\n06/10/2024 \u2014 [M]: The June 10, 2024 progress note documents follow-up after an \nepidural injection [2]. The note reports inability to walk more than two blocks before \npain, difficulty sleeping with nighttime waking, and driving limited to 20 minutes [2]. \nDressing is performed without difficulty, and modified duty continues with no lifting \nover 10 pounds [2]. (p. 2)", "sha256": "c3ac93b3799bd36e836164b56cdf392cb5a9d18e22373d588b04fce41b14fa4e" }, { "src": "/evaluation/previews/original-2.webp", "width": 1160, "height": 1501, "page": 2, "text": "06/10/2024 \u2014 R. Nguyen, M.D. \u2014 Sunrise Spine & Pain Clinic \u2014 [M]: At the June 10, \n2024 follow-up, the patient reported approximately 50% relief following the May 6, 2024 \nepidural steroid injection, with pain now 4/10. [6] Modified duty was continued, with re-\nevaluation in 6 weeks. [6] (Bates LEX000104)\nUndated Records\n[R] \u00b7 lumbar spine: Correspondence from Law Offices of North Shore Defense asks \nwhether medical findings are consistent with a February 1, 2024 lifting incident [1]. It \nalso asks whether a referenced March 28, 2024 MRI supports left L5 contact and whether \nthe records document prior lumbar injury; these are questions posed by the \ncorrespondence, not independent clinical findings [1]. (p. 1)\nThis concludes the review of the submitted records.", "sha256": "dea8f5d2ba948a208c26e42fdeb704c1afef2a13df4be1e1a100723726ad5313" } ] }, { "key": "after", "label": "Chronology after the edit", "word_url": "/evaluation/generated/after-edit-chronology.docx", "word_sha256": "735f8c1247af2adb6b3bb64090ab5fd9d65178b809289f351b910b5f2bf8e673", "pdf_url": "/evaluation/previews/after.pdf", "pdf_sha256": "ac56160cadad3f8305f2dab5feced33965d0b8ffb6fa0f1cf5b395f1ff7af986", "pages": [ { "src": "/evaluation/previews/after-1.webp", "width": 1160, "height": 1501, "page": 1, "text": "Fictional chronology example\nAlex Testcase. Historical generated wording from October 20, 2026, rendered with the \ncurrent application Word renderer. After the documented meaning-preserving reviewer \nwording edit. This is not a completed physician review or a report approved for service.\nThe records submitted for review are summarized below in chronological sequence.\nTypes of encounter: M=Medical visit, N=Non-operative procedure, R=Report or letter, \nX=Imaging study, *=Other\n02/01/2024 \u2014 R. Nguyen, M.D. \u2014 Sunrise Spine & Pain Clinic \u2014 [*] \u00b7 low back, left \nleg: The 03/12/2024 progress note records a reported lifting incident at work on \n02/01/2024 [3]. The chief complaint was low back pain radiating to the left leg after that \nincident [3]. (Bates LEX000101)\n03/12/2024 \u2014 R. Nguyen, M.D. \u2014 Sunrise Spine & Pain Clinic \u2014 [M] \u00b7 low back, left \nleg: At the 03/12/2024 visit, the patient reported persistent lumbar pain rated 7/10, worse \nwith prolonged standing, and denied prior back injury [3]. Lumbar spine MRI was \nordered, and the plan was to continue NSAIDs [3]. Modified duty was directed with no \nlifting over 10 pounds [3]. (Bates LEX000101)\n03/28/2024 \u2014 S. Patel, M.D. \u2014 Bayview Imaging Center \u2014 [X] \u00b7 lumbar spine, left \nlower extremity: MRI of the lumbar spine without contrast documented a clinical history \nof low back pain with left lower extremity radiculopathy. [4] Findings included an L4-L5 \ndisc protrusion contacting the left L5 nerve root and mild degenerative disc disease at L5-\nS1. [4] The impression was left paracentral disc protrusion at L4-L5 and mild lumbar \nspondylosis. [4] (Bates LEX000102)\n05/06/2024 \u2014 R. Nguyen, M.D. \u2014 Sunrise Spine & Pain Clinic \u2014 [N] \u00b7 L4-L5, left L5: \nR. Nguyen, M.D., performed a LEFT L4-L5 transforaminal epidural steroid injection on \n05/06/2024 [5]. The documented indication was L4-L5 disc protrusion with left L5 \nradiculopathy and failed conservative management [5]. The patient tolerated the \nprocedure well without complications, and post-procedure pain decreased from 7/10 to \n3/10 [5]. (Bates LEX000103; Bates LEX000104)\n06/10/2024 \u2014 [M]: The June 10, 2024 progress note documents follow-up after an \nepidural injection [2]. The note reports inability to walk more than two blocks before \npain, difficulty sleeping with nighttime waking, and driving limited to 20 minutes [2]. \nDressing is performed without difficulty, and modified duty continues with no lifting \nover 10 pounds [2]. (p. 2)", "sha256": "b44111ff35d13d3adf7f856d7a90faa891df9330442ea376025a3abfe389ca28" }, { "src": "/evaluation/previews/after-2.webp", "width": 1160, "height": 1501, "page": 2, "text": "06/10/2024 \u2014 R. Nguyen, M.D. \u2014 Sunrise Spine & Pain Clinic \u2014 [M]: Reported \napproximately 50% relief after the May 6, 2024 epidural steroid injection; pain 4/10. \nContinued modified duty with re-evaluation in 6 weeks. [6] (Bates LEX000104)\nUndated Records\n[R] \u00b7 lumbar spine: Correspondence from Law Offices of North Shore Defense asks \nwhether medical findings are consistent with a February 1, 2024 lifting incident [1]. It \nalso asks whether a referenced March 28, 2024 MRI supports left L5 contact and whether \nthe records document prior lumbar injury; these are questions posed by the \ncorrespondence, not independent clinical findings [1]. (p. 1)\nThis concludes the review of the submitted records.", "sha256": "648a717f3c23f06d78a7971c6c7dc070a31ceefd2678e80856e58a7d9eb827b2" } ] }, { "key": "report", "label": "Historical unreviewed report draft", "word_url": "/evaluation/generated/report-draft.docx", "word_sha256": "837fe5fb959f7736428328628e2bed99704f70dc44cbc732c9aaba283a57fce7", "pdf_url": "/evaluation/previews/report.pdf", "pdf_sha256": "1da5f3b04b012b27224a08aeee23ef9ed69018d3beda41c22775bd8f1dcef66f", "pages": [ { "src": "/evaluation/previews/report-1.webp", "width": 1160, "height": 1501, "page": 1, "text": "Re: Alex Testcase Claim No.: SYN-2024-001\n1\n[DRAFT assembled by Lexamed \u2014 not for service. Statutory deadline not yet running; \nreport due date on file ____________. Complete every evaluator section, verify the \ndrafted narratives against the cited pages, then delete this line.]\n[Print on the evaluator's letterhead.]\nDate of report:____________\n[Addressee \u2014 the DWC Disability Evaluation Unit or the requesting party, with \naddress.]\nRe: Alex Testcase\nSSN: ____________\nD/I: ____________\nC/N: SYN-2024-001\nWCAB: ____________\nEmployer: ____________\nD/Exam: ____________\nD/Dict:____________\nBody parts at issue: ____________\nReferring parties: ____________\nQualified Medical Evaluation \u2014 \n____________ (specialty)\nThe above-captioned applicant was seen in this office on ____________ for a medical-\nlegal evaluation, with the undersigned acting in the capacity of a Qualified Medical \nExaminer.\n[If an interpreter assisted the evaluation, state so here with the interpreter's name, \nlanguage, and certificate number; if none was used, say so.]", "sha256": "e1dfff41d4b233a0d2c8ac4e8f89d92fa67aa6d78f9100585072e9eda53c0a2a" }, { "src": "/evaluation/previews/report-2.webp", "width": 1160, "height": 1501, "page": 2, "text": "Re: Alex Testcase Claim No.: SYN-2024-001\n2\nExamination Metrics and Disclosures\n[To be completed by the evaluator. 8 CCR \u00a7 35.5(b) requires the report to state the date \nthe examination was completed and the street address where it was performed.]\n\uf0b7 [Street address where the examination was performed: ____________]\n\uf0b7 [Date the examination was completed: ____________]\n\uf0b7 [Examination start time ________ / end time ________]\n\uf0b7 [Face-to-face time (excludes records review, research, and report writing \u2014 8 CCR \u00a7 \n49(b)): ________ minutes. Minimums for an uncomplicated evaluation: \nneuromusculoskeletal 20 min (8 CCR \u00a7 49.2); cardiovascular 30 min (8 CCR \u00a7 49.4); \npulmonary 30 min (8 CCR \u00a7 49.6); psychiatric 60 min (8 CCR \u00a7 49.8); other 30 min \n(8 CCR \u00a7 49.9). Below the minimum, the report must explain the variance (8 CCR \u00a7 \n49(a)).]\n\uf0b7 [Interpreter: name, language, and certificate number, or state that none was used.]\n\uf0b7 [Others present during the examination, and in what capacity.]\n\uf0b7 [Whether audio or video recording was requested, and the ruling.]\n\uf0b7 [The 8 CCR \u00a7 40 disclosures given to the injured worker before the examination: the \nright to ask questions about the evaluation process, the right to discontinue for good \ncause, and probationary status where disclosure is required.]\nTime Spent and Who Performed the Work\n[To be completed by the evaluator. Labor Code \u00a7 4628 requires this by name and by \ntask; the declaration at the end of the report incorporates it.]\n\uf0b7 [Time face to face with the injured worker: ________]\n\uf0b7 [Time in records review: ________]\n\uf0b7 [Time preparing the report: ________]\n\uf0b7 [Every person other than the evaluator who performed any service in connection with \nthis report \u2014 including diagnostic studies but excluding clerical preparation \u2014 with \ntheir name and qualifications and what they did.]\nIssues Presented\n3 questions were put to the evaluator by the parties. 8 CCR \u00a7 35.5(c) requires the \nreport to attempt to address each one.\n[Transcribed from the cover letters \u2014 verify each against the cited pages, and answer it \nbelow. Where the parties' questions rest on conflicting legal theories, state the opinion in \nthe alternative rather than choosing between the theories.]", "sha256": "8059f7ee160196a3f7354eac0a7d4d0f58136252a914d678335f659da94c8c81" }, { "src": "/evaluation/previews/report-3.webp", "width": 1160, "height": 1501, "page": 3, "text": "Re: Alex Testcase Claim No.: SYN-2024-001\n3\n1. Are the medical findings consistent with the February 1, 2024 lifting incident? (p. \n1; Law Offices of North Shore Defense)\n[Answer.]\n2. Please comment on whether the March 28, 2024 MRI supports left L5 contact. (p. \n1; Law Offices of North Shore Defense)\n[Answer.]\n3. State whether the records document any prior lumbar injury. (p. 1; Law Offices of \nNorth Shore Defense)\n[Answer.]\nOccupational History\n[To be completed by the evaluator. State the employer, job title, dates of employment, \nphysical demands of the job, and whether there was concurrent employment.]\nHistory of Injury\nAI-DRAFTED NARRATIVE \u2014 summarizes the records; verify every statement \nagainst the cited pages, then edit or replace before signing. Nothing here is an \nevaluator conclusion.\nDr. R. Nguyen\u2019s March 12, 2024 progress note recorded the claimant\u2019s history of low \nback pain radiating to the left leg after a lifting incident at work on February 1, 2024 (p. \n3). At the March 12 visit, the claimant reported persistent lumbar pain rated 7/10, \nworsened by prolonged standing, and denied prior back injury (p. 3). Dr. Nguyen ordered \na lumbar spine MRI, continued NSAIDs, and prescribed modified duty with no lifting \nover 10 pounds (p. 3).\nA lumbar MRI without contrast was performed on March 28, 2024 for low back pain \nwith left lower extremity radiculopathy (p. 4). The report documented an L4-L5 disc \nprotrusion contacting the left L5 nerve root and mild degenerative disc disease at L5-S1; \nthe impression was a left paracentral L4-L5 disc protrusion and mild lumbar spondylosis \n(p. 4). On May 6, 2024, a left L4-L5 transforaminal epidural steroid injection was \nperformed, with the procedure note identifying L4-L5 disc protrusion with left L5 \nradiculopathy and failed conservative management as the indication (p. 5). The note \ndocumented that the claimant tolerated the procedure well without complications and that \npain decreased from 7/10 to 3/10 post-procedure (p. 5).", "sha256": "9d0bf80a620b40b857b3dc8669afa85e8a949c22668b4ddfd045b30df013f281" }, { "src": "/evaluation/previews/report-4.webp", "width": 1160, "height": 1501, "page": 4, "text": "Re: Alex Testcase Claim No.: SYN-2024-001\n4\nAt the June 10, 2024 follow-up, Dr. Nguyen recorded the claimant\u2019s report of \napproximately 50% relief following the May 6 injection, with pain rated 4/10 (p. 6). The \nJune 10 record also described inability to walk more than two blocks before pain, \ndifficulty sleeping with nighttime waking, dressing without difficulty, and driving limited \nto 20 minutes (p. 2). Modified duty continued with no lifting over 10 pounds (p. 2). Dr. \nNguyen planned reevaluation in six weeks (p. 6).\nMechanism of Injury \u2014 Accounts in the Record\n1 account of how the injury occurred appears in the records, listed in date order.\n[Compiled from the records \u2014 verify each quote against the cited pages. Whether the \naccounts are consistent, and what the mechanism means for causation, are the \nevaluator's determinations.]\n03/12/2024 \u2014 as recorded by a provider: \u201cLow back pain radiating to left leg after \nlifting incident at work on 02/01/2024.\u201d (Bates LEX000101)\nPast Medical History / Prior Injuries\n[No date of injury is recorded on this case, so records before it cannot be identified. \nEnter the date of injury, or summarize the prior history here.]\nHistorical mentions in later or undated records\nThese source passages require physician review. A historical mention does not establish \nthat the original record was received, and a later degenerative finding does not establish \npre-injury onset.\nTiming needs review; source dated unknown: State whether the records document any \nprior lumbar injury. (p. 1)\nHistory denied in source; source dated 2024-03-12: Denies prior back injury. (p. 3)\nTiming needs review; source dated 2024-03-28: Mild degenerative disc disease at L5-S1. \n(p. 4)\nTiming needs review; source dated 2024-03-28: Mild lumbar spondylosis. (p. 4)\nActivities of Daily Living \u2014 Documented in the Records\n4 statements about daily function appear in the records, by category.\n[Compiled from the records \u2014 verify each against the cited pages. Whether a limitation \nfollows from the industrial injury, and what it rates, are the evaluator's determinations.]", "sha256": "7d12318f3bfef65e4557768e371af036434d20fe284bd4f827d471c6b5374622" }, { "src": "/evaluation/previews/report-5.webp", "width": 1160, "height": 1501, "page": 5, "text": "Re: Alex Testcase Claim No.: SYN-2024-001\n5\nSelf-care and personal hygiene: 1 statement cannot be placed before or after the injury. \nCheck the observation dates, the case's injury date, and the cited pages.\nCommunication: No ability level summarized; review the source statements below.\nPhysical activity: 1 statement cannot be placed before or after the injury. Check the \nobservation dates, the case's injury date, and the cited pages.\nSensory function: No ability level summarized; review the source statements below.\nNonspecialized hand activities: No ability level summarized; review the source \nstatements below.\nTravel: 1 statement cannot be placed before or after the injury. Check the observation \ndates, the case's injury date, and the cited pages.\nSexual function: No ability level summarized; review the source statements below.\nSleep: 1 statement cannot be placed before or after the injury. Check the observation \ndates, the case's injury date, and the cited pages.\n[Statements were found but their timing relative to the injury is unresolved, for: Self-care \nand personal hygiene; Physical activity; Travel; Sleep. Check the observation dates and \nthe case's injury date. The records may establish a baseline in these categories \u2014 read \nthe cited pages before treating one as missing.]\nStatements relied on:\n06/10/2024 \u2014 Physical activity (at this date): \u201cHe is unable to walk more than two \nblocks before the pain.\u201d (p. 2)\n06/10/2024 \u2014 Sleep (at this date): \u201cShe sleeps with difficulty and wakes at night.\u201d (p. \n2)\n06/10/2024 \u2014 Self-care and personal hygiene (at this date): \u201cHe dresses himself \nwithout difficulty.\u201d (p. 2)\n06/10/2024 \u2014 Travel (at this date): \u201cDriving is limited to 20 minutes.\u201d (p. 2)\nPrevious and Subsequent Injuries\n[To be completed by the evaluator. Record prior and subsequent injuries and claims as \nreported by the applicant, including those to body parts not at issue \u2014 this is the factual \nbasis for any apportionment.]", "sha256": "d6be0c1fc8af24d9e0b4936fa2e362d6b7e10469a9e7587bf23e5791f49d1026" }, { "src": "/evaluation/previews/report-6.webp", "width": 1160, "height": 1501, "page": 6, "text": "Re: Alex Testcase Claim No.: SYN-2024-001\n6\nPersonal and Social History\n[To be completed by the evaluator. Record living situation, tobacco and alcohol use, \ncurrent medications, and allergies.]\nPresent Complaints\n[To be completed by the evaluator. Record the applicant's current symptoms as reported \nat evaluation, by body part, with what aggravates and relieves them.]\nActivities of Daily Living\n[To be completed by the evaluator. AMA Guides 5th ed. rates impairment by its effect on \nactivities of daily living, so the rating is only as good as this section. Record the \napplicant's limitation in each activity, before and after the injury, and whether the \nlimitation follows from the injury, a compensable consequence, medication side effects, \nor pain.]\n\uf0b7 [Self-care and personal hygiene; eating; dressing; grooming.]\n\uf0b7 [Communication, hearing, and vision.]\n\uf0b7 [Standing, sitting, walking, climbing, lifting, grasping, and other physical activity.]\n\uf0b7 [Sleep, travel, driving, household work, and shopping.]\n\uf0b7 [Sexual function.]\n\uf0b7 [Social and recreational activity.]\n\uf0b7 [A 0% impairment is available only where there is no limitation of activities of daily \nliving and no loss of function in personal, social, or occupational life \u2014 state the \nbasis if you reach it (AMA Guides 5th ed., p. 5).]\nPhysical Examination\n[To be completed by the evaluator. Document the examination performed and objective \nfindings: vital signs, general appearance and gait, then by region. Note any non-organic \nfindings. Health & Safety Code \u00a7 1254.7 requires pain to be assessed as the fifth vital \nsign.]\n\uf0b7 [By region: inspection, palpation, range of motion, motor, sensory, reflexes, and \nmeasurements.]", "sha256": "300220aea29ab1e2cf1e09ff373ddaebd0e98c007e5e892b0867d464289ca793" }, { "src": "/evaluation/previews/report-7.webp", "width": 1160, "height": 1501, "page": 7, "text": "Re: Alex Testcase Claim No.: SYN-2024-001\n7\nDiagnostic Studies\n[To be completed by the evaluator. Report studies taken in this office \u2014 date, who \nperformed them and under what certificate, and who interpreted them \u2014 and your own \nreview of imaging and studies contained in the records.]\nReview of Medical Records\nThe records submitted for review are summarized below in chronological sequence.\nTypes of encounter: M=Medical visit, N=Non-operative procedure, R=Report or letter, \nX=Imaging study, *=Other\n02/01/2024 \u2014 R. Nguyen, M.D. \u2014 Sunrise Spine & Pain Clinic \u2014 [*] \u00b7 low back, left \nleg: The claimant's history documented in the 03/12/2024 progress note identifies a \nlifting incident at work on 02/01/2024. [3] The chief complaint describes low back pain \nradiating to the left leg after that reported incident. [3] (Bates LEX000101)\n03/12/2024 \u2014 R. Nguyen, M.D. \u2014 Sunrise Spine & Pain Clinic \u2014 [M] \u00b7 lumbar spine, \nleft leg: At the 03/12/2024 progress visit, the claimant reported persistent lumbar pain \nrated 7/10, worse with prolonged standing, with the chief complaint describing radiation \nto the left leg. [3] He denied prior back injury. [3] The plan ordered a lumbar spine MRI \nand continued NSAIDs; the MRI was an order, not a documented completed study. [3] \nModified duty specified no lifting over 10 pounds. [3] (Bates LEX000101)\n03/28/2024 \u2014 S. Patel, M.D. \u2014 Bayview Imaging Center \u2014 [X] \u00b7 lumbar spine, left \nlower extremity: MRI of the lumbar spine without contrast was performed on 03/28/2024 \nfor low back pain with left lower extremity radiculopathy [4]. Findings included an L4-\nL5 disc protrusion contacting the left L5 nerve root and mild degenerative disc disease at \nL5-S1 [4]. The impression was left paracentral disc protrusion at L4-L5 and mild lumbar \nspondylosis [4]. (Bates LEX000102)\n05/06/2024 \u2014 R. Nguyen, M.D. \u2014 Sunrise Spine & Pain Clinic \u2014 [N] \u00b7 Lumbar spine, \nL4-L5, Left L5 nerve root: A left L4-L5 transforaminal epidural steroid injection was \nperformed for L4-L5 disc protrusion with left L5 radiculopathy following failed \nconservative management [5]. The patient tolerated the procedure well without \ncomplications, and pain decreased from 7/10 to 3/10 post-procedure [5]. (Bates \nLEX000103; Bates LEX000104)\n06/10/2024 \u2014 R. Nguyen, M.D. \u2014 Sunrise Spine & Pain Clinic \u2014 [M]: Reported \napproximately 50% relief after the May 6, 2024 epidural steroid injection; pain 4/10. \nContinued modified duty with re-evaluation in 6 weeks. [6] (Bates LEX000104)", "sha256": "56ac3af307ffe65b1a10ccbd36f1a928d4b1db99874af1a3223c4b872d5d3744" }, { "src": "/evaluation/previews/report-8.webp", "width": 1160, "height": 1501, "page": 8, "text": "Re: Alex Testcase Claim No.: SYN-2024-001\n8\n06/10/2024 \u2014 [M]: The June 10, 2024 visit was a follow-up after an epidural injection \n[2]. The note describes inability to walk more than two blocks before pain, difficulty \nsleeping with nighttime waking, and dressing without difficulty [2]. Driving was limited \nto 20 minutes [2]. Modified duty continued with no lifting over 10 pounds [2]. (p. 2)\nUndated Records\n[R] \u00b7 lumbar spine, left L5: Undated claims correspondence from the Law Offices of \nNorth Shore Defense asks about medical findings in relation to a February 1, 2024 lifting \nincident and whether a referenced March 28, 2024 MRI supports left L5 contact [1]. It \nalso asks whether the records document prior lumbar injury; these are administrative \nquestions, not independent clinical findings, and the embedded dates are not the letter's \nissue date [1]. (p. 1)\nThis concludes the review of the submitted records.\nRecords Reviewed \u2014 Summary\n7 pages reviewed across 1 production; 1 duplicate page identified (retained in the record \nand summarized once); 0 blank.\nDiagnostic Impressions\n[To be completed by the evaluator. List diagnoses with supporting findings.]\nDiscussion: Causation\n[To be completed by the evaluator. Causation determination is reserved to the evaluator; \nAI drafting is not performed for this section. State the reasoning, not only the conclusion, \nand frame every opinion in terms of reasonable medical probability \u2014 an opinion that \ndoes not show its reasoning is not substantial evidence.]\n\uf0b7 [Whether the mechanism described is medically sufficient to have produced the \nfindings.]\n\uf0b7 [Cause of each injury and of any compensable consequence.]\n\uf0b7 [Any disease process lit up, aggravated, or accelerated by the industrial trauma.]\n\uf0b7 [Where a specific injury is claimed, whether cumulative trauma also contributed.]\nMaximum Medical Improvement / Permanent & Stationary Status\n[To be completed by the evaluator. MMI/P&S is reserved to the evaluator; AI drafting is \nnot performed for this section.]", "sha256": "d83900cd42a7af4594e1b6330ea790972fc9f7fe479d72777e25f3aff95bd62b" }, { "src": "/evaluation/previews/report-9.webp", "width": 1160, "height": 1501, "page": 9, "text": "Re: Alex Testcase Claim No.: SYN-2024-001\n9\n\uf0b7 [Whether the applicant is at MMI, and as of what date; if not, when MMI can be \nexpected and what remains to be done.]\n\uf0b7 [Whether an adequate course of treatment has been provided \u2014 a condition is not \npermanent and stationary where indicated treatment has not been tried.]\n\uf0b7 [Whether specialist evaluations reasonably necessary to confirm or rule out injury to \nother body parts remain outstanding.]\n\uf0b7 [Any periods of temporary total or temporary partial disability, with the basis for \neach.]\nImpairment Rating\n[To be completed by the evaluator. The rating is reserved to the evaluator; AI drafting is \nnot performed for this section. Show the derivation \u2014 a judge and the Disability \nEvaluation Unit have to be able to follow how each number was reached, and a rating \nstated as a bare percentage is not substantial evidence.]\n\uf0b7 [Edition of the AMA Guides applied, and the date of injury that determines which \nschedule governs.]\n\uf0b7 [For each body part: the chapter, table or figure, and page relied on, and the method \nused.]\n\uf0b7 [Each measured value and the arithmetic, including any comparison to the \nuninvolved side.]\n\uf0b7 [Any rating by analogy, with the reasoning for it (AMA Guides 5th ed., ch. 1, p. 11).]\n\uf0b7 [Chapter 18 pain add-on: 0% to 3% whole person impairment where the burden of \nthe condition is increased by pain beyond what the conventional rating already \nincludes, 3% maximum per injury however many impairments there are, applied at \nthe whole person level. State the basis, or state that the conventional rating captured \nthe pain.]\n\uf0b7 [Whole person impairment for each body part, the combined value, and the table \nused to combine.]\n\uf0b7 [Any impairment caused by medication side effects, to any body system, \npsychological or cognitive included.]\nApportionment\n[To be completed by the evaluator. Apportionment determination is reserved to the \nevaluator; AI drafting is not performed for this section. Labor Code \u00a7 4663 makes \napportionment causation-based and requires a report on permanent disability to address \nit; \u00a7 4664 makes a prior award conclusively presumed to exist. Apportion the causes of \nthe permanent disability, not the causes of the injury.]", "sha256": "57d13026421b6c2514e1d1cce7336327ae1a243d4d803dc50359cc469ebe8f37" }, { "src": "/evaluation/previews/report-10.webp", "width": 1160, "height": 1501, "page": 10, "text": "Re: Alex Testcase Claim No.: SYN-2024-001\n10\n\uf0b7 [Approximate percentage of the permanent disability caused by the industrial injury, \nand the percentage caused by other factors before and after it, including prior \nindustrial injuries.]\n\uf0b7 [For each other cause: how and why it is causing permanent disability now, and what \nmedical evidence establishes that.]\n\uf0b7 [The nature of the permanent disability the applicant would have had absent the \nindustrial injury, described in detail \u2014 individualized to this applicant's history, not \nto statistics about similar cases (Escobedo v. Marshalls).]\n\uf0b7 [If you cannot make an apportionment determination, state the specific reasons why, \nas Labor Code \u00a7 4663(c) requires.]\nWork Capacity and Restrictions\n[To be completed by the evaluator. State work status and any permanent restrictions, \nactual and prophylactic, and whether the applicant can return to usual and customary \nduties. Distinguish risk (harm from the activity), capacity (what the applicant is able to \ndo), and tolerance (what the applicant can sustain).]\nLoss of Future Earning Capacity and Vocational Rehabilitation\n[To be completed by the evaluator. State whether a work tolerance evaluation or a \nvocational expert is needed to determine work-related disability and loss of future \nearning capacity, and whether the applicant is a qualified injured worker if the employer \ncannot accommodate the restrictions.]\nFuture Medical Care\n[To be completed by the evaluator. State anticipated future care, if any, with its \nfrequency and duration, and the evidence-based guideline relied on. Since SB 863 the \ntype and amount of current treatment in dispute is decided by utilization review and \nindependent medical review, not here \u2014 but what future care the injury will require \nremains yours to state.]\nIssues Outside Scope of Practice\n[To be completed by the evaluator. 8 CCR \u00a7 35.5(d): identify any disputed medical issue \noutside your scope of practice or area of clinical competence, so the parties can obtain \nan additional evaluation. The parties must be advised in writing no later than the date \nthis report is served. As a panel QME, send a copy of that notice to the Medical Director \nat the same time. State 'none' if there are none.]", "sha256": "802d53b7574ee0226802b60469a2f86d34c034870f460ea2ce8030dd9e9e5e68" }, { "src": "/evaluation/previews/report-11.webp", "width": 1160, "height": 1501, "page": 11, "text": "Re: Alex Testcase Claim No.: SYN-2024-001\n11\nDeclarations and Signature\n[Labor Code \u00a7 4628 declaration: identify every person who performed any part of the \nhistory, examination, record review, and report preparation, state the time spent on each, \nand verify the record-review count of 7 pages. Statutory language is not auto-inserted \u2014 \nconfirm current wording.]\n[Labor Code \u00a7 139.3 declaration: no violation of the prohibited-referral statute, and any \nstatements concerning billing are true and correct.]\n[Penalty-of-perjury declaration required by Labor Code \u00a7 5703.8 and 8 CCR \u00a7 10682, \nincluding the qualification as to information received from others.]\n[Declaration that the evaluation was performed personally, and that the time spent \ncomplied with the applicable guidelines.]\nDated: ____________ at the County of ____________\n[8 CCR \u00a7 35.5(b): if this report is signed on a date other than the date the examination \nwas completed, enter the signing date here, next to the signature.]\n____________\n[Evaluator name, degree, and board certification.]\nService\n[8 CCR \u00a7 36 sets who is served and with which form, and it turns on whether the \napplicant is represented and on whether this report reaches permanent disability. \nRepresentation is not recorded on this case, so both paths are set out \u2014 record it and this \nreport will carry only the one that applies. Confirm before serving.]\n\uf0b7 [Represented applicant: serve the applicant, their attorney, and the claims \nadministrator (or the employer if there is none), with QME Form 122 (Declaration of \nService of Medical-Legal Report) attached.]\n\uf0b7 [Unrepresented applicant: serve the applicant and the claims administrator with \nQME Form 111 (QME Findings Summary Form) completed and attached.]\n\uf0b7 [Unrepresented applicant: where this report addresses permanent impairment, \npermanent disability, or apportionment: also serve the Disability Evaluation Unit \noffice for the applicant's ZIP code, at the same time, with Form 111, DWC-AD Form \n100, and DWC-AD Form 101.]\n\uf0b7 [Retain a copy of this report for 5 years from its date (8 CCR \u00a7 39.5), and return \noriginal films and records to whoever supplied them on written request.]", "sha256": "2ae5786474255d66a8f0d80575a959d8d90be14aad7218479c3a5fb5dbce0e91" } ] } ] }