Free MIR Impairment Rating Report - Tennessee

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) __________________________________________________ __________________________________________________________________________________________

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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) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

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PHYSICAL EXAMINATION
__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

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CLAIMANT'S CHRONOLOGICAL MEDICAL HISTORY
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.

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MEDICAL RECORD REVIEW (Use additional pages as required)
In the space below,

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) .
DATE(S) PERFORMED
Please note whether it was the actual images reviewed or if the paper report was reviewed.

SUMMARY OF RESULTS

[

]

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

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[

]

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.

Attach

List operative findings:

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STEP TWO--Analysis of the Findings
1. 2. Does the claimant have a permanent impairment? YES _____ NO _____ 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? Yes _____ NO _____ If NO, state why they do not.

4.

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 _____ If YES, please

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

the percentage of impairment chosen. Calculated total whole person impairment: _____%.

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STEP THREE--Discussion
1. 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.
th

Diagnosis # 1 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
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Diagnosis # 2

Diagnosis # 3

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Diagnosis # 4 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

Diagnosis # 5

Diagnosis # 6

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Submit this section 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 _____ this Modifier is not used:

Criteria that support choice of this Grade Modifier, or reason

Physical Exam, Grade Modifier ______ this Modifier is not used.

Criteria that support choice of this Grade Modifier, or reason

Clinical Studies, Grade Modifier_____ this Modifier is not used.

Criteria that support choice of this Grade Modifier, or reason

Burden of Treatment Compliance Grade Modifier (if Chapter 9 or 10 was used) _____ choice of this Grade Modifier, or reason this Modifier is not used.

Criteria that support

=====================================================================================

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 _____ this Modifier is not used:

Criteria that support choice of this Grade Modifier, or reason

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Physical Exam, Grade Modifier ______ this Modifier is not used.

Criteria that support choice of this Grade Modifier, or reason

Clinical Studies, Grade Modifier_____ this Modifier is not used.

Criteria that support choice of this Grade Modifier, or reason

Burden of Treatment Compliance Grade Modifier (if Chapter 9 or 10 was used) _____ choice of this Grade Modifier, or reason this Modifier is not used.

Criteria that support

=====================================================================================

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 _____ this Modifier is not used:

Criteria that support choice of this Grade Modifier, or reason

Physical Exam, Grade Modifier ______ this Modifier is not used.

Criteria that support choice of this Grade Modifier, or reason

Clinical Studies, Grade Modifier_____ this Modifier is not used.

Criteria that support choice of this Grade Modifier, or reason

Burden of Treatment Compliance Grade Modifier (if Chapter 9 or 10 was used) _____ choice of this Grade Modifier, or reason this Modifier is not used.

Criteria that support

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Use this table for any Central Nervous System injury, condition, or diagnosis to be rated:
% Impairment of the Scheduled Member % Impairment of the Whole Person If appropriate

Chapter 13 Central Nervous System Diagnosis or Condition a.

Table Number/ Page Number

Rationale for Impairment % Chosen

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 CHPATER 14

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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. Is there a pre-existing impairment that should be considered for subtraction for the impairment(s) described above? YES ____ NO _____ If YES, state the pre-existing diagnosis, the impairment related to the pre-existing condition, and in the next section (Comments), when discussing the final impairment rating, and calculate the final rating both WITH AND WITHOUT subtraction of this pre-existing condition's 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 #2 #3 #4 #5 #6 Final Whole Person Impairment from Combined Values Chart ­ pages 604-606
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Comments (including a discussion of apportionment or subtracting pre-existing impairments, if applicable):

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 above, 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 _______________________________________________ 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

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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.

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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. It doesn't matter which hand or arm you use to perform the activity; please answer based on your ability regardless of how you perform the task.

1. Open a tight or new jar. 2. Write. 3. Turn a key. 4. Prepare a meal. 5. Push open a heavy door. 6. Place an object on a shelf above your head. 7. Do heavy household chores (e.g., wash walls, wash floors. 8. Garden or do yard work. 9. Make a bed. 10. Carry a shopping bag or briefcase. 11. Carry a heavy object (over 10 lbs).

1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5 5

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Pain Disability Questionnaire
Patient Name _______________________________________________ Date _______________________
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

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CLEAR FORM