60 AI Prompts for IME Physicians Reviewing Medical Records

Practical prompts to accelerate your medical record review while maintaining clinical accuracy and defensibility

Independent Medical Examinations demand precision. You're reviewing hundreds of pages, identifying causation, assessing impairment, and producing a report that will be scrutinized by opposing counsel. AI can accelerate this process—but only if you prompt it correctly.

These 60 prompts are organized by the actual workflow of an IME physician: from initial record triage through causation analysis, impairment rating, and report drafting. Each prompt is designed to extract clinically relevant information while flagging what needs your expert judgment.

Record Triage & Organization

1. Initial Record Assessment

Summarize the volume and types of medical records in this file. 
List each provider, date range, and approximate page count. 
Identify any obvious gaps in the treatment timeline.

2. Provider Timeline Construction

Create a chronological timeline of all healthcare providers seen by 
this claimant. Include: provider name, specialty, first visit date, 
last visit date, and primary reason for treatment.

3. Identifying Key Records

Which records in this file are most relevant to the claimed injury 
date of [DATE]? List the documents that reference the incident 
or immediate post-injury treatment.

4. Missing Records Detection

Based on the treatment timeline, what records appear to be missing? 
Consider: referral patterns, typical diagnostic workup for this 
injury type, and gaps between provider visits exceeding 30 days.

5. Duplicate Record Identification

Flag any records that appear to be duplicates. Compare: dates, 
provider names, visit types, and clinical content. Do NOT flag 
records that are true follow-up visits.

6. Pre-Injury Medical History Extraction

Extract all medical records dated BEFORE the claimed injury date. 
Summarize: conditions treated, medications prescribed, healthcare 
providers seen, and any relevant diagnostic findings.

7. Post-Injury Treatment Summary

Summarize all treatment received AFTER the claimed injury date. 
Organize by: acute care (first 72 hours), subacute phase (weeks 1-6), 
and chronic phase (beyond 6 weeks).

8. Referral Pattern Analysis

Map the referral pattern: who referred the patient to whom, when, 
and for what stated reason? Identify any referrals that seem 
clinically unusual or potentially unnecessary.

Clinical Content Extraction

9. Chief Complaint Tracking

Extract the chief complaint from each visit. Track how it evolves 
over time. Note any discrepancies between documented complaints 
and claimed disability.

10. Symptom Documentation

List every symptom documented in the medical records. Include: 
date first reported, frequency of mention, severity descriptors, 
and any changes over time.

11. Physical Examination Findings

Extract all physical examination findings. Organize by body system. 
Highlight: objective findings (e.g., ROM measurements, reflexes), 
subjective findings, and any inconsistencies across providers.

12. Diagnostic Test Results

Compile all diagnostic test results: imaging, lab work, nerve 
conduction studies, etc. For each test, note: date, type, findings, 
and who interpreted the results.

13. Medication History

Create a complete medication history. For each medication, include: 
name, dosage, prescribing provider, start date, end date (if known), 
and indication.

14. Procedure and Surgery History

List all procedures and surgeries. For each: date, procedure name, 
provider, indication, complications (if any), and outcome.

15. Work Status Documentation

Extract all work status restrictions. Track: date, provider, 
restrictions given, duration, and any changes over time. Note 
any discrepancies between restrictions and functional capacity.

16. Pain Scale Tracking

Document every pain scale rating in the records. Note: date, 
context (rest vs. activity), and any analgesic use at time of 
rating. Track trends over time.

Causation Analysis

17. Mechanism of Injury Documentation

Extract all descriptions of the injury mechanism. Note: source 
(patient report, witness statement, incident report), date of 
documentation, and any inconsistencies between accounts.

18. Temporal Relationship Assessment

Analyze the temporal relationship between the claimed event and 
onset of symptoms. Document: first symptom report, time lag 
between event and treatment, and any pre-existing symptoms.

19. Pre-Existing Condition Identification

Identify any pre-existing conditions relevant to the claimed injury. 
For each: condition name, evidence in pre-injury records, treating 
provider, and whether it was symptomatic before the event.

20. Aggravation vs. Exacerbation Analysis

Based on the records, distinguish between: (1) new injury, 
(2) aggravation of pre-existing condition, or (3) temporary 
exacerbation. Cite specific clinical evidence for your conclusion.

21. Diagnostic Evidence for Causation

What diagnostic evidence supports or refutes causation? Consider: 
imaging findings, objective clinical findings, and whether 
diagnostics are consistent with the claimed mechanism.

22. Alternative Causation Hypotheses

Are there alternative explanations for the claimant's condition 
besides the claimed event? Consider: degenerative changes, 
pre-existing conditions, subsequent injuries, or non-organic factors.

23. Maximum Medical Improvement (MMI) Assessment

Based on the treatment records, when did the claimant reach 
MMI? Cite: plateau in improvement, cessation of active treatment, 
and any provider statements regarding prognosis.

Functional Capacity & Disability

24. Activities of Daily Living (ADL) Documentation

Extract all documentation of ADL limitations. Include: specific 
activities affected, degree of limitation, source of information, 
and any objective corroboration.

25. Employment History Analysis

Summarize the claimant's employment history. Include: job titles, 
physical demands, dates worked, and reason for leaving each position. 
Note any work-related injuries.

26. Functional Capacity Evaluation (FCE) Analysis

If an FCE was performed, summarize: date, type, results, and 
validity indicators. Note any discrepancies between FCE findings 
and clinical examination.

27. Work Restriction Reasonableness

Are the documented work restrictions clinically reasonable given 
the objective findings? Identify any restrictions that lack 
clinical justification or appear excessive.

28. Disability Duration Analysis

Calculate total duration of disability. Distinguish between: 
total disability, partial disability, and able-to-work periods. 
Note any discrepancies with treatment timeline.

29. Secondary Gain Indicators

Flag any potential secondary gain indicators in the records. 
Consider: litigation history, disability applications, workers' 
comp claims, and inconsistencies in symptom reporting.

Impairment Rating Preparation

30. Impairment Rating Methodology Selection

Based on the jurisdiction and injury type, which impairment rating 
guides should be used? (AMA Guides 5th/6th, state-specific, etc.) 
Cite the rationale for methodology selection.

31. Objective Findings for Impairment

List all objective clinical findings that can be used for 
impairment rating. For each: cite the specific examination finding, 
date, and which guide section applies.

32. ROM Measurements Compilation

Compile all range of motion measurements. Include: date, joint, 
motion type, degrees, and examiner. Note any significant 
variability between measurements.

33. Neurological Deficit Documentation

Document all neurological deficits. Include: type (sensory, motor, 
reflex), distribution, severity, and objective evidence (EMG, 
clinical exam).

34. Pain-Related Impairment Considerations

If pain is a component of impairment, document: location, severity, 
chronicity, and whether it meets criteria for pain-related impairment 
under the applicable guides.

35. Pre-Existing Impairment Calculation

Calculate any pre-existing impairment. Use pre-injury records to 
establish baseline. Document methodology and apportionment rationale.

36. Maximum Impairment Assessment

What is the maximum impairment rating supported by objective 
findings? Cite specific guide sections and clinical evidence. 
Note any areas of clinical judgment.

Consistency & Credibility Analysis

37. Symptom-Consistency Check

Are the reported symptoms consistent with the objective findings 
and diagnosed condition? Flag any inconsistencies between subjective 
complaints and clinical evidence.

38. Cross-Provider Consistency

Compare clinical findings across different providers. Identify: 
consistent findings, inconsistent findings, and findings that 
appear or disappear without explanation.

39. Waddell Sign Assessment

Document any positive Waddell signs or other non-organic physical 
findings. Note: which signs, when observed, by whom, and clinical 
context.

40. Symptom Magnification Indicators

Flag any indicators of symptom magnification. Consider: 
inconsistent examination findings, disproportionate pain behavior, 
and discrepancies between reported and observed function.

41. Treatment Compliance Analysis

Assess treatment compliance. Document: missed appointments, 
non-compliance with recommendations, and any patterns of 
treatment-seeking behavior.

42. Return-to-Work Barriers

What barriers to return-to-work are documented? Distinguish 
between: medical barriers, psychological barriers, and 
non-medical barriers (e.g., job availability, employer issues).

Report Drafting Assistance

43. Executive Summary Draft

Draft a one-paragraph executive summary of this IME. Include: 
injury date, diagnosis, causation opinion, current functional 
status, and impairment rating (if applicable).

44. History of Present Illness Section

Draft the History of Present Illness section. Include: mechanism 
of injury, immediate symptoms, treatment timeline, and current 
status. Cite specific records for each fact.

45. Past Medical History Summary

Summarize the Past Medical History. Organize by: relevant 
pre-existing conditions, prior injuries, surgeries, and current 
medications. Note relevance to claimed injury.

46. Physical Examination Findings Section

Draft the Physical Examination Findings section. Include: 
general appearance, vital signs, and system-specific findings. 
Distinguish between objective and subjective findings.

47. Diagnostic Studies Summary

Summarize all diagnostic studies. For each: date, type, findings, 
and clinical significance. Note any studies that were recommended 
but not performed.

48. Causation Opinion Formulation

Draft the causation opinion section. State: whether the condition 
was caused by, aggravated by, or unrelated to the claimed event. 
Cite specific evidence supporting this opinion.

49. Functional Capacity Opinion

Draft the functional capacity opinion. State: current work 
capacity, specific restrictions (if any), and whether restrictions 
are temporary or permanent.

50. Impairment Rating Explanation

Draft the impairment rating explanation. Include: methodology used, 
specific findings rated, calculations, and final whole person 
impairment percentage.

51. Prognosis Statement

Draft the prognosis statement. Include: expected course, potential 
for further improvement, anticipated treatment needs, and any 
factors affecting prognosis.

52. Recommendations Section

Draft the recommendations section. Include: further diagnostic 
studies, treatment recommendations, work restrictions, and 
follow-up timeline.

Quality Assurance & Review

53. Citation Verification

Verify that every clinical statement in the draft report has a 
corresponding citation to the medical records. Flag any 
uncited statements.

54. Opinion Consistency Check

Review the draft report for internal consistency. Check: do the 
opinions align with the documented findings? Are there any 
contradictions between sections?

55. Defensibility Review

Review the draft report for defensibility. Consider: Are all 
opinions supported by evidence? Are alternative explanations 
addressed? Is the reasoning clear?

56. Missing Information Flag

What critical information is missing from the records that would 
strengthen or clarify the IME opinion? List specific documents 
or diagnostic studies needed.

57. Cross-Examination Preparation

Prepare for potential cross-examination questions. Identify: 
weak points in the opinion, alternative interpretations of the 
evidence, and areas where clinical judgment was required.

58. Peer Review Checklist

Generate a peer review checklist for this IME report. Include: 
methodology verification, citation accuracy, opinion support, 
and compliance with standards.

59. Report Completeness Audit

Audit the report for completeness. Check: all required sections 
present, all records reviewed cited, all opinions stated, and 
all recommendations clear.

60. Final Quality Check

Perform a final quality check. Verify: spelling of claimant name, 
accuracy of dates, correct impairment calculations, and consistency 
of terminology throughout the report.

How to Use These Prompts Effectively

Best Practices:

Start with Triage — Use prompts 1-8 to organize the file before diving into clinical analysis
Extract Systematically — Work through prompts 9-16 to build your clinical foundation
Apply Clinical Judgment — Prompts are tools, not replacements for your expertise
Verify Everything — Always cross-check AI output against the original records
Document Your Reasoning — Use prompts 43-52 to draft, then refine with your clinical voice

What AI Cannot Do:

Replace your clinical examination of the claimant
Make the final causation determination
Apply clinical judgment to borderline findings
Assess credibility during the face-to-face interview
Sign the report and take professional responsibility

What AI Does Well:

Rapid extraction of clinical data
Pattern recognition across large record sets
Timeline construction and gap identification
Drafting structured report sections
Citation verification and cross-referencing

The Bottom Line

These prompts accelerate the mechanical aspects of IME record review—extracting data, organizing timelines, and drafting structured sections. But the core of an IME remains your clinical expertise: examining the claimant, interpreting findings in context, and rendering opinions you can defend under cross-examination.

Use AI as a force multiplier, not a replacement. Your signature on that report means you stand behind every word.

Need help implementing AI in your IME practice? Contact us to discuss workflow integration that maintains clinical accuracy and defensibility.