Workplace Injury Files: What Adjudicators Look For

The Adjudicator's Perspective

You're writing an IME report for a workers' compensation case. You're focused on causation, diagnosis, and impairment.

But the adjudicator — the person deciding the claim — is looking for something different. They're looking for answers to specific questions that determine eligibility, benefits, and return-to-work.

This post shows you what adjudicators look for in workplace injury files, and how to structure your report to answer their questions.

The Key Questions Adjudicators Need Answered

1. Did the Injury Arise Out of and in the Course of Employment?

What this means: Did the injury happen because of work, while the worker was doing their job?

What adjudicators look for:

• Clear description of the work-related incident
• Mechanism of injury (how did it happen?)
• Witnesses (were there coworkers who saw it?)
• Timing (did it happen during work hours?)
• Location (did it happen on the work premises?)

What you should document:

• Date, time, and location of the incident
• Description of the work task being performed
• Mechanism of injury
• Whether the incident was witnessed
• Any incident report or employer documentation

Example:

"The worker reports that on January 15, 2024, at approximately 10:30 AM, while lifting a 50-pound box in the warehouse, they felt a sudden pain in their lower back. The incident was witnessed by a coworker, John Smith, and was reported to the supervisor the same day. An incident report was completed (see Employer Incident Report, p. 1)."

2. Is the Diagnosis Supported by Objective Evidence?

What this means: Is there medical evidence that confirms the diagnosis?

What adjudicators look for:

• Imaging results (X-ray, MRI, CT)
• Physical examination findings
• Diagnostic test results (EMG, nerve conduction studies)
• Specialist opinions

What you should document:

• All objective findings
• All imaging and diagnostic test results
• Whether the diagnosis is consistent with the mechanism
• Any discrepancies between subjective complaints and objective findings

Example:

"MRI of the lumbar spine dated January 20, 2024 shows a left paracentral disc herniation at L4-5, impinging on the left L5 nerve root. This is consistent with the worker's report of left leg pain and the physical examination finding of decreased sensation in the left L5 dermatome."

3. Is the Current Condition Causally Related to the Work Incident?

What this means: Did the work incident cause the current condition, or is it unrelated?

What adjudicators look for:

• Temporal relationship (did symptoms start after the incident?)
• Mechanism consistency (does the mechanism explain the injury?)
• Pre-existing conditions (was there a prior condition that was aggravated?)
• Alternative explanations (are there non-work-related causes?)

What you should document:

• Timeline of symptoms
• Whether symptoms started immediately or were delayed
• Any pre-existing conditions
• Whether the current condition is a new injury, an aggravation, or an exacerbation

Example:

"The worker had no prior history of low back pain. Symptoms began immediately after the lifting incident on January 15, 2024. MRI shows an acute disc herniation. There is no evidence of degenerative changes that would suggest a pre-existing condition. On a more probable than not basis, the current condition is causally related to the work incident."

4. What Is the Current Functional Status?

What this means: What can the worker do now? What can't they do?

What adjudicators look for:

• Current symptoms
• Physical limitations (lifting, bending, standing, sitting)
• Ability to perform job duties
• Need for accommodations

What you should document:

• Current pain levels
• Range of motion
• Strength
• Functional limitations
• Ability to perform specific tasks (lifting, carrying, pushing, pulling)

Example:

"On examination, the worker has limited lumbar range of motion (flexion 40 degrees, extension 10 degrees). Straight leg raise is positive on the left at 30 degrees. The worker is unable to lift more than 10 pounds, cannot stand or sit for more than 30 minutes at a time, and cannot bend or twist repetitively. These limitations would preclude return to the worker's pre-injury job as a warehouse worker, which requires lifting up to 50 pounds and prolonged standing."

5. What Is the Prognosis?

What this means: Will the worker recover? If so, how long? If not, what are the permanent limitations?

What adjudicators look for:

• Expected recovery time
• Need for further treatment
• Likelihood of return to work
• Permanent restrictions

What you should document:

• Whether the condition is expected to improve
• What treatment is recommended
• Expected timeline for recovery
• Whether permanent restrictions are anticipated

Example:

"The worker has been treated with physiotherapy for 12 weeks with minimal improvement. The disc herniation is unlikely to resolve without surgical intervention. If surgery is performed, the worker may be able to return to modified duty in 3-6 months. Without surgery, the worker is likely to have permanent restrictions on lifting, bending, and prolonged standing."

6. Is the Treatment Reasonable and Necessary?

What this means: Is the treatment the worker is receiving appropriate for the injury?

What adjudicators look for:

• Consistency with treatment guidelines
• Whether treatment is evidence-based
• Whether treatment duration is appropriate
• Whether treatment is likely to improve function

What you should document:

• What treatment has been provided
• Whether treatment is consistent with guidelines
• Whether treatment has been effective
• What further treatment is recommended

Example:

"The worker has received 12 weeks of physiotherapy, which is consistent with treatment guidelines for acute disc herniation. However, there has been minimal improvement. Further physiotherapy is unlikely to provide additional benefit. Surgical consultation is recommended."

7. Can the Worker Return to Work? If So, with What Restrictions?

What this means: Can the worker go back to their job? Do they need modifications?

What adjudicators look for:

• Ability to return to pre-injury job
• Need for modified duty
• Specific restrictions
• Timeline for return

What you should document:

• Whether the worker can return to pre-injury job
• What modifications are needed (if any)
• Specific restrictions (lifting limits, hours, duties)
• When the worker can return

Example:

"The worker is unable to return to their pre-injury job as a warehouse worker due to lifting restrictions. The worker may be able to return to modified duty with the following restrictions: lifting no more than 10 pounds, no repetitive bending or twisting, no prolonged standing or sitting (more than 30 minutes at a time). These restrictions should be reassessed in 3 months."

How to Structure Your Report for Adjudicators

Section 1: Introduction

• What you were asked to review
• What questions you were asked to answer

Section 2: Incident Description

• Date, time, location
• Mechanism of injury
• Witnesses
• Incident report

Section 3: Records Reviewed

• List of records
• Date range
• Gaps in records

Section 4: Medical History

• Pre-injury medical history
• Prior conditions
• Prior treatment

Section 5: Current Condition

• Diagnosis
• Objective findings
• Current symptoms
• Functional limitations

Section 6: Causation Analysis

• Temporal relationship
• Mechanism consistency
• Pre-existing conditions
• Conclusion on causation

Section 7: Treatment Review

• Treatment provided
• Effectiveness
• Further treatment recommended

Section 8: Prognosis

• Expected recovery
• Permanent limitations

Section 9: Return-to-Work Opinion

• Ability to return to pre-injury job
• Restrictions
• Timeline

Section 10: Conclusions

• Summary of findings
• Answers to specific questions

Key Takeaways

1. Adjudicators need specific questions answered: Did the injury arise out of employment? Is the diagnosis supported? Is there causation? What is the functional status? What is the prognosis? Is treatment reasonable? Can the worker return to work?
2. Structure your report to answer these questions clearly.
3. Document the incident, objective findings, causation analysis, functional limitations, prognosis, treatment review, and return-to-work opinion.
4. Be explicit about what the worker can and cannot do.
5. Provide specific restrictions and timelines.

What's Next?

In our next post, we'll tackle "Chronic Pain Claims: Reading Long Treatment Histories" — the third in our case-type series.

This post is part of our series on medical record review for IME physicians. For more, see our 60 AI Prompts for IME Physicians Reviewing Medical Records.

Questions for Readers:

• What do adjudicators in your jurisdiction look for?
• How do you structure your reports for workers' compensation cases?
• What's the most challenging aspect of workplace injury reviews?