History of Injury

Independent Medical Exam: What is a History of Injury?

As part of an Independent Medical Exam , I am asked the get a “History of Injury” . A medical history of injury is very similar to a story.  Information gathering typically consists of the Five Ws:  Who, What, Where, When, Why, and as many of us also learned, sometimes How .


Interestingly, the origin  of these elements are attributed to Aristotle . Rudyard Kipling memorialized these elements in a poem:


I keep six honest serving-men

            (They taught me all I know)

            Their names are What and Why and When

            And How and Where and Who.


The “History of Injury “  is usually documented as provided by the patient (claimant) at the time of the examination and thus may vary from the history  provided in the medical record. I try to get the claimant to describe the injury as the understand it . Oftentimes, I will have them carefully demonstrate what happened. In the case of an auto accident , we will often draw a diagram of the vehicle positions to get a better picture of how the accident occurred. As an  Independent Medical Examiner,  I  consider both the history as provided by the claimant and the history in the medical  record in providing an opinion “to a reasonable degree of medical certainty”. I will discuss “reasonable degree of medical certainty” in my next post.

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