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Medical assessor guidance note 13

The Skin: Scars and Skin Grafts

Assessment of Multiple Scarring

Introduction

This material is issued by the Motor Accidents Authority under s.65 (2) of the Motor Accidents Compensation Act 1999 (the Act) in the interests of promoting accurate and consistent medical assessments under the Act. The interpretation provided here is not legally binding but represents the clinically recommended interpretation in an area where more than one interpretation of existing provisions may be possible. This recommended interpretation is publically available. Any medical assessment which does not adopt this interpretation should be accompanied by clinical justification for the interpretation adopted, supported by full, robust reasons.

Reference

The Motor Accidents Authority Permanent Impairment Guidelines – Guidelines for the assessment of permanent impairment of a person injured as a result of a motor vehicle accident 1 October 2007 (MAA Guidelines): Chapter 8: The Skin clauses 8.27- 8.36, pages 51-53: Table 8.1 TEMSKI

The American Medical Association Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4 Guides): Chapter 13: The Skin section 13.5 Scars and Skin Grafts pages 279-280 & Glossary: Table - Activities of Daily Living, with examples, page 317.

Background

Injuries caused by motor accidents may result in multiple scars. Neither the MAA Guidelines or the AMA 4 Guides provide specific advice, examples or case studies on the assessment of multiple scars.

Issue requiring clarification

Clause 8.31 of the MAA Guidelines provides that the Medical Assessor is: “to consider the skin as an organ and that The effect of scarring (whether single or multiple) is to be considered as the total effect of the scar(s) on the organ system as it relates to the criteria in Table 2” however, the method of assessing multiple scarring is not outlined.

Preferred interpretation

Multiple scars may fall within any Class of Table 2 of the AMA 4 Guides but the scars most commonly seen in motor accidents fall within Class 1 or Class 2. Determining which class is applicable is primarily dependent on the impact of the skin disorder on daily activities. Examples of activities of daily living are provided in the Table on page 317 of the AMA 4 Guides.

The TEMSKI is an extension of Table 2 (Class 1) and relies on the scar/scars meeting five (5) criteria. The criteria are evaluated by means of ten (10) descriptors. According to clause 8.35 of the MAA Guidelines:

"The TEMSKI is to be used in accordance with the principle of ‘best fit’. The assessor must be satisfied that the criteria within the chosen category of impairment best reflect the skin disorder being assessed. The skin disorder should meet most, but does not need to meet all, of the criteria within the impairment category in order to satisfy the principle of ‘best fit’. The assessor must provide detailed reasons as to why this category has been chosen over other categories."

The TEMSKI was developed specifically for the assessment of Class 1 scars, however, for consistency, it is the recommended interpretation of this Guidance Note that the same 5 criteria and 10 descriptors be used in the assessment of all scars.

The assessment of multiple scars:

i. The skin must be considered as an organ, therefore the effect of scarring is to be considered as the total effect on the entire organ system.

ii. When assessing multiple scars Medical Assessors must make it clear that all scars have collectively been evaluated with reference to the 5 criteria and 10 descriptors of the TEMSKI.

iii. Medical Assessors must record negative and positive findings for all descriptors (for example, no colour contrast). Where a defect is present, the degree of the defect must be noted (for example, noticeable colour contrast)

iv. Medical Assessors must not add or combine the assessment of individual scars but rather assess the total effect of the scarring.

v. Although larger or more obvious scars tend to dominate an evaluation, the evaluation must clearly encompass all scars being assessed collectively against all criteria.

vi. Medical Assessors must select the ‘best fit’ and must provide reasons that clearly state why a value was considered the ‘best fit’.

vii. Where evaluation gives rise to a range of values in the TEMSKI impairment categories (for example 3-4%), the Medical Assessor must use clinical judgment to determine the final impairment value. The Medical Assessor must provide reasons that clearly link their clinical judgment to the decision.

Note: Facial scarring is assessed separately and must be combined with the assessment of scarring for the rest of the body.

Justification for preferred interpretation

The preferred interpretation is suggested to promote consistency and justification in the assessment of multiple scars.

Appendix

Case Study Multiple Scarring – Right upper limb and left lower limb

Case study Multiple scarring - right lower limb


Issued by:

Injury Strategy Branch

August 2015

Contact: motor@sira.nsw.gov.au