Permanent impairment medical assessment examination checklist

Assessment of spine, upper and lower extremity, nervous system and the skin

This medical assessment examination checklist is provided in accordance with section 65(2) of the Motor Accidents Compensation Act 1999 and in accordance with section 7.7 of the Motor Accident Injuries Act 2017 to promote accurate and consistent medical assessments.

In 'Crnobrnja v Motor Accident Authority of NSW' [2010] NSWSC 633 (Crnobrnja), Hulme J at [28] found that the overriding issue related to "whether an assessor is obliged to refer, either expressly or by necessary implication, to each of the matters necessary to place a claimant in DRE Category l if that is what an assessor concludes".

His Honour at [32] concluded that, in the medical assessor not making express reference to each of the differentiators, he "did not regard [the Assessor’s] Assessment as complying with the obligation, contained in s61 of the [Motor Accidents Compensation Act 1999] 1999 Act to provide reasons".

The findings in this judgement are relevant to the assessment of all injuries. When conducting a medical assessment a medical assessor must specifically refer to each of the objective clinical findings relevant to the injury being assessed and record both positive and negative findings.

It is very important that a clinical examination is thoroughly documented to demonstrate that a complete clinical examination has been undertaken and that all of the objective clinical findings, relevant differentiators, relevant structural inclusions, and/or methods of assessment associated with each injury have been considered.

The following medical assessment examination checklist was developed after 'Crnobrnja' was decided. This checklist serves to assist medical assessors when conducting a medical assessment to consider and document all the clinical findings relevant to the assessment. The list may include some clinical findings that are not listed in the relevant guides and may not refer to tests that may be applicable clinically to determine the most appropriate diagnosis.

Medical assessment examination checklist

Cervical spine

• Range of motion (ROM) - uniform or non-uniform
• Muscle guarding
• Upper extremity neurological    
  • Reflexes
  • Sensation
  • Power
  • Atrophy (circum. measurement)
  • Non-verifiable radicular complaints
• Lower extremity neurology if applicable
• Review of x-rays/ imaging - structural inclusions.

Thoracic and Lumbar spine

• Deformity (scoliosis, kyphosis, lordosis)
• Range of motion (ROM) - uniform or non-uniform
• Muscle guarding
• Lower extremity neurological
  • Reflexes
  • Sensation
  • Power
  • Atrophy (circum. measurement)
  • SLR supine
  • SLR sitting
• Lower extremity
• Review of x-rays/imaging
  • structural inclusions
  • compression fractures measured.

Upper extremity

• Atrophy (circum. measurement)
• Tenderness - location, local/general
• Range of motion (ROM) - limited by:
  • both sides measured
  • use of worksheet recommended, especially for complex hand impairments
• Peripheral nerve assessment
  • motor, sensory
  • severity of impairment
• Complex regional pain syndrome (CRPS)
• Consider any other applicable disorders -  e.g crepitus, arthroplasty, instability
• Consider assessment by analogy
• Consider permissible combinations

Lower extremities

• Gait
• Atrophy (circum. measurement)
• Weakness
• ROM/ankylosis
• Arthritis
• Patellofemoral crepitus
• Ligamentous laxity, other tests
• Diagnosis based estimates
• Limb length discrepancy (note method)
• Neurology – affected nerve, grade severity
• Skin
• Vascular
• Complex regional pain syndrome (CRPS)
• Review of x-rays/imaging
  • recommended view for measuring cartilage interval?
  • fractures - angulation/deformity (note methodology for measurement, if applicable)
• Consider permissible combinations

Pelvis

• Gait
• Leg length
• Back movements
• Palpate tenderness/irregularity (signs)/asymmetry
• Hip ROM (acetabular fractures)
• X-rays – displacement/separation/joint involvement

General

• Weight
• Hand dominance
• Inconsistencies considered/noted/explored with claimant e.g. ROM, surveillance DVDs
• History covers pre-existing/subsequent injuries
• Review all listed injuries with claimant - any not listed but caused by motor accident

Nervous system

• Disturbances of consciousness and awareness
• Aphasia and communication disorders
• Mental status and integrative function
• Emotional and behavioural disturbances
• Episodic neurologic disorders
• Any cranial nerves, spinal cord or long tract injury
• Comment on requirements re mental status impairments and emotional and behavioural impairments
• Reasons for clinical dementia rating (CDR)
• Nominate reasons for impairment percentage
• Brain injury protocol

Scarring

• All TEMSKI (table for the evaluation of minor skin impairment) criteria and 10 descriptors considered:
  • claimant conscious of scar
  • colour contrast
  • claimant able to locate
  • trophic changes
  • staple/suture marks
  • anatomic location
  • contour defect
  • activities of daily living (ADLs)
  • treatment
  • adherence
• Facial scarring assessed separately