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Draft of Forensic Evaluation

INTRODUCTION

An independent medical Examination (IME) is where a psychologist who is not involved in a person's care examines an individual. It does not include any relationship between the therapist and the patient. It is conducted to evaluate the cause, degree of injury and medical treatment of work-related injury where there is an issue with its liability (Edens& Boccaccini,2017). Additionally, it assesses if an individual has reached maximum benefit for treatment and whether the individual suffered from permanent impairments. It is conducted upon the request of an employer, insurance company or a law firm to get an independent viewpoint on the clinical status of the plaintiff.

IME is requested for several reasons such as the individual was in treatment for a specified period. There is a concern regarding the medication if it continues to be indicated and if the procedure will be needed for a specified period in the future. When the treatment in progress is about a particular event and cases where there is a permanent injury or disabilities due to trauma IME is conducted.

INDEPENDENT MEDICAL EVALUATION REPORT

I. IDENTIFYING INFORMATION:

Examinee: Mr. John DOB: 7/17/82

Employer: Blooms Flower Company Sex: Male

Requesting Client: ABC Insurance Company Race/Ethnicity: Caucasian

Type of Evaluation: Independent Medical Evaluation

This essay involves an evaluation test for a fictional client Mr. John a 36-year-old man, who was referred for independent medical evaluation because he required compensation as a result of psychological damage. This evaluation focuses on addressed issues as requested by the client in the letter. Before the assessment, the referral letter and the transcript of the interview with the examinee and extensive medical records and other documents were assessed. The independent medical examination was explained to Mr. John he fully understood the reason for the review. Mr. John was informed that the information would not be private and confidential and the report will be sent to the insurance company. Informed consent was got which the evaluee provided written permission to go on with the evaluation. Mr. John was advised not to get involved in anything that could result in harm an agreement was reached that in case of any difficulties he should report the matter during the examination.

The information he provided was overall and consistent with the medical records provided. Accuracy was followed in that the clinical history was dictated in the presence of Mr. John. He also reported that there are no new complications that occurred during the examination. Mr. John showed frustration over certain Independent Medical Evaluators his employer and the insurance company. At the end of the evaluation Mr. John he completed a survey agreeing to four statements they are I was treated with respect, the interviewer was thorough and thoughtful, there were no further injuries sustained during the period of the examination, I was happy for the visit. The medical information and other documents were to be returned to the insurance company. The evaluation report and additional relevant information concerning the client will be retained electronically by scanning the files with previous IME, S the employer and the insurance company.

MEDICAL RECORD REVIEW

Mr. John is a 36-year-old man with the following medical history of Psychological Damage. The medical report explains that in the year 2014 he complained of a persistent headache due to work, in the same year he was diagnosed to have had forehead injury because of driving at high speed. In 2015 a report filled by Dr. Murray it read John is a 36-year-old man, he sustained damage to the head about two months ago, and the pain is recurrent. The head injuries indicate that there was an object which fell on him from a certain distance. The damage is not that serious and does not require any further surgery. Mr. John complains that the falling of the object is due to the poor arrangement at work.

On July 2015 Dr. Kennedy issued a report regards to the allegation that Mr. John had an injury on the head, his medical report by then stated that the evaluee suffered from persistent pain in the head. The doctor reported that the activities performed were similar to those performed daily.

In October 2015 employers claim for workers Compensation Benefit was filed, it stated that I was lifting specific boxes in the store, suddenly some of them that were not adequately stacked fell on my head I felt a sharp pain through the neck region and the head. It caused subsequent complaints about depression on the head.

In January 2016 a report by Brook was provided by Brook consultancy services. It was a 15-page report. He noted that the patient suffered psychological damage due to boxes that fell on his head. Additionally, he said the absence of records between Septembers to December 2015. He also notes the inconsistency in the reports presented particularly concerning psychological damage caused. He felt that the July 2015 claims were not satisfactory to warrant compensation. He also pointed out that the mental damage caused due to the fall of boxes was severe and needed MRI scan to obtain the extent of the injury. He concluded that the persistent pain experienced by the patient was due to recurrent symptoms and consequences of stressful circumstances and preexisting injury on the head.

HISTORY OF THE EVALUEE

Mr. John reports that his psychological damage was as a result of lifting boxes and blocks. As a result, he is faced with work-related problems hence needs treatment. Additionally, he says he did not miss any critical time for work. He claims that he once had shoulder surgery due to falling from a certain height when he was working in another company this is not related to the current claim. He also adds that he was involved in a particular exercise program at the gym where he was to lift specific pounds as he was performing some duties with disabled people. He started employment in the current company in the year 2014 as a trolley driver for transporting flowers to the packed house. He also helped in lifting boxes for packing flowers in the cold room.

INJURY JULY 2015

Mr. John reports that on July 2015 as he was lifting boxes at the packed house some boxes at some particular point which were to appropriately stacked fell on his head. He felt infuriating sharp pain in his head and the neck region which made him unconscious for some hours. He was rushed to the hospital by the company’s vehicle. The doctor examined him and referred him to be in the ward for further examination; the doctor reported significant improvements that he was in a position to return to work but should not carry anything heavy.

CLINICAL SEQUENCE

Mr. John explains that he is experiencing persistent pain in the head which has affected sitting, standing, and his other activities. He had MRI scan on his head which showed significant damage to his head which has changed his thinking capacity. He also consulted a psychologist who helped referred him to a doctor; the doctor recommended the same scan to be conducted to see the extent of the damage. Mr. John did not feel helped at all. The insurance companies did not approve certain medications hence was not warranted any compensation. John claims that he had no money therefore no options for further treatment. He states that he was not in the capacity to perform surgical operations. The damage has affected his daily activities.

CURRENT STATUS

Mr. John’s concern is whether the pain he fills will ever go away. The pain is located at the neck extending to the back of his head it does not allow him to bend. At times the pain subsides when he undergoes medication. He also reports numbness around the neck region.

FUNCTIONALITY

Mr. John reports that he cannot carry a bucket of flower or lift a massive bag of vegetables not even a pale of water. He can stand for 30 minutes and walk for 30 minutes. John finds himself screaming for no reason at times hence waking up early so that he cannot disturb his family members. He adds that he cannot make decisions on his own, he cannot be able to work and is not receiving benefits and his lifestyle is limited.

OCCUPATIONAL HISTORY

He was employed at Bloom's flower company in the year 2013and he last worked in the year 2016. As noted he was a trolley driver and lifted boxes on the farm. This involves activities such as driving, lifting, bending, and climbing heights. He also has a high school certificate in which he attended a specific school in Hawaii. He was to further his studies but became disadvantaged due to lack of school fees.

SOCIAL HISTORY

He currently lives in Hawaii District and does not do any job. As a kid he was raised in California his parents died after a tragic accident which made him disadvantaged. He stayed with his two children and divorced his wife two years ago. He has not been involved in instances of substance abuse. He smokes 5 to 6 bowlfuls of tobacco every day.

Past Medical History Medical: Unremarkable

Surgery; Shoulder Medication: Ibuprofen

Allergy: No reported instances of allergy

FAMILY HISTORY

Positive for cancer and diabetes cases, not aware of any family history of psychological damages that affected his family, He was raised by a Christian family as such he was very religious and obedient person. He grew up with love and affection as he was the only child of his parents who were from a poor background. His mother was a gardener at an individual school while his father was a cook. He was introduced to sexuality when he encountered his girlfriend at the age of 16 years. He is divorced with his wife because she realized that Mr. John was in a serious relationship with another woman

BEHAVIORAL EXAMINATIONS

The evaluee was cooperative and appeared focused on his pain and complains and injury. During the visit, Mr. John seemed to be uncomfortable at the start of the evaluation. He sat continuously and changed positions at an interval of 30 minutes.

Legal History

Mr. John has not been engaged in any illegal activity.

Psychiatric History

Mr. John has no history of Psychiatric illness except the surgery done on the right shoulder. He reports instances where he was anxious especially the moment he divorced with his wife. He says that he prays his condition heals so as he can be able to work again anf=d be in a position to provide for his children.

MENTAL STATUS EXAMINATION

Mr. John is a 36-year-old man, who worked in Blooms flower farm. He claims that he was psychologically affected as a result of some boxes falling on his neck and head for this John demands for compensation from that company he worked. This has dramatically altered his daily activities. He was oriented to time place and the year that the injury occurred. He was aware of the purpose of the interview. He seemed confused at first but came to understand the use of the discussion. Mr. John is a well-groomed person who maintains a sense of consciousness in his appearance. He took the evaluation seriously, and these resulted in the accuracy of the information provided. The interview placed him in above average person who can comprehend every question asked.

Battery Test

VALIDITY

Mr. John did not endorse any of the validity tests. Hence reducing the risk risks that the information was produced the random response. The level of disclosure was low 30% about other patients. Though this could indicate that he can be troubled at times and that is life lacks significant functions it can show a tendency where the report was not given fully and wholeheartedly. As such patients cannot comprehend the importance of self-examinations and lack psychological mindedness or it can be difficult to acknowledge any mental dysfunction that can occur. The patient can be reluctant in providing and psychological injuries due to fear that his symptoms may not be taken seriously in case he reports any mental problem. Because he is in litigation they can fear that the personal information provided can be used against him, Corruption can also interfere with the information hence presenting bias. He can also give personal information that is confidential.

PSYCHOLOGICAL SCALES

Mr. John job dissatisfaction score is high compared to other patients; he has a feeling of resentment towards his employer hence may create conflicts with his supervisor. It is essential to determine if there is a reasonable basis for the anger towards the employer. If his symptomatic complaints are association with the incidences at a job there is a possibility that the symptoms influence the psychosocial factors and should be considered in the workplace.

AFFECTIVE SCALES

Mr. John showed a low level of anger and hostility that is seen in 3% of some patients; This indicates a complete absence of violence and aggressive tendencies. He is an easygoing person who is ready to face frustrations in life and accept those that he encounters. Anger can also be seen if there are instances denial by family members.

CONCLUSION

Mr. John through various medical evaluations has suffered from psychological damage related to work. This has made him not to be able to provide for himself and family, and therefor he is legible for compensation by the insurance company. The battery test administered showed his capability to understand the purpose of the evaluation

REFERENCES:

1. Melton, G. B. (2007). Psychological Evaluations for the Courts, Third Edition, 3rd Edition. [Bookshelf.Online]. Retrieved from https://bookshelf.vitalsource.com

2. Browne, K., Beech, A. R., Craig, L. A., & Chou, S. (Eds.). (2017). Assessments in forensic practice: a handbook. John Wiley & Sons.

3. Edens, J. F., & Boccaccini, M. T. (2017). Taking forensic mental health assessment "out of the lab" and into "the real world": Introduction to the particular issue on the field utility of forensic assessment instruments and procedures. Psychological assessment, 29(6), 599.

4. Shapse, S. (2018). Forensic Psychological Assessment. Retrieved from https://www.hg.org/article.asp?id=5100

5. Richter, J. G. (2014). Assessment of Malingered Psychosis in Mental Health Counseling. Journal of Mental Health Counseling, 36(3), 208-227.

6. Vilariño, M., Arce, R., & Fariña, F. (2013). FORENSIC-CLINICAL INTERVIEW: RELIABILITY AND VALIDITY FOR THE EVALUATION OF PSYCHOLOGICAL INJURY. European Journal of Psychology Applied To Legal Context, 5(1), 1-2