AI disclosure language for IME reports
Short version: if software organized the records or drafted from your notes, say so in 1 or 2 plain sentences in the records-reviewed or methods section, and say that you reviewed the records your opinions rely on and wrote the opinions. Never describe the software as having reviewed, verified or concluded anything.
Limits: This site gives templates and a process, not legal advice. We read the rules it cites on 2026-11-12; your state, your requesters' contracts and your counsel decide what your practice must do.
Why put it in the report at all
No rule we found requires every IME report to carry an AI statement. 3 reasons make a short one the safer default anyway:
- The question comes anyway. "Did you use software to prepare this report?" is easy to ask in a deposition. An answer that matches a sentence already in the report reads as candor. An answer that surprises the room reads as concealment.
- The guidance points that way. The AMA's November 2024 AI principles say AI used in decision-making should be disclosed and documented. The FSMB's April 2024 policy asks physicians to be prepared to explain how they used AI and what safeguards they used.
- Some reports must name who helped. In California workers' comp, Labor Code 4628(b) has medical-legal reports disclose each person who performed services other than clerical preparation. Software is not a person, but the people who ran it are.
Version A: the methods sentence (default)
For most IME reports. Place it at the end of the records-reviewed section.
Records received for this evaluation were organized with software, including artificial intelligence, which sorted them by date, removed duplicate pages and indexed each entry to its source page. I reviewed the records on which my opinions rely, and every opinion in this report is my own.
Version B: the full methods paragraph
For requesters that ask for a methods section, for files where software also drafted parts of the report, or when you expect the report to be contested.
Use of software. I received [NUMBER] pages of records from [REQUESTER]. [PRACTICE NAME] processed them with [TOOL], software that uses artificial intelligence, under a business associate agreement. The software put the records in date order, flagged [NUMBER] duplicate pages and produced a chronology in which each entry cites its source page. I opened the source page for each fact on which my opinions rely and corrected the chronology where it was wrong. The software also produced a first draft of the history and records sections from my notes; I edited every sentence. The software did not take part in the examination and did not form, suggest or edit any opinion on [causation, apportionment, impairment, maximum medical improvement or work restrictions]. The records listed as reviewed are records I read.
Version C: California workers' comp variant
For medical-legal reports under Labor Code 4628. This wording is a starting point for a conversation with counsel, not a compliance opinion.
The following persons performed services in connection with this report other than its clerical preparation: [NAME, QUALIFICATION, SERVICE, for example "J. Lee, records coordinator, uploaded records to software that produced a dated index of prior records"]. The excerpting and outline of prior medical records was produced with software, including artificial intelligence, operated by the person named above. Under Labor Code 4628(c), I reviewed the excerpts and the entire outline and made additional inquiries and examinations as I found necessary to identify and determine the relevant medical issues. I personally examined the injured employee and prepared the conclusions of this report.
Version D: the addendum note
For this addendum I received [NUMBER] pages of additional records dated [RANGE]. They were organized with the same software described in my report of [DATE]. I read each new record listed below, and my opinions [are unchanged / change as follows, for these reasons].
Where it goes in the report
| Report section | What to put there |
|---|---|
| Records reviewed | The list of records you read, then Version A or B. Do not list records you saw only in the chronology. |
| Methods or introduction | Version B, if the requester's format has a methods section |
| Persons who performed services | Version C names, in California workers' comp |
| History and exam | Nothing about software; these are your findings |
| Opinions and discussion | Nothing about software; reasons in your own words |
| Signature and declaration | Unchanged. Read Version B against the declaration you sign and make sure they agree |
Words to keep out of the report
| Avoid | Problem | Use instead |
|---|---|---|
| "Records were reviewed using AI" | Says the software did the reviewing | "Records were organized with software; I reviewed..." |
| "AI-verified chronology" | Verification is your job, and the phrase invites a question about error rates | "A chronology in which each entry cites its source page" |
| "The AI found no evidence of prior injury" | Absence found by software is not absence; it puts the conclusion on the tool | "I found no record of prior injury in the records reviewed" |
| "Generated by [tool]" | Suggests the report, opinions included, came from the tool | Version B's description of what the tool drafted |
| No mention, when software drafted sections | Leaves the first deposition answer to explain the gap | Version B |
Deposition questions and honest answers
Practice these out loud. The right answer is the true one, and the log on the audit trail page should back each one.
| Question | Answer that matches the playbook |
|---|---|
| "Did a computer write this report?" | "Software drafted parts of the history and records sections from my notes. I edited every sentence. I wrote the opinions." |
| "Did you read all [NUMBER] pages?" | "I read the records my opinions rely on, and I listed them as reviewed. Software indexed the rest, and I used the index to find what to read." |
| "How do you know the software did not miss something?" | "I do not rely on it alone. I search a 2nd way when it says something is absent, and the report lists only records I read." |
| "Which software, and who else saw the records?" | "[TOOL], under a business associate agreement with my practice. Our staff and the vendor, under that agreement." |
| "Did the software suggest your causation opinion?" | "No. Our policy bars that use, and the log shows the opinion sections were left blank in the draft." |
Requester terms override defaults
Some requesters write AI terms into panel agreements or report instructions. Read them before choosing a version. If a requester bans AI on its files, mark those cases "no AI" at intake, the same as an examinee objection. If a requester asks for a fuller statement, use Version B. Log which version each report used, so a later question about a batch of reports has a quick answer.
The examinee hears a matching message before the exam; the wording is on the examinee notice page.