Frequently Asked Questions about Impairment Ratings

This article is intended for RateFast users who have questions about the Whole Person Impairment ratings that come with each PR-4 Permanent & Stationary work injury report.

This FAQ contains answers to a few common questions that we’ve received regarding RateFast impairment ratings.

We pride ourselves in the accuracy of our impairment ratings, and would be happy to explain how they are being calculated. If your question isn’t answered here, then please contact us with questions about your PR-4 report.

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What is a PR-4 Permanent & Stationary Report? (for patients)

What is a PR-4 report? What is a permanent and stationary report?

The significance of a PR-4 report can be confusing to patients. This video below explains the significance of PR-4 reports for injured workers. This video introduces the topic of PR-4 reports. I’ve shown it to a few of my patients before the actual PR-4 examination takes place. It answers about 80% of the common questions that patients have about the report and the exam—a real time saver for everybody.

If you’re a patient and you have a work injury, then this video will cast some light on how your work injury is going to be evaluated and rated.

If you’re a medical provider or office manager at a medical clinic, please feel free to use the video to help explain the significance of the permanent and stationary report to injured workers that you are going to examine. Send your patients the link to this post via email, and they can watch it on their home computer—or on their cell phones while they’re in the waiting room.

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3 tips to help you get paid for your PR-4 report

This article is intended for medical providers and other medical professionals.

When you complete a Permanent & Stationary PR-4 report, it can be difficult to get paid for the full and correct amount.

This article includes a few tips to help ensure that you get compensated for your report.

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How to measure range of motion for a PR-4 report

If your patient has injured a joint, then you (the medical provider) should be sure to measure the range of motion (ROM) of that joint. It’s particularly important to report the range of motion of an injured joint in a PR-4 Report (or the PRIMARY TREATING PHYSICIAN’S PERMANENT AND STATIONARY REPORT).


Measuring the range of motion for an injured joint is essential for calculating an accurate impairment rating.

If you don’t know how much motion your patient has lost, then you can’t tell how much the work injury impaired him or her.

4 Steps to taking accurate range of motion (ROM) measurements for work comp

1. Have your patient warm up by stretching for two minutes

If your patient warms up before measuring, then your measurements  will be more accurate and consistent, with greater reproducibility.

Reproducibility of measurements within 10% is necessary for measurements to be considered valid by the AMA guides.

2. Use the proper tool

If the joint is in the upper or lower extremity (arm or leg), then use a goniometer.

If the injured joint is in the spine, then use an inclinometer.

3. Measure both sides

Notice that the PR-4 report says “Include bilateral measurements – injured/uninjured – for injuries of the extremities.”

So, if your patient has injured her right shoulder, then measure the range of motion of both shoulders. This shows the contrast between the injured body joint and the uninjured joint.

Unless, of course, both sides are injured! But in this case, you should still measure both sides and report your measurements.

4. Measure multiple times!

If the injured joint is in the upper extremity, then take two measurements across each plane (flexion, extension, etc.).

If the injured joint is in the lower extremity or the spine, then take three measurements across each plane.

5. Report your results in the “Physical Examination” section of the PR-4 report

You will find the “Physical Examination” section on the second page of the PR-4 report form that’s currently on the California Department of Industrial Relation’s website.

Make sure that you present your measurements clearly so that it’s easy to read for a claims adjuster, employer, or another doctor. Indicate the plane of motion and the side of the measurement.

We like to show our measurements in a table. This is how the new version of RateFast, our PR-4 reporting web app, displays the range of motion of a body part:

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Adjuster’s Corner: For Insurance Adjusters

Introducing the RateFast “Adjuster’s Corner”.

Adjuster’s Corner is brought to you by, well, adjusters. This series of newsletters are based on real life letters and questions from insurance carrier adjusters seeking clarity and knowledge of the AMA Guides 5th Edition impairment rating situation in California.

Our responses are provided by Dr. John Alchemy, MD, DABFP, QME, CIME. Dr. Alchemy’s credentials include:

A) A current Qualified Medical Examiner (QME) for the State of CA

B) A certified educational provider for the State of CA DWC Medical Unit, specifically approved for content in the AMA Guides 5th Edition, Chapters 1,2,15, 16 and 17, in addition to advanced impairment report writing (12 hrs CME).

C) Currently certified by the American Board of Independent Medical Examiners (ABIME) as a Certified Independent Medical Evaluator (CIME) and have successfully passed a proctored written exam demonstrating competency in the AMA Guides 5th Edition rating system.

Got a great rating question? Send it in (info email link here)!  We love questions almost as much as answers.

Case Study #1 Submitted by adjuster DS:

Question: Dr. Alchemy, why did the cervical spine rating come out so high for a non-surgical neck?

Answer: Dear DS, Do not fall into the trap of responding to impairment values based on the result value. If one reads the rating criteria, surgery is only a subset of the DRE categories, and in no way, a single gateway for rating inclusion etc. Additionally, surgery plays only a subset in the rating determination when using the ROM spine rating.

Rather, I would urge you to focus on the data set that is presented, the validity of the measurements, and the application of the results to the tables and figures. The goal in providing AMA ratings is to provide the stakeholders a numeric value  based on statistical rigor, objectivity, and reproducibility.

If you have specific questions as to the validity of a number or the application of a table/figure, please let me know specifically which part of the data set is appears inconsistent and let’s have learning opportunity.

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Assembling the Perfect PR-4 Report

Your patient or injured worker has reached MMI and is ready for their final impairment rating: it’s time to complete the California PR-4 Report.

What goes into these reports, which are required for each reported work comp injury in California?   A summary of how the injury occurred, attempted treatments to date, how the patient is doing currently, future care and medications… to name a few items.

But perhaps most important to the PR-4 report is a detailed set of measurements which create a value for the injury (Whole Person Impairment or WPI%). These measurements are required by the AMA guides to be reproducible, and determine if the employee is eligible for a payment benefit based on permanent impairment findings.

We recommend using RateFast for fully reproducible findings on PR-4 reports. RateFast provides a digitized patient exam for correct prioritization of all data. But, whenever you’re performing a PR-4 report, keep these tips in mind:

  • For multiple body part claims remember to keep all injuries in mind when providing treatment.
  • Create a consistent system for collecting information for all patients.
  • Remember incorrect measurements lead to incorrect impairment ratings. Always measure twice for accuracy.

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AMA Guides 5ed Glossary Definitions (Pages 599-603)

AMA Guides 5ed Glossary Definitions (Pages 599-603)

Below is a common list of terms that help RateFast users better understand the basics definitions used for impairment ratings. You will find many of these terms used in RateFast to provide more consistent and reproducible reports.


A factor(s) (eg, physical, chemical, biological or medical condition) that adversely alters the course or progression of the medical impairment. Worsening of a preexisting medical condition or impairment.


Fixation of a joint in a specific position by disease, injury or surgery. When surgically created, the aim is to fuse the joint in that position, which is best for improved function.


A distribution or allocation of causation among multiple factors that caused or significantly contributed to the injury or disease and existing impairment.

Assistive devices

Devices that help individuals with a functional loss increase function. Examples include reachers, extended grabbers, hearing aids, and telephone amplifiers.


An identifiable factor (eg. accident or exposure to hazards or disease) that results in a medically identifiable condition.

Chronic pain

Pain that extends beyond the expected period of healing or is related to a progressive disease. It is usually elicited by an injury or disease but may be perpetuated by factors that are both pathogenically and physically remote from the original cause. Because the pain persists, it is likely that environmental and psychological factors interact with the tissue damage, contributing to the persistence of pain and illness behavior.

Combined Values Chart

A method used to combine multiple impairments, derived from the formula A+ B(1-A) w combined values of A and B, which ensures that the summary value will not exceed 100% of the whole person.


A permanent shortening (as of muscle, tendon, or scar tissue) producing loss of motion, deformity, or distortion.

Desirable weight

A range of optimal weight given an individual’s sex, age, height and body habitus.


Alteration of an individual’s capacity to meet personal, social, or occupational demands or statutory or regulatory requirements because of an impairment. Disability is a relational outcome, contingent on the environmental conditions in which activities are performed.

Effects of medication

Medication may impact the individual’s sign, symptoms, and ability to function. They physician may choose to increase the impairment estimate by a small percentage (1% to 3%) to account for effects of treatment.

Functional limitations

The inability to completely perform a task due to an impairment. In some instances, functional limitations may be overcome through modifications in the individual’s personal or environmental accommodations.


A historical term used to describe disability or a person living with a disability or disabilities. A handicapped individual has been considered to be someone with a physical or mental disability that substantially limits activity, especially in relation to employment or education.


A loss, loss of use, or derangement of any body part, organ system, or organ function.

Impairment evaluation

A medical evaluation performed by a physician, using a standard method as outlined in the Guides, to determine permanent impairment associated with a medical condition.

Impairment percentages or ratings

Consensus derived estimates that reflect the severity of the impairment and the degree to which the impairment decreases an individual’s ability to perform common activities of daily living as listed in Table 1-2.


A conscious and willful feigning or exaggeration of a disease or effect of an injury in order to obtain specific external gain. It is usually motivated by external incentives, such as receiving financial compensation, obtaining drugs, or avoiding work or other responsibilities.

Maximum medical improvement (MMI)

A condition or state that is well stabilized and unlikely to change substantially in the next year, with or without medical treatment. Over time, there may be some change, however, further recovery or deterioration is not anticipated.


A range or zone that represents healthy functioning and varies with age, gender, and other factors, such as environmental conditions.


An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.


A sensation of prickling, tingling, or creeping on the skin, usually associated with injury or irritation of a sensory nerve or nerve root.

Permanent impairment

An impairment that has reached maximal medical improvement.


An artificial device to replace a missing part of the body.


Any pathological condition of the nerve roots.


A return of the disorder or disease after a remission.


Synonymous with reliability. Consistency in results when examinations (tests) are repeated.


Pain along the course of a sciatic verve, especially in the back of the thigh, caused by compression, inflammation, or reflex mechanisms.


A radiographic method used to determine actual limb length.


The action or manner of treating an individual, medically or surgically. Medical treatment is the action or manner of treating an individual, medically or surgically by a physician. Treatment may include modalities recommended by a health care provider.


An accurate measurement apart from random errors. Validity refers to the extent to which a test measures what it is intended to measure.

Whole person impairment

Percentages that estimate the impact of the impairment on the individual’s overall ability to perform activities of daily living, excluding work.

Workers’ compensation

A compensation program designed to provide medical and economic support to workers who have been injured or become ill from an incident arising out of and in the course of their employment.

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Effects of Medication and Impairment Rating

How the AMA Guides 5th Edition approaches impairment is complex, and accurate impairment ratings are tricky as a result.

For example, many medical providers don’t realize that the effects that medication has on an injured worker can actually change the worker’s impairment rating. This is defined on page 600 of the AMA Guides.

With page after page of definitions and tables, little details like these can easily be glossed over. We designed RateFast so that you don’t need to spend your time reading and re-reading the Guides. If you use RateFast to write your California PR-4 reports, then our software will prompt you with easy-to-answer questions about the effects that medication has on your patient.

But it’s still important to understand how the effects of mediation impact a worker’s whole person impairment. Here are a few key facts:

  1. “Effects of medication” are defined on page 600 of the AMA Guides, 5th Edition: “Medications may impact the individual signs, symptoms, and ability to function.”
  2. If an injured worker is affected by the medication he or she takes for the work-related injury, then the physician may choose to increase the impairment by small amount—between 1% and 3%. (Frustratingly, the AMA Guides do not give specific instructions on how to do this.)

So imagine that your patient has reached MMI for an injury to the low back. Let’s say that she is assigned a DRE category II and given a 5% WPI.

Now, imagine that the muscle relaxant she has been prescribed causes excessive drowsiness and limits her ability to drive. Is she eligible for an increased whole person impairment rating? Yes. The muscle relaxant has affected her life by limiting her ability to drive.

The moral of the story: if you’re a medical provider, make sure to ask your patients if their medications cause any side effect. It could make a real change in their impairment rating.

If you need help remembering to ask if medications are affecting your patients symptoms, try RateFast today for free. This question is built into our patient history questionnaire and our impairment calculations.

What exams are included in the RateFast application?

In order to guarantee accurate impairment ratings and truly complete work-comp reports, the Ratefast app guides users through various medical examinations according to the requirements of the AMA Guides.

RateFast asks questions, prompts you to indicate abnormalities, and requests that you take measurements based on your patient’s injury. A set of these questions and prompts for measurements are called exams.


RateFast currently has customized exams for injuries to the following body parts:

  • AMA Guides 5th edition cervical spine exam
  • AMA Guides 5th edition thoracic spine exam
  • AMA Guides 5th edition lumbar spine exam
  • AMA Guides 5th edition shoulder exam
  • AMA Guides 5th edition elbow exam
  • AMA Guides 5th edition wrist exam
  • AMA Guides 5th edition thumb exam
  • AMA Guides 5th edition index finger exam
  • AMA Guides 5th edition middle finger exam
  • AMA Guides 5th edition ring finger exam
  • AMA Guides 5th edition little finger exam
  • AMA Guides 5th edition pelvis/hip exam
  • AMA Guides 5th edition shoulder exam
  • AMA Guides 5th edition knee exam
  • AMA Guides 5th edition ankle/foot exam
  • AMA Guides 5th edition toe exam
  • AMA Guides 5th edition skin exam (for various skin areas)

Related Reading

If you’re a current RateFast user and you want to learn how to access the body part exams, then check out this article in the How to Use RateFast – Basic Tasks section.

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