The first and closing medical reports on treatment of an injury are always key evidence in a personal injury claim. Each item recorded will be scrutinized for what it says and what it does not say. Knowing your reports may eventually be scrutinized by attorneys may affect how you write them.
This article discusses what attorneys will be looking for in your medical reports, particularly the first report after an injury and the closing report when treatment of an injury has been completed. We hope this will help you write your reports in a way that avoids misinterpretation and, possibly, avoids the need for depositions.
The attorneys representing your patient in personal injury claims will rely on your reports for a description of the nature, severity and extent of the patients’ injuries; the extent of treatment and follow up care needed; and any permanent impairments (including pain and discomfort) resulting.
The attorneys opposing your patients’ personal injury claims will scrutinize your reports as with a fine tooth comb for inconsistencies which may be used to question your or your patient’s credibility and for indications of prior injuries or conditions which may minimize their clients’ liability.
Past Relevant Medical History The history of the present illness is one part of your report, which is of great interest to attorneys opposing your patient’s claim. If this part of your patient’s body was already injured or afflicted before the injurious incident their client was liable for, then their client may avoid at least some measure of responsibility.
A nurse may be the first to ask the patient about his or her history. You and your nurses should be aware of the risk that your patients may be so focussed on the present injury, that they have difficulty seeing beyond the incident, which caused their present pain. Your patients may not think your questions about history relate to medical treatment they had several years ago concerning to the same part of the body. Your patients may simply have forgotten about prior treatment, or it just doesn’t come to mind. Your patients may think your questions relate only to the recent past, say the last few weeks or months.
Historical information is best obtained by a series of specific questions. Did this part of your body bother you in the days and weeks before this injury? Do you recall ever injuring or requiring medical treatment for this part of your body before? If so, approximately when and when did it resolve?
If you report “No prior related injuries or treatment,” and the opposing attorney digs up a record of related treatment your patient had forgotten, your patient’s credibility will be cast in doubt. It would be safer to report, “Patient does not recall any prior related injuries or treatment” or “Patient had no related medical complaints at the time of the injury.”
There’s a strong chance you will not know or be able to learn your patient’s relevant medical history at the first visit. Your patient’s pain and need for immediate medical care may be so emergent that an exploration of prior related medical history would not be appropriate or fruitful. If so, a notation to this effect would be useful.
How the Injury Occurred
How was your patient injured? This would be best stated in general terms to avoid misinterpretation and misuse. Unless you witnessed the incident, you are not in a position to detail the circumstances of the injury. The trauma of the injury may have affected your patient’s ability to recount with accuracy the details of the incident.
So, the safest course is not to record in medical records details like “Patient injured when rear ended by drunk going 65 miles per hour.” The speed and state of intoxication of the person who rear ended your patient are facts which may later be proven to differ with your patient’s impressions at the time he/she is first treated. The risk is the opposing attorney turning it into an inconsistency, which could jeopardize your patient’s credibility, or an inconsistency which could also jeopardize your credibility and the usefulness of your medical reports and opinions.
A good rule of thumb: don’t write it if you can’t defend it on cross-examination.
At the time of your patient’s final examination, you will release him or her and be in a position to write a closing report. If your patient has recovered from his/her injuries to the point of no longer needing treatment, you may feel there is no more to say than that the patient is better. Please take a few minutes to summarize the course of treatment and the effects of the injury. A closing report, which addresses these items will help your patient, and it will help you avoid the need for letters, additional consults and depositions with lawyers.
At the completion of treatment your closing report should address the following areas, especially if they were not covered in your chart notes:
- The medical care given and why it was reasonable and necessitated by the accident injury trauma.
- Physical limitations and restrictions imposed by the injury. Often these are not addressed unless the patient asks for an “off-work” slip. However, even patients who were not working at the time of the injury will need medical documentation of how long and in what way they were put out of commission. What functional capacity restrictions and limitations were imposed by the injury and during the recovery period?
- What are the residual effects of the injury? What functional capacity restrictions or limitations resulting from the injury persist even though the patient is medically stationary? Are they permanent? If not, how long will they persist? Is there residual pain? Will follow up medical care or palliative care or treatment of any sort be needed or desired? Will any problems develop in the future resulting from or accelerated by this injury or these injuries? In short, what is your long-term prognosis?
We hope your awareness of your “audience” – those who will be looking to your records as critical evidence – will help you draft your first and closing reports in a manner which avoids misinterpretation, misuse and time-consuming follow-up questioning, and best serves your patients’ needs.
This article was prepared by Robert L. Chapman