Lucid, succinct reports for workers’ compensation cases keep your patients and practice healthy.

During the past few years while teaching and organizing continuing education seminars, I have realized that although you attended a seminar, it may be a challenge to apply what you have learned. It is important for us to address and report our patients’ needs in a concise, lucid manner whether it is the initial narrative, permanent, and stationary report or evaluation report (QME and AME).

Just the Facts, Please

Take time to obtain a thorough patient history. As it pertains to work injuries, it is important to ascertain the biomechanical aspect. If another office staff member takes the history, you must personally review the information with the patient yourself. The history is the most critical part of the information-gathering process because it gives the doctor the basis for many conclusions in the case.

Important questions to ask include:

• Did the patient report the injury? To whom was it reported?

• What is the patient’s past medical history? This includes childhood diseases, previous industrial injuries, personal injuries, and past illnesses and surgeries.

• How has the injured worker been affected with regard to pre-injury job activities?

• What physical complaints does the patient have as a result of the injury? Do not add extraneous body parts to the claim. If it is low back, then do not include the neck, wrist, and ankle. If there are additional body parts relative to which the patient has complaints, then report it, but obtain authorization to examine and/or treat that particular body part before doing so.

• Is your patient presently working?

• Is he or she working in a modified-duty or full-duty capacity? While you may think that you are helping a patient when advising not to work, this may not be the case. If the employer has modified duty, I suggest keeping the injured patient working. If there is a discrepancy between your recommendations and what is required at work, ask for a description of the modified position to review with your patient. Let’s face it, how many of us could survive on the present temporary total disability (TTD) rate. It is better—psychologically and economically—to keep our patients working. However, do not jeopardize their physical well-being.

• Does the patient require a work restriction as a result of the industrial injury?

• What has been the patient’s loss of pre-injury capacity? If the patient reports lifting 500 lbs prior to the injury, but can only lift 10 lbs post-injury, this needs to be investigated further.

At times, the physical job duties exceed what we feel patients are capable of performing. This conclusion should be substantiated by examination findings and objective diagnostic testing and not based solely on what patients tell you. Our job is to correlate all of the pertinent information for injured workers’ cases. Provide the patient with the appropriate paperwork that verifies modified or restricted work duty. This may also warrant a PR-2, to denote the change in the condition. For example, if a patient was TTD, but is now temporarily partially disabled (TPD and returning to modified work, then render a PR-2 report.

Add Diagnosis to Injury

Perform a complete clinical examination relative to the body part(s) claimed as a result of the injury for an accurate diagnosis. Not every condition is a sprain or strain. Do the mechanics of the injury or symptoms surrounding the onset of pain warrant the diagnosis assigned to the condition? Diagnoses change as patients’ conditions improve or decline. One of the greatest flaws within our profession is that doctors do not update diagnoses or refer for diagnostic testing when clinically indicated. Also, there is a tendency to treat beyond what is considered reasonable and necessary within the chiropractic community. Therefore, it is our responsibility to assess our patients’ conditions accurately, and recommend what is medically necessary.

Review all provided medical records. This usually entails a detailed narrative, or as an alternative, an interim narrative report; or include the review of these records in your final report. It is not necessary to document records already noted. For instance, if you include a secondary physician’s report with your PR-2 report, it does not need to be addressed again in other documentation. However, if the information in the report bolsters or supports a position you have taken, then reference that portion of the secondary physician’s report accordingly.

Determine whether or not your patient is permanent and stationary, which denotes that there is some sort of disability—objective, subjective, or both. Do not render a permanent and stationary report when an individual has recovered from said injuries.

Dot the "i"s; Cross the "t"s

Although a lengthy report does not necessarily constitute a good one, correlating the information in the case is a critical factor. Assessing the physical examination findings in conjunction with the individuals’ complaints requires your expertise. Do not make conclusions based on hypotheses, unless asked to do so. If you do not have all the information you require, this needs be stated. Requesting additional information suggests thoroughness in formulating your opinions. Frequently omitted information is doctors not providing reasons for their opinions.

Apportionment, which many doctors have trouble with, should be addressed in your report. It essentially deals with any disability prior to the injury you are treating and/or evaluating. Reviewing all provided medical records, including the patient’s past medical history, gives you the basis for issues of apportionment. If you require records that have not been provided, request the additional records you need.

You can comment on issues such as vocational rehabilitation without review of a job analysis or RU-91 if patients outline a description of their job duties. However, you may not want to rely solely on that as the basis for your opinion. If you do, make sure that you maintain the right to change your opinion when provided with documentation that reflects information to the contrary. When there are discrepancies, address those issues and request clarification from the patient. You may also want to obtain a description of employee’s job duties or job analysis prior to making your final determination.

When you refer to another specialist, make sure to maintain control of the case by sending a cover letter to the secondary physician. Send a copy to the workers’ compensation carrier and the attorney of record. Have your staff follow-up with the secondary physician’s office to request a report. Often, the physician will send the report directly to the carrier. It is your responsibility as the primary treating doctor to include and incorporate the opinions of secondary physicians who you refer in your reports. This can be accomplished with the PR-2 report.

Another area where we fall short is SOAP notes—the standard within the chiropractic community, at least in California. This is not an option. Most doctors think noting in the PR-2 report that a patient has improved is sufficient. Be sure that you know the purpose of the PR-2 report and the frequency that you can use this form.

For example, if the patient is improving, document this in your SOAP notes, and decrease the frequency of treatment accordingly. When you document that a patient is improving and yet continue treating for another 6 months at the rate of three times per week, this is unacceptable. Periodic examinations for a treating case or reflecting a change in a patient’s condition are acceptable.

Address all pertinent issues—injury history, patient complaints, past medical history, work status, review of records, diagnosis, assessment of the disability (subjective and objective), work preclusions, apportionment, further recommendations (ie, treatment, surgery, testing), and vocational rehabilitation. Your report should conform to Labor Code and Industrial Medical Council requirements. CP

About the Author

Tami S. Auerbach, DC, practices in San Diego specializing in disability evaluation. She also has been involved with teaching and orchestrating the IDE course, QME CE courses, and basic WC courses for the CCA. Auerbach can be reached at 619-542-1534, or 2903 Fourth Ave, San Diego, CA 92103.