For a lawyer, the management of an Accident case is essentially the management of an information system. Attorneys gather information from clients, doctors, wits, employers etc. and package it for the insurance company. For the lawyer to handle a case successfully, all info must have 3 qualities: be Accurate, Current and Relevant, to the requirements of the case.
There is clearly an art to writing a med legal report, and for many years Gribow taught “How to Write a Med/Legal Report” at the Annual Conference of Orthopedic Surgeons at their annual Beverly Hills Convention. Most doctors don’t realize that stating the patient has recovered and is ok or symptom free…is the KISS OF DEATH for the patient/clients and the attorney. Instead, maybe the doctor should indicate “Prognosis is Guarded.” If the patient is still symptomatic, the report should indicate a guesstimate of future medical costs and the possibility of recurrent pains. In other words try to guesstimate what the cost would be for a doctor, hospital, anesthesiologist and therapy after that.
Many local doctors don’t understand that charging for a medical reports will cause the insurance company to back OUT that cost on the bill. Most PI doctors, don’t charge for reports but I assume they absorb it by billing more for what should be a more comprehensive initial and final exam as it is more important to gather all the info when it will be needed for a legal proceeding.
Reports should be written in a report fashion, and not a summary of the notes. If the patient has seen other doctors, the main treating doctor preparing the report should coordinate his/her report with that of the other treating docs. The report physician can make an indiscrete contribution to his patients welfare which may be no less important or dramatic than his physical treatment of the patient.
It takes time to learn the rules. One of the most general is that, if it is not mentioned, then it does NOT exist. If it exists and is not mentioned, the patient is done a disservice.
When commenting on pain the doc should inquire whether the pain is severe, moderate, slight or minimal and make sure s/he understands what you mean by those terms. For instance severe pain we rate as incapacitating, meaning that the patient can’t perform his/her normal duties and responsibilities. Moderate pain is not incapacitating, but does require relief in the form of medication, therapy or both. Slight pain, is pain which is disabling enough to interfere with the full enjoyment of life. Minimal pain is noticeable and annoying.
In addition to quantifying the magnitude of the pain the doc should comment on its duration either stating it is intermittent or constant. After the final exam, in my office we ask that the physician estimate the maximum future pain and suffering by addressing the area of symptom: Type of Symptom (pain, numbness), Intensity of symptom (severe, moderate etc.) and Duration of symptom (Constant or intermittent).
A complete med record note would say: “Constant moderate pain in the neck. Unable to move to right, raise or lower head. Must take pain medication and rest when at its worst.” It would also say there is a 50% chance the patient will not recover, rather than a 50% chance of recovery. In addition the patient would explain “it hurts when I try to do X”, rather than I can’t do it.
