"Timing of the Final Narrative & Chronology of Symptomatology"
WARNING: If you have not read all previous consultations, then you stand the chance of being a "one-and-done" with the lawyers. You have to learn to speak their language of admissibilty.
When a final narrative is requested by the patient’s attorney, it is usual and customary to comply with that request and render one. I don’t. It is for that reason that I have been able to use the refusal as a way of ensuring many more referrals. Before I go on to explain why, let’s look at the chronology of the injured patient in his/her rehabilitative process.
1. Gets injured.
2. Goes to the hospital or the doctor’s office.
3. Gets evaluated and has diagnostic tests.
4. Has a diagnosis rendered and in many instances, is taken out of work or put on light duty.
5. Commences care with:
b. Physical Therapy
d. Injection Therapy
e. Massage Therapy
g. Exercise Rehabilitation
6. Is taken out of his/her normal work and is no longer doing his/her repetitive occupation, i.e. no longer lifting, carrying, pushing, pulling, etc.
7. No longer doing housework, laundry, yardwork, sports activities, etc.
8. Basically, for the length of his/her care, is relegated to getting treatment and watching Oprah.
9. Is then re-evaluated every 30-45 days, as per Medicare guidelines, documenting the progression of his/her recovery.
10. Has an IME, 3-6 months later, or the doctor renders him/her as having met MMI (maximum medical improvement) and discontinues care, ordering him/her back to his/her normal life.
At this point, the patient stops coming for active care and the last evaluation was either when the patient was released or more commonly, was the month prior to the last visit. The patient’s attorney then requests an evaluation and the information you rely on is the last evaluation. You are aware that the attorney can only argue for permanent damages and that is based upon residual problems after a course of care. I would venture to say that 99% of doctors nationwide create narratives for lawyers based upon the last evaluations of the patients. In truth, it is 100%. That is the proper way to determine what residual problems the patient is left with post trauma. However, it isn’t accurate in documenting permanent residual problems resulting from injury.
The problem is when the exit evaluation is performed. At the end of a few months of care, the patient is at his/her very best, perhaps for the balance of his/her life. The patient has been taken from his/her repetitive occupation, so he/she is not lifting, carrying, etc. There's no housework being done, he/she is getting massaged, adjusted, taking medication, being guided through exercise rehabilitation and overall, fluffed and puffed.
It is in this condition that you are basing your narrative and it is not an accurate portrayal of the true nature of the patient’s injury. The patient needs to go to work for 4-6 weeks minimum, back to his/her normal life with lifting, carrying, pushing, pulling, being stressed, and doing housework, not receiving active care 2-3 times per week, nor on anti-inflammatory drugs daily.
If there is a true injury where the supportive structure has been damaged (ligaments, discs, tendons, etc.), then the supportive structure of the human body will begin to fail when stressed both physically and mentally, rendering numerous signs and symptoms over time. These signs and symptoms will not have been present at the end of care because the patient was in an artificial state and not in his/her normal repetitive lifestyle.
Therefore, a subsequent evaluation needs to be done no sooner than 4-6 weeks following subsequent to the last day of active care, preferably closer to 3 months for the true problems to surface. The best and most accurate way to objectively document this is through range of motion. In 30 years of practice (doing it wrong for 10), following this standard of practice, the patient’s ranges of motion got significantly worse 99.9% of the time in the injured areas. In those areas not injured, the ranges were stable and were reported as such.
So…when a lawyer requests a final narrative on his/her client and it is at the end of care, have breakfast, bring the chart and explain the "chronology of the patient’s symptoms" to the lawyer. Then educate the lawyer as to why you want to wait 8-10 weeks minimum post care to create the subsequent narrative. Should there be no benefits, bill private insurance, take a lien or do it as part of the care already rendered and chalk it up as goodwill.
Remember, we only want to bring out the truth of the injury. Once the lawyer understands, he/she will know that you get it…and that is the goal.