“The No-No’s And Yes-Yes’s of Narrative Writing”
First and foremost, you are writing a narrative for a lawyer to present to the courts, not a letter of medical necessity for an insurance company to pay your claims. Understanding the difference is the balance between having a successful or failed personal injury practice. Regardless of what the lawyer needs to make a case, your responsibility is to report the truth of the findings. It is my job to show you how to organize those findings so that the lawyer can use them to bring out the truth of the residual problems as a result of the injury. A great report is one where you can clinically correlate causality, with bodily injury and persistent functional loss.
Many doctors include in their narrative only the initial evaluation findings and do not include, or perform final evaluations. Why? If the lawyer can only argue for permanent loss of bodily part or function, why include any information regarding pre-care findings? They do not explain what residual losses are present within your patient. An insurance company needs that information to determine the necessity for care; the lawyer DNGARA (does not give a rat’s ass…I do apologize, I can’t help myself), because the courts expect injured people to need to care. It’s what’s left over that counts, after care has ended.
So…do not waste time or space writing about what’s needed, simply have a section that says how many evaluations were performed and how many treatments were rendered, and attach your SOAP notes to the narrative. The only initial findings needed are the range of motion results, so that you can do a comparative study of what was present initially and what the residual losses of motion are. Courts nationwide have accepted persistent loss of range of motion as demonstrative evidence as objective loss of function.
Lawyers are also not interested in your treatment goals, your techniques or what tests you are considering ordering. All of those are also useless because they do not discuss causal relationship, bodily injury or persistent functional loss. What is important is to clearly delineate what tests have been performed and what the results are. What persistent functional loss is present how does it affect the life of the patient. I have previously written a whole consultation on functional loss, if you do not remember it, please go back and read it again.
99.99999% of the lawyers, claim adjustors and judges only read the conclusion. Therefore, your conclusion must have 1 concise paragraph that ties in the entire case. An example would be:
Mrs. Jones was rear ended while stopped; she immediately had severe pain in her neck that radiated into her right arm. Her MRI findings revealed a herniated disc at C5 on the right and her subsequent EMG/NCV revealed a right C5 radiculopathy. This accounts for her not being able to lift her right arm and use her right arm as a normally functioning person does.
What follows is the patient’s account of what functional losses are persistent personally, socially and in work.
In the history, many write that the patient was hit by a car traveling approximately 30 mph. My questions are, "Were you there? Did you witness the accident?" If not, then you cannot state what happened. Leave that to the police, accident reconstructionists and lawyers. Stick to the medical issues and you will be on firm ground especially on direct testimony.
When recounting the accident, if you have credentials in biomechanical engineering, or crash reconstruction, then feel free to explain the results of seatbelts or airbag damage. However, if you do not, then limit your report to bodily injury; focus your report to your specialty and credentials.
Regarding diagnosing, I have previously suggested that you do not use strain/sprain as the diagnosis, as it does not accurately describe your patient’s injuries. The ICD-9 does not give you the choice to differentiate between primary, secondary or tertiary sprain/strain and by using the code, your diagnosis cannot be accurately interpreted.
Radiculopathy is another diagnosis to be careful with. This should be used when you have the results of an EMG/NCV to objectively diagnose that a radiculopathy is present. In absence of an EMG/NCV use a different diagnosis.
Prior to diagnostic testing, I have used (as an example) cervicobrachial syndrome (723.3), low back syndrome (724.1) or injury to nerve root (953.1). You have to make a clinical determination as to what is the correct diagnosis for your patient.
You also need to learn the significance of somatosensory evoked potentials (SSEP), vestibular electronystagmography (V-ENG), brain stem auditory evoked potential (BAER), and visual evoked potential (VEP) tests. These are neurodiagnostic tests used to determine neurological pathology that in many cases occurs as a result of the truama. You don’t need to know how to do the test, or interpret the results, you do, however, need to understand when to refer and the significance of the conclusions. A teleconference will soon be available for you to learn about these electrodiagnostic modalities. Please check the Web site (www.lawyerspiprogram.com) for dates. The teleconferences will be offered both live and recorded and will be available for CE credits.
A narrative report should be based upon your practice and diagnostic ability, through clinical excellence and the objective and subjective results of your patient. Lawyers will know in a very short amount of time, who gets it, and who doesn’t. That is the difference between getting future referrals or being a “1 and done,” with the lawyer not wanting to work with you again.