Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 972
“Documenting All Injuries”
“If I get sidetracked, it’s OK as long as I finish timely” Mark Studin 2018
Today I received an email from a doctor who was requested clarification from a lawyer on thoracic injuries. He explained that the accident happened over two years ago, and he has been treated consistently ever since. This doctor’s patient was co-treating with a pain management doctor who was performing injections for facet syndrome in the thoracic spine over the two years. As a result, the Dr. did not document any thoracic issues over the two years as he was treating only the cervical and lumbar spine.
As the case is coming close to fruition, the lawyer contacted the doctor (chiropractor) and wanted to know what he had for documentation of the thoracic spine because the defense is stating that the lack of documentation indicates the patient did not have any level of serious injury in that area. The chiropractor commented “since I was only treating the other areas I didn’t really think it’s important to document any issues pertaining to the thoracic spine.”
Needless to say, the lawyer is extremely unhappy as this is very damaging to the case because the treating doctor did not bother over a two-year period to document anything pertaining to the thoracic spine. Although I am sure that I do not have the facts 100% accurate in this case, the point that is to be made is that you need to document all injuries persistently over the course of care of the patient. If you do not feel inclined to document every injury on every treatment soap note, then at the very least in your evaluation and re-eval’s, which should be done every 30 days should have a complete set of facts regarding bodily injuries and treatments ongoing by collaborating or co-treating physicians.
The only answer this doctor can give the lawyers is” I forgot to document the other injuries.” No matter the reason, this is a problem you will have created the lawyers unnecessarily and they will long remember it.
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
Adjunct Associate Professor of Chiropractic, University of Bridgeport, College of Chiropractic
Adjunct Post Graduate Faculty, Cleveland University-Kansas City, College of Chiropractic
Adjunct Professor, Division of Clinical Sciences, Texas Chiropractic College
Graduate Medical Educational Presenter, Accreditation Council for Continuing Medical Education Joint Partnership with the State University of New York at Buffalo, School of Medicine and Biomedical Sciences
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