Academy of Chiropractic’s Lawyers PI Program
Clinical Information CI 2
From the Desk of :
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
"Accurate and Complete Diagnosis"
Based upon a significant amount of research with medical specialists and lawyers, the expansion of the number of diagnosis reported for our patients would appear necessary in certain cases to reflect a complete and accurate picture of the patient's condition. It is important to understand that our job is to paint a clinical picture with diagnosis.
The chiropractor is the primary care provider for everything spine. Therefore when we care for a patient is very important to do a complete evaluation and document all that is going on which is reflected in the complete diagnosis. When it comes to documentation I have always held to the "neurosurgical standard " because neurosurgeons are considered at the top of the "food chain" in both the healthcare and medical-legal systems and are universally most accepted by all. When it comes to managing a case is where we differ in that the neurosurgeon will be focused only on the brain and spine with one goal in mind: does the person need surgery or not and they will have blinders on to almost every other non-life-threatening condition except that which will affect their focused diagnosis.
Chiropractors being the primary care provider for everything spine become the quarterback and we are required to pay attention to every issue in both triaging and following up with the patient. We are then responsible to determine work – ability, functional losses and every other facet of the patients care. If we do not have a complete list of diagnoses in the beginning of care than as the patient progresses and previously "gated pain" could become either not be consider or not covered because it wasn't initially documented.
The goal is to accurately report what is wrong with our patients as completely as possible. Historically most of us diagnose the primary problem area and ignore diagnosing the sequella as a result of the primary problem. When diagnosing every clinical issue should carries a diagnosis as long and is it corroborated in your history and clinical evaluation and/or testing findings.
An example would be headaches. If your patient was in a car accident where a whiplash or CAD (cervical acceleration deceleration) occurred you should be able to diagnose a closed head injury. In addition if there was any level of dizziness, sleep disturbance, nausea, cognitive losses or any of the other myriad of signs or symptoms of a concussion, you should also consider diagnosing concussion along with each of the sequella as a result of the concussion. The scenario above alone renders 7 individual diagnosis each with their own ICD – 9 delineation. (To learn more about concussion, take the Head Trauma Brain Injury continuing education course at teachdoctors.com, it is only 2 hours).
The same holds true for any joint problem. Should there be a problem with the joint you must also consider the ligaments of the joint, the muscles, fascia and possibly the skin above the joint in a trauma case. Each level should also carry its own diagnosis and ICD – 9 delineation. The clinical rationale is, rarely does a joint problem exist without connective tissue or muscular attachments being affected as well.
As a result it would not be considered inconsistent to have 15 to 20 diagnoses per injury if clinically present. In addition as I have reported previously you should also consider those diagnoses with a higher relative weight, again if clinically present.
When it comes to diagnosing there is a caveat: you must be credentialed in order to render the diagnosis in a legally defensible posture. This caveat is something that needs to be heeded to strictly so that you do not put yourself in jeopardy while trying to accurately diagnose your patient. The above example of concussion is a prime example of that caveat. Should you go to court or deposition with a diagnosis of concussion for your patient the opposing counsel can ask you what your credentials management concussion a patient or cross-examine you on details of a concussion. As a result you must understand concussion at a professional level with formal credentials and simply by looking it up on Google will not cut it. In addition upon reading your report and diagnosis list the plaintiffs attorney can also ask you a myriad and if you can't answer the questions accurately it will destroy your credibility as an expert and probably prevent future referrals.
Another example would be the diagnosis of "depression", (ICD-9 296.3) which as you can see carries a valid ICD – 9 code. However, that diagnosis can have tremendous negative ramifications for both your patient and yourself. One such negative ramification could be in your patient goes through a divorce and custody battle. If the opposing attorney for the opposing spouse gets a hold of the records of your patient they can site depression as a reason for not being a qualified caregiver to children and the reason for not being granted custody. In addition should an employer require past medical records for future employment, this could be a reason for not getting the job. As a result you leave yourself exposed to being sued for misrepresenting the condition of your patient, and/or defamation of the patient in a specialty that you are not trained. This comes directly from a divorce lawyer who has employed the strategy on many occasions.
In addition should you go to court the first question the defense lawyer will ask is are you a psychiatrist or psychologist? Then they will ask you what your training in psychiatry or psychology is and in an attempt to discredit you and then ask you why you are practicing out of your scope and render a diagnosis of which you are not trained to do. You then have an opportunity to justify your position as a primary care provider in the healthcare field in trying to explain why you came up with that diagnosis.
In the end you probably will prevail after much anxiety, but the jury would have already heard the objections and it would help to discredit you in the end. In an extreme scenario should patient be a sociopath or find themselves in a an unfortunate life situation and end up murdering someone you will potentially be liable to both your license and society for not taking definitive action on a condition you diagnosed. It would be much better to handle the situation by simply reporting in the history the patient appeared to be anxious and/or depressed and not diagnosis this mental state as I believe we are not qualified or have any training to handle depression or similar conditions.
Another issue is that of referrals and/or triaging. Should you diagnose a condition such as "loss of erection" as sequella to trauma, you now must consider a referral to a urologist. Your license as a primary care provider allows you to diagnose almost any condition known to mankind, however only treat within your scope. As a result for every diagnosis you render that is beyond what a licensed chiropractor in your state can treat you are mandated to render that referral and follow-up with your patient. An omission in a referral can lead to a licensure violation by delaying necessary care that you have already diagnosed the condition of.
Many of you have taken courses and/or attended seminars from both entrepreneurs and others who teach that expansive diagnosing will help prevent "lowball offers" to the lawyers of your patients. Both in theory and practice they are accurate in what they are reporting, however you must ensure that your diagnoses are accurate, legally defensible, non-inflammatory and do not expose you to potential future litigation. With that being said I support a complete and accurate diagnosis, no matter how lengthy the list.