Academy of Chiropractic’s Lawyers PI Program
From the Desk of :
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
"Reporting Work Loss & Earnings"
Work status is extremely important to document in many formats. It is usual and customary to ascertain the beginning of care if the patient is working or not as it can lead you to different lines of questioning as to what they can do, can't do, what they are doing that can hurt themselves or what you need to do to modify their work.
This is different than disability status and needs to be explored starting at your initial intake. Many lawyers will contend that doctors need to document the specific financial loss of our patients. I contend that is the job of the lawyer and not the Doctor as that information has no bearing on our prognosis, diagnosis or treatment plan.
We as primary health care providers for everything spine must pay careful attention as to what a person does on a daily basis that can create exacerbations or further damage the already injured tissues and structures. This is where decisions are made as to whether work modification is required, a leave of absence is required, bracing is required or creation of focused exercise rehabilitation.
In your daily SOAP Notes you must also continually document the persistence of those modifications at work. The initial documentation should include what the patient is required to do at work such as continual bending, lifting, standing, carrying, sitting, etc. This will set the foundation and clinical rationale for your recommendations.
Currently millions are self-employed with many working at home. As a result the lines often get blurred as to what a person does on a daily basis and the physical demands. These people and occupational circumstances cannot be overlooked and might take a little more probing to come up with an accurate picture so you can help create the best prognosis and treatment plan that includes work and/or lifestyle modifications and/or supports.
It is also critical to document how long the person has not been able to work, which is usual and customary in all medical reports.