Academy of Chiropractic’s Lawyers PI Program

Narratives 47

From the Desk of :
Mark Studin DC, FASBE (C), DAAPM, DAAMLP

"Initial and Re-Evaluation History"












History taking is critical in every evaluation and re-evaluations and problems arise with either omissions or shortcuts. The most common action is that of limiting your report to the "primary complaint". Understanding this is usually the focus of the specialist, such as the orthopedic surgeon, neurosurgeon or a neurologist who focuses their entire examination on only what they will directly treat it is quite different with chiropractic.

Chiropractors are considered primary care providers through your scope of practice and we are working very hard to be considered the primary care of spine for all primary care medical providers to refer to. Those 2 statements would appear to contradict the opening statement. Although we want to be considered the primary care for spine, our license dictates that we consider everything going on within the human body as the patient enters our office for the purpose of triage and potential co-management of the patient. However, it is our responsibility from a neuro-musculoskeletal perspective to go from the tip of the head to the bottom of the feet when doing the complete history and it becomes more critical in a trauma case.

To accomplish this you must often get the patient to take their focus away from their primary complaint. This starts when I am taking a history and I ask them what hurts. After listening to their explanation I will then instruct the patient to focus away from their pain and answer the following questions. "Do you have pain on the top of your head? On the side of your head? On the back of your head? On the front of your head? In your eyes? In your ears? Do you ever have ringing in your ears? Do you have spots in your eyes? Do you have pain in the front of your neck? In the back of your neck?… And so on.

I will ask them to focus on every joint in their body from the neck down with also asking them questions about breathing, bladder and bowel functions. Historically in almost every case the patient responds as follows "oh my goodness, I do have pain in my elbow and I didn't realize it, I am glad you asked". These secondary problems are usually "gated" off by the primary pain and often never get reported and that is HUGELY problematic.

Another issue is location descriptors. I have read many reports where left and right was reversed and as simple as that sounds it is "often the kiss of death" in court or settlement proceedings.

PQRST

For the layperson the above string of letters means nothing, however for a Doctor it is what we are trained to do. Pain, quality, radiation, severity, time all needs to be documented in the history. Where does it hurt, what is the quality of pain (sharp, stabbing, radiating, throbbing, burning, etc.). Radiation of pain is critically important because it underscores the possibility of radiculopathic component and/or the type of compressive neuropathy. This often sets the table for advanced imaging such as MRI or CAT scan and neuro diagnostic testing such as an EMG/NCV.

Severity is reported usually by mild, moderate or severe. This is usually determined by how much of the day the patient is in pain. It is usual and customary to report:

Occasional: 0-25% of the day
Intermittent: 26-50% of the day
Frequent: 51-75% of the day
Constant: 76-100% of the day

This level of reporting, which is usual and customary is critical to include as it communicates a more complete picture of the patient's pain pattern. However, most EMR systems plug-in the percentages after reporting each body part and level of severity. An example of such would be the patient has intermittent neck pain (26 to 50% of the day), right shoulder pain intermittent (26 to 50% of the day), intermittent low back pain (26 to 50% of the day), and left knee pain that has frequent (51 to 75% of the day).

This reads very poorly in report format and has the appearance of "computer – speak". This means if it is read in either a deposition or court you will give the appearance of not customizing the report for your patient and that appearance can often be perceived as reality. If you're going to report in tabular format, or in a preliminary report that has checkboxes reporting in such a fashion, that is fine however in narrative format it is highly unacceptable and will open you to potential difficult cross-examination by the defense attorneys. Therefore it is strongly suggested that if you are going to use this reporting of severity you list what the percentages are at either the top or bottom of the section of the report to render a key or explanation.

If the EMR systems do this, it can be explained during a lengthy direct, cross examination and re-direct testimony of why it is customized and reported as such however, this type of narrative reporting will not render any negative appearance and help you avoid that entire line of questioning.

TIME: How long has the problems persisted or how long the patient has been, or was in pain. This is a critical section as most states have statutes to certify injuries as permanent in order for a case to move forward and are often triggered by a time component. In addition insurance carriers often value cases by the same time parameter. Therefore how long the patient has been pain because a critical factor and must be accurately documented in a "care continuum" in each evaluation and re-evaluation.

In re-evaluations reporting the time of treatment is another critical area. First, it is incumbent upon you to accurately report the continuum of care of your patient and type of treatment they received. From a medical – legal – insurance perspective many states and carriers have a 90 day treatment rule where if care is less than 90 days there is often no case. I share this with you for background information as it should have absolutely no bearing on your diagnosis, prognosis or treatment plan.

In a trauma-based case there are 3 common issues in most patients:

  1. Range of motion problems
  2. Muscle spasms
  3. Radiation of pain

In every re-evaluation you should include questioning of your patients on all 3 of these issues and pay careful attention to the PQRST component for all 3 and document as such. Omissions could be problematic as they could significantly alter your treatment plan and prevent you from ordering necessary tests.

In addition the following are often and need to be considered:

  1. Headaches: you need to document duration and frequency
  2. Dizziness: this is usually experienced right after the accident and getting linked to visual disturbances or tinnitus
  3. Anxiety: this can be linked to sleep disturbance or posttraumatic stress disorder
  4. Temporomandibular joint(TMJ): this can be linked to sleep disturbances and a possible symptom of neck injuries

Triage note: Should your patient have posttraumatic anxiety it is therefore incumbent upon you to refer the patient to either a neuropsychologist or a trauma-based psychologist for further testing and treatment.

When reporting the accident history in the past I have clearly outlined in previous consultations to omit items that belong in either a police report or accident reconstructionist report. However it is critical to report if the patient was hospitalized and how they got there. Were they taken from the accident scene via ambulance or transported privately from either at the scene or after they got home due to the persistence of pain. In either scenario this now paints a complete picture of the accident history. It is also critically to report if the patient was admitted in the hospital, what type of testing was performed, was surgery performed, with medication dispensed, or any supports, etc.

Medications: Medication is therapy in the medical-legal-insurance world. It is also consider a valid form of therapy when considering gaps in care as this also includes over-the-counter self-medication because the patient is actively treating themselves. Prescription medication is easier to document because of the paper trail involved, however when considering active versus passive care all should be documented and will help explain those gaps.

Too many chiropractors believe that if no adjustments were rendered, no care was had and that is both myopic, not factual and prejudicial. It is important to note, from a "getting better perspective" that an aspirin or a Advil is a joke, but in the medical-legal-insurance systems, it is considered care and a valid form of therapy.