Academy of Chiropractic’s
Lawyers PI Program

Narratives #32 

From the Desk of:



"The Narrative NOTE" 

A Critical Breakthrough in Narrative Reporting


Over the last few weeks I have taken on court cases so that I can keep myself fresh and current as to the standards of the courts. In doing so I have worked with multiple attorneys on multiple national issues. Concurrently I have been lecturing to lawyers lawyer groups and trial lawyer associations nationally. During these presentations I have been discussing the specific narrative issues with these large medical legal groups and I have been able to work through challenges and objections that need to be overcome when trying to illustrate the truth with "words" as your only palate. 
The goal in the narrative is to be able to report accurately without "putting words in the patient's mouth" and preventing a third-party from putting their "spin" on your words. As ridiculous as it sounds I spent almost 50 hours on one report and in the end accomplished my goal with 2 simple sentences. What I realized was that I had an opportunity as the expert to qualify either the intent, result or reasoning behind the patient's history, complaint, imaging finding, functional loss or any other issue pertaining to a patient's report in the narrative types scenario.
It is this level of qualification that takes your narratives to a level NEVER realized previously in the medical profession and it is all based upon your clinical excellence. The lawyers that I worked with were so pleased they professed their admiration to both myself and the dedication and unrelenting resolve I had in illustrating the truth. They also wanted to refer dozens of more cases to me "at any price  although I politely declined as my first responsibility is to you and not have the bulk of my time taken in the courtrooms. I will however, continue to go back into the courts yearly to stay fresh. 
How this works:
 This is accomplished through a simple "Note" at the end of a section. The best way to illustrate this is for example: 

Mrs. Patient stated that for the first few days she felt as if she was in shock with "cringing and shaking". Within the week she felt pain in her face, which was severely swollen and pain in her neck, shoulder, side, arms and fingers. Within a few days the pain escalated to headaches on a visual analog scale of 7 out of a possible 10 which came about 3 times per week. She also experienced severe left jaw pain on a scale of 8-9/10, left neck and trapezius pain at 7/10 and left shoulder pain at 6/10.

NOTE: The inflammatory process post-trauma maximizes at 72 hours post trauma. Therefore for Mrs. Sakowitz to experience soreness immediately post trauma and then the pain and symptomatology to exacerbate starting a few days later is clinically consistent.

As you can see in the note above, after the initial history and inserted a note about why the patient did not have significant symptoms initially. There are many defense lawyers or medical experts that would simply say because the pain was not experienced initially that the subsequent pain was not causally related. Without the note I would be giving "interpretory" license to the reader or interpreter to spin this any way they choose. With a note I qualify my statements with an explanation to explain my opinion and conclusion about the previous statement. 
The following sample qualifies a previous injury and prevents a third-party from misinterpreting my opinion on causality: 

Ms. patient's past history is significant for a previous automobile accident in 2004. Her previous injuries according to records reviewed were a posterior disc herniation at L4/L5 and severe pain in the right thumb requiring surgery on 12/17/2004.

She received therapy for approximately 1 year. She has had no treatment or problems in her neck or back since approximately July 2005.

NOTE: Since Mrs. Lopez has had no treatment or complaints for 4 years no apportionment is clinically indicated or warranted, however the previous accident predisposed her to greater risks of bodily injury with less force as will be explained later.            

The note above qualifies this patient's previous history as being noncontributory to the current injury and certifies that no apportionment is warranted. Without this note a third-party could interpret this to saying that there was a previous injury and a portion of the current problem is attributed to this accident nine years ago. This note clarified that issue with no room for interpretation. 

The next sample describes how to clarify in imaging report: 

NOTE - MRI Discussion: 
In reviewing the images, due to the limited studies on the earlier films, it is critical to consider clinical correlation in concluding an accurate diagnosis. My opinion was validated by Del Grande in their published 2012 report indicating that a "close communication between clinician and imager" (page 640) is required for an accurate diagnosis and causal relationship.  The 2004 study revealed a small central lumbar herniation that appears resolved and has degenerated into a disc bulge (bulge and degeneration are synonyms). As a result of the ligamentous failure (discs are ligaments) the segment above and below function aberrantly biomechanically and over time bulged as evidenced in the 2009 images. The 2012 images showed even further degeneration.

The herniated disc at L3-4 affects the L4 nerve and innervates the upper front and back of her legs, which clinically correlates to the exacerbations of pain and numbness she experiences. This explains her pain and reason for measures as significant as the epidural she received 2 months ago. Although the current MRI indicates that there is a bulge in the L3-L4 region, it is because the herniation desiccated over time and resorbed. However, the resultant disc bulge has left a mass effect on the thecal sac causing compression and explains her current pain that has persisted with resultant functional losses that are detailed in the conclusion.

This note allows me to explain the MRI findings and how they relate to the current injury and the resultant symptomatology of my patient. It is through this note that I am able to clinically correlate the imaging findings to clarify how they are related to both the injury and my patient's current symptomatology. Without this note, it again leaves open to interpretation if the injuries are causally related and connected to the symptoms. Although my narrative conclusion that all sizes the entire case it does not leave me enough "digestible" areas to write my rationale. 

Although you want to ensure that all of your aliens and findings are clear you do not want to overdo your utilization of the note field. It must be strategically utilized to fully clarify potential "spin – able" findings. Remember, your goal is to both report the facts and since this is a narrative your opinion as an expert must be fully and clearly explain. 

In the end your opinion will be accepted only to the extent that your credentials bolster the validity of that opinion.