Academy of Chiropractic’s


Lawyers PI Program


#155

 From the Desk of:

 Mark Studin DC, FASBE (C), DAAPM, DAAMLP

 

“The Top 10 Narrative Mistakes”

 

1. Due to the loss of lumbar lordosis, it can be assumed that there has been tearing and overstretching of the synovial tissue that surrounds the articular capsules of the spinal joints. The overstretching of these synovial joints can be the cause of malpositions along the above referenced lumbar vertebrae.

Assumed...can be, should have, would have...blah, blah, blah...All of these are admissible, but you are providing the court with documents you do not want to be seen. That is the problem. This language can be construed as "could" or "could not." Only discuss what is in the affirmative. Detail what you patient DOES have, not what they could have.

 

2. This type of traumatic injury, with many tissues becoming involved at different levels, has largely affected the future functioning of the individual. 

I wasn’t aware that crystal ball readings were taught in professional school nor will the courts believe it. Only discuss what is, not what could be.

 

3. According to Dr. Smith’s MRI report, dated August 18, 2008, this patient has suffered from not only a disc protrusion at the L5-S1 level, but also an annular tear at the same involved region.

It is abundantly clear that this radiologist is a general radiologist and doesn’t understand spine...and neither does the doctor that wrote this in their narrative. If you want a prime reason why some doctors have huge practices and others don’t, here it is. The protrusion, by definition, has to have the annulus torn, therefore making this a redundant statement.

 

4. This type of injury heals with scar tissue and tends to leave the spine in a less resilient, less flexible state

“This type of injury.” What type of injury? You have the latitude to only discuss your patient’s injury and nothing else or you will “look the fool.”

 

5. The first stated symptom is neck pain...the second stated symptom is...

Do you know of anyone who writes like this or even talks like this? I don’t and neither do the courts. In fact, this type of language sounds and reads as if it was generated by a computer and not a person because it is. The courts will then consider that statement not specific for you patient and consider striking your whole report. This is too common and a simple fix. As rule, computer generated narratives cause more grief than they are worth at the end of the day. Utilizing the computer generated reports are efficent in the short run and often catastrophic in the long run. Most specialists, dictate their reports and do not use computers for this very reason. I have given you a system that works simply and takes virutally no time to complete.

 

6. DIAGNOSIS: Mr. Holt has acute hyperflexion hyperextension injury to the cervical and lumbar ligaments and muscular structures with spasm and soft tissue injury causing ligaments instability of the joints and possible disc injury, with resulting nerve root irritation and brachial neuritis of the right arm, with complication of neurovascular disturbances (headaches, dizziness and blurred vision), and a possible crush fracture at C5 and C6.  He is being sent for an MRI for differential diagnosis.

I checked the ICD-9 and there are absolutely no descriptions that match these. Use exact language of the ICD-9 with the exception of herniated discs. For those, list either bulge or herniation.

 

7. PROGNOSIS: This patient will be placed on a regimen of conservative care consisting of physical therapy for approximately two (2) to three (3) months with periodic evaluations..

This is a classic. First, it is not a prognosis, it is a treatment plan and second, if there is a future treatment plan, why is the doctor writing a narrative to discuss the permanencies of the injury? Treatment plans indicate that there is more progress that can be made and the patient’s injuries might resolve. Lastly, look at the double punctuation at the end. Grammar counts!

 

8. Emergency Physician record, and VA, from Providence Medical Center dated March 11, 2007.  The handwriting in these notes is difficult to discern.  Pain drawing indicates a circle at the left posterior cervical region.  Corresponding note is illegible.  Three prescriptions are given. They are difficult to read. They appear to be for Vicodin, Darvocet, and Ibuprofen.

You are saying that you can’t read the notes and you think you guessed right, but never bothered to inquire as to the accuracy of the information. With that “really good guess,” you formulated a diagnosis, prognosis and treatment plan and began care. It is this type of “amateur hour” that will cause you to lose your license...It’s only a matter of time until someone gets hurt when you treat without accurate information. What’s even worse is that this doctor wrote on a public document to the courts that he didn’t practice within the standards of his license.

 

9. Dear Mr. XXXXXX,

The patient, Andrea XXXXX, presented to my office on Monday, September 17, 2007, for examination and treatment of injuries she sustained in an automobile collision which occurred on Thursday, September 06, 2007.  Her last examination was performed on Monday, November 26, 2007.  The following is the final report of my findings and conclusions pertaining to this patient. 

First and foremost, the entire report of this doctor is inadmissible as it is based upon an examination performed 9 weeks post trauma. The patient is still supposed to have residual problems that soon after an accident. There needs more time than 9 weeks to certify permanent sequella from an accident.

 

10. Lumbar AROM: flexion 70º, extension 5º, ® lateral flexion 15º, (L) lateral flexion 20º, ® rotation 30º and (L) rotation 10º.   Cervical AROM: flexion 50, extension 30, ® lateral flexion 40, (L) lateral flexion 25, ® rotation 45, (L) rotation 25

First, never abbreviate. Did you use a device to determine the range of motion? If you did a visual exam, then this is unacceptable according to the AMA Guide to the Evaluation of Permanent Impairment, 5th Edition, pages 398-400. With a visual analysis, you can only write normal or restricted with or without pain. Although the AMA Guides has a 6th Edition, which is out over 2 years now, the 5th is still the standard for ranges of motion.