Academy of Chiropractic’s
Lawyers PI Program


Narratives #29
 
From the Desk of:
Mark Studin DC, FASBE(C), DAAPM, DAAMLP

 

 "Proper History Reporting" 


The following is a typical history documented by a doctor:
 

"The patient was the restrained passenger of a compact car that was turning left off of Stills Road onto the turnpike in Sometown USA, when another compact car ran a red light going approximately 50 mph and hit Mrs. Smith on the passenger side of her car forcing the car off the road where she hit the curb and had a violent impact with the guard rail on the side of the ramp.  The collision caused Mrs. Smith’s head to hit the steering wheel and she was thrown about within the confines of her seatbelt.  She immediately began to experience neck and back pain, left knee pain, left wrist pain and right ankle pain.  She went to Community Hospital emergency the following day due to continued severe pain." 

Let's dissect the reporting process:

 The patient was the restrained passenger 

Good 

of a compact car 

Good 

that was turning left off of Stills Road onto the turnpike in Sometown USA, 

How do you know? Where you there observing?

 going approximately 50 mph

Did you have a radar gun on the car at the time?

 when another compact car ran a red light and hit Mrs. Smith on the passenger side of her car forcing the car off the road where she hit the curb and had a violent impact with the guard rail on the side of the ramp. 

How do you know? Where you there observing? Are you an accident reconstructionist where you have reconstructed the accident site? Were you stopped at a red light? the sentence makes no sense with the reference to the red light. What is the patients' relationship to the red light?

The collision caused Mrs. Smith’s head to hit the steering wheel and she was thrown about within the confines of her seatbelt.

 

How do you know? Where you there observing? 

She immediately began to experience neck and back pain, left knee pain, left wrist pain and right ankle pain.  She went to Community Hospital emergency the following day due to continued severe pain 

How do you know? Where you inside her body? 

These are all questions a good defense lawyer will ask upon cross examination and things a sharp plaintiff's lawyer will see in your report that will want them to NOT WORK WITH YOU. Most doctors feel they have great narratives and know that first hand because they have either been on the witness stand or they have a solid group of 3-4 lawyers that work with them for years. 

That is the problem...only 3 or 4, not 30 or 40 because if your work was that good, they would all be flocking. These are the nuances that destroy relationships. This is one "hole in the bucket" that we will fix. 

The following is an appropriate level of suggested language that will be widely accepted and admissible. 

"Mrs. Jones was a seat belted driver who reported that she was making a left turn and her car was broadsided in a "T-Bone" fashion by an oncoming vehicle at a rapid speed. She recalls that her car was thrown to the side of the road where it struck multiple objects before coming to rest. She recalls her head striking an object inside the vehicle. She also reported immediate pain in her neck and back pain, left knee pain, left wrist pain and right ankle pain, however she didn't go to the hospital. The next day, the pain was so severe she stated that she had to be driven to the hospital to be treated.

The mechanism of injury is reported only to the extent that is lends information in creating a medical diagnosis. Any additional information is the job of the lawyer, the police and an accident reconstructionist. IF...you have credentials in accident reconstruction or biomechanical engineering, then you can delve further into the nature of the crash. However, you must be careful as too many doctor write what they perceive is reported by the patient, only to have multiple versions of the same accident told in too many ways. This makes for an inaccurate picture. 

Therefore please limit your comments about the accident history to only that which is required for you to make an accurate diagnosis, prognosis and treatment plan.