Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 101
"More Narrative Tidbits"
Never say, “For the purposes of a final examination,” or “P-IME,” in a history.
Business format heading…always.
Always document that "The patient related the history to you." You weren’t there and will look the fool on the witness stand if you say otherwise.
Never, ever, ever abbreviate.
Grammar counts…You are a professional. Sound like one!
Too many are leaving out the diagnosis…Why???
Never use strain/sprain as a diagnosis…Read the consultations to find out why.
Treatment: On a narrative, do not put your treatment plan or how the patient responded to your great care…No one really cares. All that you list is the number of treatments, attach the SOAP notes, the number of re-evaluations and the reports from them.
Orthopedic Testing: List the name of the test, how it was performed and the significance of a positive test.
Do a complete examination, including motor, sensory, orthopedic, neurological and ranges of motion findings. JUST LIKE REAL DOCTORS DO!!!!
List muscle spasticity in simple terms.
Avoid nonsensical statements like, "X-ray findings reveal the presence of a sprain/strain soft tissue injury."
Do not quote research; it is non-admissible.
Do not make up a diagnosis like “post-traumatic radicular symptoms that radiate down the radial nerve.” That does not exist. Use ICD language with the exception of herniated discs.
Stop causally relating disc bulges to the accident. If you do not know why, you must take the MRI course….This one issue will invalidate you as an expert…It is a BIGGIE!!!!!