How to Document Your Patient’s Injuries
Properly documenting your injuries is among the most critical pieces of building a successful claim. But what exactly does it mean to “properly” document your injuries?
Addressing this question is our goal. Although the letter is meant for your physician, it contains information that is of great value for you, the patient, as well. I urge you to openly discuss the issue of documentation with your doctor, and to offer a copy of this chapter to help facilitate this critical conversation.
Today in personal injury, your comprehensive medical examination, history and prognosis are tossed aside by the insurance industry in favor of norms embedded in silicone. The complex evaluation of your patient’s injury, which was in the past handled by a trained adjustor, is in many cases now delegated to a machine. For the sake of your patient’s insurance claim, it is important to understand what this machine considers in its evaluation.
Your notes should always indicate if immobilization was a part of your patient’s care. This care is something the computer understands and values. If a cervical collar was prescribed, be certain that your treatment record sets forth the dates and duration of immobilization.
As with human communication, it certainly helps to speak the same language. The computer’s language is comprised of what are called ICD-9 codes. Accordingly, all diagnoses should likewise be rendered in ICD-9 codes. In addition, it is also important to consider that computers, not unlike their human programmers, have a very small vocabulary when it comes to understanding what insurance companies euphemistically refer to as a “soft tissue injury”—a name the insurance industry uses to imply that if soft tissue is involved, the injury is somehow less compensable. Here is a list of some words, which, if they apply to your patient, may communicate the injury more effectively:
Limited range of motion Headaches
Dizziness
Anxiety (if it is treated by a mental health professional)
Spasms Radiating pain
These are just a few things that should be written down. Our office is here to assist you in all your needs.
If you or someone you care about has been in an accident, we’re here to talk.
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