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The Importance of Documenting a Detailed History

Personal Injury3
Any encounter with a new patient always begins with the initial history. An experienced doctor understands that asking the correct questions can guide the examination and treatment of their patient. In the case of musculoskeletal injuries, the how it happened is vital to putting the pieces together. With a motor vehicle crash, certainly some of the history will be included in the Police Report such as direction of impact, approximate speed, road conditions and liability. Other qualifying questions about how the patient was situated at the time of impact need to be asked as well. These are of paramount importance in being able to explain the mechanism of injury should the need arise.
Examples of additional qualifying and clarifying questions might include:
  • Did they have the foot on the brake?
  • Were they aware of the impending impact?
  • Were both hands on the steering wheel?
  • Where on the steering wheel were their hands positioned?
  • Was one hand on the shifter?
  • How was the head restraint adjusted?
  • Do they drive with the head restraint touching the back of their head?
  • What were they looking at when they were hit?
  • Was their body turned?
  • Were they reaching for something?
  • How was the seat adjusted?
  • Did it move as a result of the collision?
  • Does their time line a account for every second after the accident? (People don’t often realize they lost consciousness)
  • The lists goes on…

Crash Reconstruction – Making Sense of the Mess

The point is, the answers to these questions can often explain why two occupants in the same vehicle often present with very different sets of injuries. For example, a belted driver being rear-ended at 15 mph with both hands on the wheel at 10 and 2 position with no back set, will most likely only experience hyper-flexion of the neck. Contrast that to the belted passenger who was turned to her left reaching for something in the back seat. Because the passenger is “Out of position,” she is at a much greater risk for both hyperflexion and hyperextension to the cervical spine, brachial plexus traction on the right, left shoulder impingement syndrome, left rotator cuff injuries, left costo-thoracic sprains, left SI and possibly lumbar disc injuries ( depending upon severity of impact.) A physician who has been trained in documenting and interpreting crash dynamics can explain the mechanism behind what may appear to be a disconnected set of injuries to an insurance adjuster reviewing the case file. The science of crash reconstruction hinges on collecting s much crash data as possible. When all the pieces of the puzzle are gathered such as relative speed of vehicles, impact vectors, body position, etc….then the other important data can be extrapolated such as vehicle acceleration, body mechanics and more importantly, occupant peak head acceleration.
Getting an accurate history can and should be one of the most time consuming aspects to the patient initial encounter. Often the time required to elicit a proper history will exceed the time spent on the examination. Also as stated previously, a good history will guide the doctor as to what types of injuries he will likely encounter in the exam. Some injuries will be obvious such as cervical strains. However, some other injuries may be more subtle and not become grossly obvious for several weeks to even moths down the road. Tempomandibular joint (TMJ) and mild traumatic brain injuries (MTBI) are two examples of slow to manifest injuries. If these are not identified in the early history and exam, it can often be hard to draw a line of causality later.

“If it isn't in the record, did it happen?” 

This brings us to the last topic of Documentation.  There is no doubt in my mind when doing a Peer Record Review, that there was a wealth of information exchanged between the patient and his doctor during the History and treatment phase of care.  To be blunt and forthright, writing things down is quite possibly the least enjoyable aspect about working in health care, which probably explains why record charting is often put off until later in the day.  We all like to think our memories are steel traps.  However, after several hours and multiple encounters things can get jumbled.  At settlement, the only thing we will have to reference are the medical records.  Common red flags I find when reviewing a chart are;
1. No history as to casualty.  The doctor never connected the dots between the crash and the patients’ injuries.
2.The billing records are not mirrored in the treatment notes.  This situation allows for an easy attack of the doctors credibility.    
3. Subjective statements are not mirrored in the objective documentation.  
4. No periodic comprehensive examinations.  
5. Work history / restrictions absent.  
6. Quality of life assessment absent.  The effect an injury has on someone’s daily activities.  
7. Lack of co-management with other Specialists or testing.
8. Diagnosis does not correlate with the length and/or extent of care administered.
9. No Goal setting...how did the doctor determine the amount of care needed?
10. Past History lacking.  Is there a prior history of pain?  Have there been other accidents? Again, this omission sets the Treating Doctor up for the inevitable cross examination question….”Doctor, would it change your mind to know…?”   (fill in credibility destroying question)”.  
A well-documented chart should read like a story with each clinical decision explained and each conclusion substantiated.  
Xavier Martinez, DC

Special Points of Interest

Is the Police report all you need?
The out of position occupant
Crash Dynamics
Mild Traumatic Brain Injury (MTBI) and TMJ injuries
The Medical Record