Your first visit with a new PI patient usually occurs 3-10 days after the car crash has occurred. They have been hurting almost constantly after the initial surge of adrenaline wore down about 8-10 hours after the wreck. As the adrenaline goes down, their pain can become more evident. The patient goes to the Emergency Room and gives the triage nurse a detailed history of what happened and what hurts.
After the patient leaves the emergency room, they go home and the one pain area they shared with the doctor in the ER triage now, 24-36 hours later, becomes 3 or 4 additional body areas that are producing pain. For example, after the wreck, they may have had pain when they presented at the ER of “neck pain” only . Then later, they go home and wake up the following day with mid-back, low back pain with radiation down the right leg, in addition to the original neck pain. They take medication provided by the ER, as well as OTC medication. The pain does not go away, gets worse, so they decide to make an appointment for a day or two later to come see you.
The patient then comes into your office and fills out a detailed accident history questionnaire where you ask them to provide a detailed history of when their pain began.
This is Where The Problem Starts
When your new patient completes the detailed history form, you ask them to share with you, subjectively, what hurts. They put “neck, mid back, low back, and right leg”. Then your next question asks them, “When did your pain begin?” They put “Car Wreck 4 days ago.” The problem is, when you dictate your notes, you will likely put something to the effect of “New patient presents with history of neck, thoracic, and lumbar pain with radicular complaints, all of which began immediately after an MVA 4 days ago.”
Do You See the Potential Problem Here?
Let me show you how this plays out in the real world of litigation. Let’s fast forward a year later when you are getting deposed by the insurance company’s lawyer. Here is how questioning from the insurance lawyer might very well go, based upon the above scenario:
Q: Dr. Smith, when a new patient comes to see you, do you take a history?
Q: And is it important to take a detailed history from your patients?
Q: And is it important for your patient’s to be honest with you when they give you their health history?
A: Of course.
Q: And that is because if their history is not accurate, then your opinions might be inaccurate as well, true?
A: Yes, possibly.
Q: Well, let’s look at Ms. Jones history. Did she tell you when she first came to see you that she was in a car collision on [June 1, 2016] ?
Q: And did you ask her when her what pains she was having after that collision?
Q: And did she tell you that she had neck pain, mid-back pain, and lower back pain that began immediately after the car accident with my client?
Q: Doctor, have you ever seen the ER record from Williamson Medical Center for your patient, Ms. Jones?
Q: I want to show it to you. Take a minute to read over it, please.
Q: Doctor, tell us please, where on that entire ER record does Ms. Jones complain of mid back pain?
A: I don’t see that she did.
Q: Tell us where she complains of low back pain following this wreck?
A: I don’t see that she did.
Q: And tell us where she had complaints of right leg extremity weakness or tingling?
A: She did not have that complaint in the ER.
Q: Yet she told you that all of her pains began immediately after this wreck, true?
A: Yes, she did.
Q: And doctor, you are providing opinions today that this lady may need a back surgery which you relate to the car wreck, in part based upon when she told you her pains first began?
So, How Do You Fix This?
Here are three helpful suggestions:
1. Require your patients to bring you the Emergency Room medical record
As a matter of practice, I provide the ER records to all of my clients’ doctors to make sure they have a complete picture and can look at the patient’s medical care in proper context. This also includes showing them prior medical records if they have similar prior injuries. If you did not do this, then see #3, below.
2. Make sure your patients are aware of giving you a very detailed accident history.
Take some time with them when going over their history. You have to rely on what they tell you. Simply make sure they understand to tell you when each pain began. If they don’t know, it is better to err on the safe side and simply state that the pains began “sometime following the MVA”. If you use the term “immediately” then you should be very sure that is true, and your patient should understand that immediately means immediately.
This is elementary for obvious objective injuries (i.e. fractures) but not so much for soft tissue injuries.
3. Correct your record if it is wrong.
If you later learn from your client or from medical records that your initial note is incorrect, you need to supplement the note. The insurance adjuster and their hired gun defense attorney pays closest attention to your initial intake notes and paperwork completed by your patient, and your discharge summary. If your intake is off a bit, and you later get the ER records, take a look at them while you are completing your discharge summary.
You can only go on what your patients tell you. Most of the time, any discrepancies or errors are not done intentionally by your patients. They simply do not expect to have to file a lawsuit later in their case. Your patients do not realize how extremely technical the insurance defense lawyers will be in trying to infer your patient is being dishonest with you. Your patients do not understand that exactly when their pain began will be one of the number one defenses to their claims by the insurance company lawyer. Insurance defense lawyers wish to infer that your patient is a liar, or is embellishing the truth. This is why I educate my clients so heavily in the initial stages of how the insurance lawyers think, and how to beat them at their own game. Educating them on why getting their health history exactly right is extremely important. Don’t let the insurance company dictate your client’s, and your, credibility.