Re: My approach to Patient Care and Documentation
The patient's current condition should be obvious from my latest and prior notes and recommendation about limitations. Any diagnosis I can provide is under "Assessment" in the initial visit note or the first paragraph of subsequent visits. If I can not state a specific diagnosis, I will provide the patient's complaints or symptoms as is medically prudent in hopes of not misleading either the patient or those interested in the patient's problems. The relationship of symptoms to an injury or accident as provided by the patient's problems, is as stated in the first paragraph of the initial work-up unless stated in the first paragraph of later visits.
My assessment of the relationship of the patient's condition to the industrial claim: I can only describe what the patient's provides unless without further agreement. I do not document the source of other pieces of information, as a recorder of patient information. The patient provides me with his or her impression, and should there be a difference between that impression and something you might have from somewhere else, I am not in a position to question the patient's integrity. This question has nothing to do with the care that I provide for the patient. Any information you seek from me related to historical discrepancies, other than specific diagnostic test results, will only be dealt with hypothetically but not specific to my patient.
I must take my patient's information as first hand, being untrained at questioning one's integrity. I must leave processing of contrary impressions to administrative process, except for diagnostic results.
The patient is medically stationary when he or she has had sufficient time to complete a home program physical conditioning either after undergoing surgery or having been debilitated by inactivity. I hope to keep the patient at work during the process. That is my medical goal according to the AHCPR Guideline #14 and other means of reliable information.
Is further treatment indicated? Usually this question arises as it either relates to surgery or no surgery, which should be obvious from my clinic notes. With or without surgery, I usually recommend home conditioning
to allow the patient to overcome any deconditioning of inactivity to improve comfortable activity tolerance. I fully expect that return to working status is the reason the question is asked.
Stanley J. Bigos, MD
Professor of Orthopedics and Environmental Health
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