5 Must Have Details of PI Medical Records

As a certified chiropractic insurance consultant, I have performed numerous utilization reviews for med-pay claims. The most common reason an adjuster requests a review is due to the poor quality of the medical records.

In most cases, the denial of services is due to the lack of proper documentation: in short, the docs fail to prove the medical necessity of their care. The biggest problem is too many docs tend to document the personal injury care in the same manner as a health insurance case. By doing this, they fail to include key elements that relate to the injury and can have the unfortunate results of reduced payment.

5 KEY NECESSARY DETAILS

There are 5 key components that should be included in the medical records to effectively document and establish medical necessity. They include: the mechanism of injury, proper diagnosis, complicating factors, treatment rational, and prognosis.

1.    MECHANISM OF INJURY: The absolute first essential component is the mechanism of injury. This establishes the causal relationship of the physical impact to the subjective complaints and the objective finding.

Medically documenting the causal relationship requires including the three following key elements from the patient’s history. (1)

  • * “There must be a biologically plausible or possible link between the exposure, and the outcome.” In other words, the description of the impact must match up with the presented injuries.
  • * “There must be a temporal relationship between the exposure and the outcome.” Such a determination requires an accurate documentation of the signs and symptoms of the condition of interest both before and after the exposure of interest. Additionally, the outcome cannot postdate the exposure by a period that is considered, from a clinical perspective, to be too long or too short to relate the two.
  • * There must not be a more likely or probable alternative explanation for the symptoms.

2. DIAGNOSIS: Based on examination, the diagnosis is formulated. In many instances, only strain/sprain of the neck or back are diagnosed. However, in many collisions other injuries occur that must be noted. Some common ones:  include concussion, post-traumatic headaches, dizziness, tinnitus, contusions or abrasions, shoulder or hip impingement, strain/sprain of the wrist, foot or ankle, as well as rib sprains.

3. Complicating factors are a key to note in the records as they impact the type, duration of care and prognosis. Many individuals, especially the elderly, have other health issues that can be complicating factors in their recovery. Common conditions include advance age, disc protrusion/herniation, prior vertebral fracture, metabolic disorders, spondylosis and/or facet arthrosis, osteoporosis or bone disease, congenital anomalies of the spine, foraminal stenosis, development anomalies of the spine, spondylarthropathy, paraplegia/tetraplegia, degenerative disc disease, prior cervical or lumbar spine surgery, Prior spinal injury; scoliosis. (2)

4. TREATMENT RATIONAL must be based on the commonly accepted standards of care. Two of the most commonly used regarding personal injury are The Quebec Taskforce and Crofts Guidelines. Both categorize cervical injury into 4 and 5 basic categories with typical time frame of care. Each is subject to modification based on complicating factors.

5. PROGNOSIS: Multiple studies indicate that approximately 50 percent of those sustaining a neck trauma, whiplash associated disorder (WAD) will continue to report ongoing pain and disability one year after injury. (3,4) NOTE: A RECENTLY PUBLISHED ARTICLE JUNE 2022 states 89% still suffer pain 5 YEARS AFTER THE ACCIDENT!

The most consistent risk factors for poor recovery are initially high levels of pain reported and higher levels of disability. (3,4,5) An initial pain scale on visual analog scale (VAS) greater than 5.5 and scores of 29 % on the Neck Disability Index are the most consistent factors to predict poor functional recovery (5).

These five key elements are essential to the proper documentation of a personal injury case. When included, they establish the casual relationship, medical necessity of care and are more easily defensible when questioned by the adjuster.

Our office strives to offer the most accurate documentation of your client’s personal injury care. We receive regular compliments on the detailed thoroughness of our records. We’ve been told by some attorneys; our records are better than the orthopedist or PT records they frequently receive.

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1. A Systematic Approach to Clinical Determinations of Causation in Symptomatic Spinal Disk Injury Following Motor Vehicle Crash Trauma – Michael D. Freeman, PhD, MPH, DC, Christopher J. Centeno, MD, Sean S. Kohles, PhD

2. Croft AC:  Treatment paradigm for cervical acceleration/deceleration injuries (whiplash).  Am Chiro Assoc J Chiro 30(1):  41-45, 1993.

3. Sterling M (2014) Physiotherapy management of whiplash-associated disorders (WAD). Journal of Physiotherapy 60: 5–12

4. Course and Prognostic Factors for Neck Pain in Whiplash-Associated Disorders (WAD), Eur Spine J (2008) 17 (Suppl 1): S83-S92

5. Walton D, MacDermid J, Giorgianni A, Mascarenhas J, West S, Zammit C. Risk factors for persistent problems following acute whiplash injury: update of a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2013;43:31–43.