Every claim file handler wants that first medical report to be a comprehensive document outlining the mechanism of injury, the history of the current illness or injury, a comprehensive review of the past medical history and thorough review of systems, a detailed physical examination and a cogent explanation as to what pathology occurred as a result of the compensable event. Six months into a claim, the file is thick. That first medical report is usually the thinnest document in it, and often the most honest.
Reviewing the Initial Medical Report
Or, on the other hand, that initial report may be brief, incomplete, and much less than a sophisticated assessment of what follows months after the date of injury. A brief report is not an unimportant one. The first report is the earliest clinical snapshot of what the injured employee reports to the treating provider. The perspective of the injured employee with respect to the mechanism of injury and the tangential factors can be quite telling. After the file becomes populated with clinical assessments, enhanced imaging studies, a specialist consultation diagnosis, and increasingly more complicated treatment issues, starting at the beginning can give you an indication on so many parameters. The experienced claim handler reads the first report as a baseline, not as proof that more treatment is required.
Defining the Compensable Injury
Let us start with the basics.
- What specific body part was injured and what isolated event caused the injury?
- Was this a lifting type of event, a fall, a twist, a direct blow, repetitive activities or something else?
- Did the overall symptomology begin immediately or was there a delay of hours or weeks?
- Is there a specific correlation between the anatomic location of the pain complaints relative to the reported mechanism of injury?
- If the pain involved the great toe, and the current symptoms involve the contralateral knee, this warrants a closer look before the scope of the accepted compensable injury begins to expand.
Inconsistencies Warrant a Closer Look
Compare the history in the first medical report with the employer’s first report of injury and or any recorded statement. Check the notes from the EMS run, if applicable. When those versions of the mechanism of injury differ, that inconsistency is often the most useful early signal in the file, and adjusters already have these documents in hand.
It is the mechanism of injury and initial objective clinical findings that drive the diagnostic analysis. Subsequent MRI studies should not rewrite the originally reported mechanism of injury.[1]
Symptoms Don’t Establish a Diagnosis
When assessing that initial report, those topics necessary to be addressed would include:
- Was it specifically noted where the pain is located?
- Was there radiation of symptoms, other symptoms such as numbness, tingling or weakness?
- Did the physical examination identify swelling or bruising?
- What specific functional complaints are noted after the date of injury?
And please remember that pain is merely a symptom. Pain complaints are not an objective finding or a diagnosis (contrary to the ICD 10 codes available).
Objective Findings Support the Clinical Assessment
The next step is the physical findings documented by that initial clinical evaluator. Are there issues of swelling, ecchymosis, focal point tenderness, a decrease in range of motion, strength issues, neurologic deficits, alterations in gait, or other structural abnormalities or other orthopedic tests? Conversely, a normal neurologic examination will tell you plenty.
A diagnostic label is a clinical opinion whereas examination findings are objective medical evidence.
When the Medical Report Falls Short
The next assessment must be the notation of prior symptomology, prior surgical or medical history, and taking note of the medications being listed as these are indicators of prior medical issues. Then look at the narrative offered by this evaluator determining what specific functional compromise is noted. Should this individual be at work? Or perhaps a return to work with restrictions that are appropriate for the injury sustained. Is there any objective basis for the restrictions assigned? Lastly, look for what is missing. Was a comprehensive neurologic examination conducted, particularly for cervical or lumbar spine injuries? Was strength testing completed? Was there any provocative testing, or documentation of similar symptoms prior to the date of injury? Was the assigned diagnosis supported by competent, objective, and independently confirmable medical evidence? Remember, a missing or normal finding does not prove this was a normal examination, it simply raises a small red flag declaring the need for additional clarification before the file becomes more complicated.
Does the Evidence Support the Diagnosis?
The first clinical assessment is rarely the final word on the compensable injury sustained or the treatment needed. What this is, is that very first step that takes you down the road to appropriate care in providing all the best clinical experience for that injured employee. A note that misses these data points signals the need for further investigation. Does the mechanism of injury fit the overall scenario? Are the symptoms presented consistent with the injury described? Does the narrative support a logical conclusion to the diagnosis assigned?
Claim Determinations Begin With Clinical Evidence
What the experienced adjuster today needs is not the selling of a diagnosis, but all comprehensive data necessary to support the determinations assigned. This objectified clinical information enables the work comp system to provide the best care to be delivered to the injured employee. Above all, the determinations must make clinical sense.
[1] Jensen MC, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331(2):69-73.
