Accurate Standards in Documentation

Accurate Standards in Documentation

by Dr. Mark Studin DC, FASBE, DAAPM, DAAMLP


It’s 4 pm and I have just completed critiquing my fifth narrative created by a chiropractor for both a lawyer and an insurance company. After many years and hundreds of reports, I know within a minute what pattern this particular doctor will fall into and what they will omit. My role is to critique reports and make recommendations to the doctor about how to communicate the truth in an admissible format. The problem I continually face is that doctors are not factual. They are misinterpreting the facts or lying, synonymous terms, in their reports that can’t be fixed by another party. It is the doctor’s responsibility to tell the truth.

Integrity is one of the basic foundations for success and is non-negotiable. That is an innate law.

Lying comes in many forms and slinging bull at the professional level is the quickest way to destroy your career. In fact, it would be easier to take the proverbial gun and shoot yourself between the eyes; forget the feet.


Scenario #1:

Narrative language:


“Mrs. Jones suffered from a rear end collision that resulted in a broad based disc bulge as evidenced by MRI 2 weeks post trauma. This disc bulge compressed the spinal nerve root and is the competent producing cause of her symptoms.”

This makes most lawyers smile because you causally related the bulge to the accident. What does a lawyer now do with this information? They call the carrier to make a large settlement demand and file motions and a lawsuit.

Many lawyers do not have the funds required for litigation, so they borrow the money and are directly responsible for the loan. However, the lawyer is secure in the knowledge that their expert, you, has rendered a “slam dunk” case.

During the trial, the opposition has its expert, a board certified neuroradiologist who heads the spinal research program at Harvard and correctly states that disc bulges are degenerative in nature and not from the trauma. Afterwards, you realize you were wrong and the case was lost. You feel bad, yet you cash your check for expert testimony and life is not all that bad…so you think!

The lawyer is now stuck with a debt that he has to repay.

The following week, the lawyer goes to a Bar Association function and with a $25,000 to $50,000 debt, begins the process of trashing your reputation to everyone that will listen, as his story grows along with his anger.

And you wonder why it is so difficult to have a PI practice in your community?

The insurance company, will also understand that you are not the expert your license says you are and now start to question all of your claims, causing delays and, in many cases, no payment.


Scenario #2:

Narrative language:

Based upon the 6th Edition AMA Guides to the Evaluation of Permanent Impairment, I conclude that:

(The formulas are the new 6th Edition Guidelines)Functional Assessment: PDQ score is 30/150. [GMFH-CDX= 2-1=1]

Physical Exam: Slight decrease in cervical range of motion with normal neurological exam. [GMPE-CDX= 1-1= 0]

Clinical Tests: X-rays done 1-31-08 and 1-15-09. [GMCS-CDX= 0-1=-1]

Diagnosis: Cervicalgia (723.1), headache (784.0), cervicocranial syndrome (723.2.)

Impairment Rating: Class diagnosis 1 = 2%; grade modifier for functional history = 1; grade modifier for physical exam= 0; grade modifier for clinical studies = -1; net adjustment = 0.

Whole body impairment rating: 2%.

Here are the problems. The 6th Edition does not allow for range of motion studies, thereby invalidating the physical examination. Symptoms have no bearing on the rating, functional assessment cannot be used unless there are 2 spinal regions that have ratable diagnosis and none of the diagnoses are ratable, thereby invalidating this entire section.

This lawyer will learn from the carrier that the doctor’s rationale is fabricated and will never work with this doctor again, as his work proves he is not expert.


Scenario #3:

Narrative language:728.84, cervical ligament laxity and hypermobility C3-C4, C4-C5, and C5-C6.

NOTE: 728.84 is diastasis of muscle. This description does not match the ICD-9 code, thereby giving written proof of your lack of clinical knowledge and accuracy.The insurance company or lawyer in a PI case will look at the list of diagnoses and realize that you went into creation.

The lawyer, in the future, will look for a real expert who knows what they are doing, and you are not it.


Scenario Story #4:

Narrative language:”Palpation showed fibrosis was evident at C1, C5-C6 and the right S-I joint. In addition, there was a positive foraminal compression test revealing ligamentous damage.”

You can palpate tenderness, rigidity and abnormal tissue response upon deep palpate, but diagnose fibrosis? This is virtually impossible with palpation.

Furthermore, a foraminal compression test is used to reveal nerve root compression or entrapment, not ligamentous damage. This single statement will invalidate a doctor as a specialist. The lawyer lives in the world of these tests and will know if the doctor is being factual or not. You do not get 2 chances to be the cause of a lawyer losing a case because of your incompetence.

In each of the 4 scenarios, the doctors made an error or miscalculated. These doctors have earned the title of “King of BS,” as they held themselves out to be experts at the expense of everyone else. If you are an expert, be one.

Craig Castanet, DC, from Georgia challenged me on my use of disc nomenclature, citing additional references that made mine outdated.

Due to the fact that this doctor stood his ground and repeatedly kept telling me my references were outdated, I spent 3 months checking current references, communicating with leaders in the neuroradiology community and acquired the most current research to find out he was accurate. It, therefore, made me the “King of BS,” as my understanding was outdated and, henceforth, incorrect.

To rectify the situation, I have spent the last 4 months creating an MRI certification course (soon to be released, created specifically for chiropractors) in collaboration with a world renowned medical neuroradiologist, medical physicist and neurosurgeon because, as a profession, we are entitled to be taught by the brightest minds in the world.

The message is simple: Tell the truth, the real truth. This often requires hard work and you need to work at your facts, which are a by-product of research, continuing education and asking more questions than answers often exist.

You need to challenge the experts and, if they are truly expert, they, too, will pause and seek additional research, continuing education and start to ask additional questions where answers do not yet exist.

If an expert will not pause to consider a dissenting opinion, they are not truly expert; they are simply pompous and, too often, wrong.

In the end, together we will find the truth and be able to report the same in a factual way “as a true expert.” It is that reputation that will enable you to win, not just in your practice, but in every part of your life.

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