The Five Steps to Great Spinal Injury Documentation

There is a lot of confusion about injury documentation. There are five general steps to injury documentation, and it is currently being made much more complicated than it needs to be. All injury documentation has these five basic steps in common and they are really very simple.

Step One:  You Have to Diagnose All of the Injuries

Whenever somebody is trying to adjudicate benefits for a patient, the first thing that they look for is the diagnosis. In other words, how injured is the patient? In a spinal soft tissue injury, there are two imaging biomarkers substantiate injury to the ligaments themselves.

The first is disc herniation. There are 220 specialized ligaments that hold the spine together. 23 of those ligaments are discs. The discs are evaluated generally on an MRI.

If any of the other 197 ligaments, including the disc are damaged, they can cause excessive motion to the spine. Excessive motion is one of the most significant problems that a patient can have. We must diagnose the ligament injuries thoroughly. We must diagnose what is wrong.

  • Did they fracture?
  • Do they have a disc herniation?
  • Do they have excessive motion?
  • Is it causing a spinal instability?
  • What is the grade and severity of the sprain?

That is all part of the complete diagnosis. And you need an accurate diagnosis.

Step Two: You Need to Document If the Condition is Permanent or Not

Any injury that is permanent has a section on t in the permanent impairment guides. Remember, impairment is a derangement of a body part. All injuries are derangement of body parts. The evaluation of permanent impairment that was done by the AMA could be called the guides to the evaluation of permanent injury because it is injuries that caused the derangements in the first place. You need to note whether there is permanency and that’s very easy to do. You  just use the AMA guides to determine if there is a permanency.

Step Three:  Duties Under Duress Factors?

If a patient can do something but it causes them discomfort, it is called a Duty Under Duress factor. They can ride their bicycle with a low back injury, but not like they could prior to the injury. For example, they previously were able to ride their bike for ten to twelve miles and now they are only able to ride it two miles before getting severe back pain. They can still do it, but it is causing problems when they do. These are called duties and under duress factors.

Step Four: Loss of Enjoyment of Life Factors

Let us look at that same back injury but the patient can no longer ride their bike because it is too physically painful. They must stop doing that particular activity because they are physically unable to.  These are called Loss of Enjoyment of Life Factors. These factors must be documented as well.

Step Five: Future Care Needs and General Progress Documentation

At the end of care, all doctors document reevaluation. If you’re doing any kind of a physical rehabilitation on a patient, you’re going to document outcome assessment procedures to show that you are basically gaining ground on the condition. It will show that what you are doing is actually working.

And then you also must document these five factors. All the injuries. Is their permanency, which means permanent impairment guides? Are there any duties under duress or loss of enjoyment of life factors? Now lastly, if let’s say that you’ve gone through your rehabilitation procedures and the patient’s gone through your program, whatever your program is, or you’ve sent patients out for various programs and at this point you’re at maximum medical improvement. Remember, maximum medical improvement is, I’m looking out at that patient. I’m looking out into the future the next year and no matter what I think this patient would do, their outcome is going to be the same. We’re at maximum medical improvement. Now, if a person has a permanent condition and they have a loss of enjoyment of life factor or duties of duress factor, then they also may be entitled to future care. They may need future care, supportive care, to maintain the results with their care. And in that case, it can be substantiated, but you must have all the other factors there as well.

You Help the Patient to Get Any and All Benefits That They May be Entitled to.

It is very, very easy today to document injuries, but you must be sure you have all five factors. Many doctors really struggle with one, the diagnosis, especially with ligament injuries. They don’t get a diagnosis of a severity and location of a ligament injury, and without that, the patient is going to have benefit problems. You are also missing out on permanency factors if it is not documented. Without that, there is no rationale for why they have lost the enjoyment of life of something or they have duties under duress factors. These five things must be documented clearly in doctor’s notes, on all injuries.

It doesn’t matter if it’s a work comp injury. Now some work comp providers will say, “Hey, in our work comp jurisdiction, we don’t use the AMA guides to determine disability.” Remember, impairment is how a physical injury influences a person’s activities of daily living. Disability is how it affects their ability to earn a living. In the ‘earn a living’ work comp area, they may say, “Hey, we don’t use the impairment guides for our disability.” A lot of times that confuses practitioners, but it is actually very simple. It just means that they use a modified approach. Everyone uses the impairment guides. No one is going to create new impairment guides to determine impairment. They just may have a modified system in their state that says, “Oh, we don’t use the impairment guides direct. We use a disability guide, which we’ve modified from the impairment guidelines.”

Systematize and Simplify

Injury practice and injury documentation is very easy if you’re systemizing and getting those five steps in place. If you are struggling with reimbursement issues or you’re struggling with doctor’s contesting your care, such as IMEs and utilization reviews, you must look at your documentation. In my experience, if those five elements are left out, and usually it starts with a diagnosis right from the foundation, there is no impairment, no duties under duress, or no loss of enjoyment of life factors. If they are there, they’re not documented properly.

And doctors, you know if you don’t document properly, then you don’t get paid properly and that’s not so much on you. That’s more on your patient. Your patient does not get the insurance benefits that they may be entitled to and it makes everyone’s job harder. It makes the insurance company’s job harder. It makes the plaintiff attorney’s job harder. It makes everyone’s job harder when you don’t document well.

In my experience with teaching, which I have done for doctors all over the country, these things are not being documented well. If you pick up those five things, you have seriously improved your documentation skills in the injury market, and everyone will benefit. You’ll benefit. Plaintiff attorneys will benefit. Defense attorneys will benefit. Insurers will benefit. And most importantly of all, your patients will benefit greatly.

For more information and tips on how to reduce the problems and stress associated today with growing a large and successful personal injury practice please check us out at http://www.smartinjurydoctor.comor check out our SmartInjuryDoctors® Podcasts on Apple Podcasts, Spotify, Google Play or Stitcher.

For information on spinal ligament testing by board certified medical radiologists go to www.thespinalkinetics.com


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