Critical Elements of the Medical Narrative

Transcription

1 Critical Elements of the Medical Narrative 9 th Annual Federal Workers Conference July 31- August 2, 2007 Rosemary King APRN,BC COHN-S

2 OBJECTIVES: Describe and understand the role of the medical narrative in the adjudication process. Identify critical elements of medical evidence as determined by FECA regulations. Examine medical information considered by the claims examiner in the adjudication process.

3 5 Conditions of Coverage by DOL (must meet all five conditions) Time ( filing and notice) Status as a Federal Employee (proof of employment) Fact of Injury (evidence of harm) Performance of Duty Causal Relationship (linkage) Reference: CA-810

4 Medical Documentation Medical documentation- key in the claim adjudication process: Assists the examiner in deciding whether to accept or deny a claim, Approve requested treatment Continue payment on a claim Must meet the standard of medical evidence in accordance with FECA regulations.

5 Critical elements of the medical narrative Dates of the examination and treatment; History given by the employee ( who, what, where, how, etc.); Physical findings ( both positive and negative); Results of the diagnostic tests (lab, path reports, imaging studies, etc); Diagnosis Course of treatment

6 Elements continued A description of any other conditions found but not due to the claimed injury; The treatment given or recommended for the claimed injury; The physician s opinion, with MEDICAL REASONS, as to causal relationship between the diagnosed condition(s) and the factors of conditions of employment

7 Elements continued: The extent of disability affecting the employee s ability to work due to the injury; The prognosis for recovery (if unknown, provide reason); All other material findings Reference: 20 CFR

8 Medical opinion Must be based on complete factual and medical evidence, reasonable medical certainty supported by medical rationale to establish a causal relationship between the diagnoses condition and specific employment factors described by the claimant.

9 Definition of Physician under FECA The term physicians includes surgeons, podiatrists, dentists, clinical psychologists, optometrists, chiropractors and osteopathic practitioners within their scope of practice as defined by state law. Naturopaths, faith healers, and other practitioners of the healing arts are NOT recognized as physicians within the meaning of FECA.

10 Not recognized at this time Nurse Practitioners and Physician Assistants are not considered a physician as defined by FECA. Notes from the above must be co-signed by a physician.

11 Rules of Chiropractic treatment The services of chiropractors that may be reimbursed are limited by FECA to treatment to correct a spinal subluxation. A diagnosis as demonstrated by x-ray to exist must appear in the chiropractor s report before OWCP can consider payment of a chiropractor s bill. Reference: 20 CFR (a)(b)(c)(d)

12 When to submit medical reports: Medical reports shall be submitted directly to OWCP as soon as possible after medical examination or treatment is received. Reference: 20 CFR (b)

13 How to submit medical reports Form CA-16 is used as an authorization for treatment. Form CA-20 (Attending Physician Report) may be used for the initial report and for subsequent reports. The report may be made in narrative form on the physician s letterhead stationery. The report should bear the physician s signature or signature stamp. OWCP may require an original signature on the report. Reference: 20 CFR (a)

14 Medical History Two elements: Dates of examination and treatment, including date of the first examination, subsequent dates of treatment, and, if applicable, the date of discharge and.

15 Medical History The medical history as provided by the claimant. This is the who, what, where, how, and why of the incident. Be specific. The medical history should include any relevant past medical history including pre-existing conditions which may relate to the claimant s injury or illness.

16 Pre-existing condition A pre-existing condition which was not initially disabling, but becomes disabling due to a causal relationship to conditions of employment, regardless of the degree of such exacerbation or aggravation, is compensable and considered work-related provided the medical evidence establishes that a factor of employment contributed in any way to the employees disabling condition.

17 Physical findings Examination of the claimant, providing OBJECTIVE evidence about the claimed injury. This is different from the medical history which is a SUBJECTIVE statement. The examination should include both positive and negative clinical findings.

18 Diagnostic tests Tests may be ordered to support the diagnosis. May include: x-rays (plain films, CT, MRI), laboratory tests, EMG.

19 Diagnosis The diagnosis must be definitive- not an impression. Impressions carry very little weight. An International Statistical Classification of Diseases and Related Health Problems (ICD-9CM) code can be assigned to the diagnosis.

20 Course of Treatment Treatment provided or prescribed during the office visit Recommendations for treatment Response to the treatment

21 Other conditions Need to include other conditions founds but not due to the claimed injury This may include pre-existing injury or disease or physical impairments. These conditions may influence the course of treatment, treatment options, prognosis and return to work

22 Treatment The treatment should be clearly stated The ideal document would include: - Prognosis - Estimated duration of disability - Likelihood of permanent disability

23 Opinion The medical opinion must include the medical rationale on the causal relationship between the diagnosed condition and the factors or conditions of employment.

24 Causal relationship When making a medical opinion, the following should be considered: - What was the actual occurrence of the injury? - What is the diagnosis? - Could the injury have occurred as the person described? - Is there a connection between the injury and the condition of employment?

25 Causal relationships- Types 4 main types of causal relationships Direct causation Aggravation Acceleration and Precipitation

26 Direct Causation Direct Causation: the injury or factors of employment result in the condition claimed through a natural and unbroken sequence. Example: An employee slipped on a wet floor and fractured their wrist

27 Aggravation Aggravation: a pre-existing condition is worsened, either temporarily or permanently, by an injury arising in the course of employment. Example: Employee with DJD of the knee and known meniscal tear twists and strains knee when repositioning a pt.

28 Acceleration Acceleration: a work-related injury or disease may hasten the development of an underlying condition. Example: Housekeeper who is waxing and buffing the floors with the burnisher for eight hours daily c/o carpal tunnel syndrome (constant vibrations)

29 Precipitation Precipitation: Employment brings out a latent condition that would not have been manifested itself but for employment. Example: Employee with unknown DJD in the neck who had been in very sedentary positions prior, is employed in position with overhead lifting requirements develops cervical radiculopathy.

30 Other Findings The medical report needs to include all other information, such as hospitalizations, and referrals to specialists, with rationale for the referral.

31 Extent and Duration of Disability The extent and duration of disability allows the claimant, OWCP, and the employer with expectations of the course of the injury/illness. Specific limitations should be provided; however, focus on what the person CAN DO. This may actually assist with locating modified duties for return to work.

32 Duration of Disability Will the disability be temporary or permanent?

33 Prognosis The prognosis should clarify if the disability is temporary or permanent and if/when the employee can return to modified duty or full duty.

34 Criteria for Medical Evidence Qualifications of the physician ( Are they Board Certified in the field ) Quality of the report- does it contain the elements as described Examination- did the physician actually examine the person Non-medical evidence

35 Weight of Evidence A physician that is Board certified in the field (Ortho, Neuro, etc.) is considered a specialist. Their notes hold more probative value that that of a generalist.

36 A good report: Clear? Concise? Objective? Relevant- cause and effect Medical opinion from physician gives a clear rationale?

37 Examples: Medical History: 59 year old male who presents with lower back pain and pain extending into his left leg two days after lifting boxes at work. Pt. states he has taken additional Gabapentin for his pain today yet it was ineffective against the pain. What do you think of this history?

38 Physical findings: Pain score: 8 Appearance: in obvious discomfort He is sitting crooked, prefers to sit on pillow He hobbles gait Lungs: clear to auscultation Cor: regular rhythm, no murmurs/rubs Extremities: no edema Psychiatric: oriented x 3, normal mood and affect

39 Physical findings Minimal tenderness L. SI area Neuro: R. L. Plantar flex 5/5 4/5 Dorsi flex 5/5 4/5 Leg flex 5/5 4/5 Leg ext 5/5 4/5 LLE weakness appears to be due to his pain level

40 What do you think? Is this a good physical examination? Targeted to symptoms/complaint? Comprehensive? Objective? Were other diagnostic tests, ie lab/x-ray warranted at this time?

41 Diagnosis Lumbar strain since lifting boxes at work s/p c-spine fusion since MVA- chronic pain since 8-04

42 Reasonable diagnosis? Based on objective findings

43 Treatment Remain off work for now, recheck with me on 2/5 (4 days later) Home: rest/short walks, avoid re-injury Pain medication- Morphine sulfate Oxycodone Explained I don t replace lost/stolen Consider Imaging/PM&R

44 Thoughts? Reasonable treatment Plan for follow up

45 Follow up appt 2/5/07 The pain s still there but I think I m getting better. Still pain left buttocks when sitting and numbness down LLE. No loss of bladder/bowel control. Pain score is 10. Physical: 1+ tender Left SI joint area; Motor RLE 5/5, LLE 4/5 plantar and dorsi-flexion Reflexes: 2+ at knees; achilles 1-2+

46 Follow up 2/5/07 Diagnosis: Lumbar strain Plan: x-rays: L-spine, MRI LS spine; PM&R pending; Continue pain meds, short walks; Remain off work this week; see me in 1 week; avoid driving if meds affect you.

47 There s more. Seen in follow up 11 days later in Occ. Health- This is the history that was obtained: In December I was moving a boat hitch and sustained a stiff back. It hurt for a couple of days and it was gone. Then on 1-31 I received two boxes of paper and went to move the boxes from one side to the other. I felt a pop in my back. I have been told that I shouldn t lift more than 7 pounds with my neck, but I find that difficult.

48 Significant medical history: Spinal stenosis C5-7 with fusion (20% SC for spinal disc condition)

49 Medications: Acetaminophen w/hydrocodone Gabapentin Robaxin Simvastatin

50 Does this change some of your thinking about this case? Should this information have been included in the first note?

51 Case is still awaiting adjudication from the DOL.

52 Resources available to you: Occupational Health clinicians FECA- Worker s Comp Guidebook Medical Disability Advisory reference CA-810 VHA CEOSH- VA Workers Compensation Guidebook (11/06)

53 Questions?????????????

54 Contact information Rosemary R. King APRN,BC COHN-S SAVAHCS 3601 S. 6 th Ave. (1-11C1) Tucson, Arizona Ext Fax: Rosemary.King2@va.gov