Documentation of Injuries
- Posted on: Aug 4 2013
Documentation of Injuries
Dr. Jeff Mollins, D.C.
When it comes to treating patients that are involved in accidents, documentation is not just important, it is essential. Documentation of injuries, allows Dr. Mollins to assess improvement objectively. It also enables him to achieve a proper (proven) diagnosis. In addition, accurate documentation permits patients injured on the job (workers compensation) to receive needed treatment as well as a quantitative disability status which allows the injured worker to receive proper monetary compensation. Documentation, enables Dr. Mollins to determine if the injury sustained is directly related to the accident that occurred. Furthermore (with auto accidents, construction accidents, and slip and fall accidents) , if there is a personal injury litigation case involved, precise documentation can accurately determine the extent of the injury sustained, if the injury is permanent and how it affects the patient’s activities of daily living. This can have a drastic impact on the monetary compensation received in settlement to the injured patient.
In Dr. Mollins’ office, documentation initially begins in the waiting room. Patients are asked to fill out specific paper work which provides the doctor with insight to the patient’s injuries. Patients involved in automobile accidents (no fault) have different forms to fill out compared to patients hurt on the job (workers compensation). Some examples of questions that are asked on our forms are…..how and when did the accident happen?, did the patient treat with any other facility prior to coming here?, are there any pre-existing conditions that were present prior to this accident? Patients providing specific facts relating to their health and their accident enables Dr. Mollins to begin accumulating valuable documentation.
Dr Mollins performs a concise history on every single patient. He will often repeat the 
questions answered by the patients in their initial questionnaire (in the waiting room). History is crucial in determining the mechanics of how the accident occurred which can then provide insight to the injuries sustained. The history taken by Dr. Mollins is thorough and becomes part of the patient’s medical records, providing solid documentation.
Dr. Mollins performs a comprehensive physical examination on every single patient. The examination consists of an orthopedic and neurological evaluation. All examination results are recorded and can be used as a measuring tool to determine improvement. For example, on every patient Dr. Mollins performs a range of motion examination. Injured areas of the body (joints) will have a decrease in their ranges of motion. By carefully measuring the ranges of motion of involved areas of the body, Dr. Mollins can assess which areas are injured, and how badly. These measurements are quantitatively (measured in degrees) determined and can be recorded as proof of injury. In addition, subsequent examinations (Dr. Mollins performs a re-evaluation every four weeks on every patient!) can determine level of progress. If ranges of motion of a certain body part continue to increase over time, then our patient is improving. Unfortunately, if range of motion diminishes over time, the condition is worsening. However, if range of motion remains the same over a long period of time, then it is quite possible that this injury can be documented as permanent. By performing concise, subsequent, physical examinations, Dr. Mollins can accurately document the extent of all injuries sustained.
Another crucial tool to provide uncontested documentation is diagnostic testing. They say “a picture is worth a thousand words”. Dr Mollins regularly refers his patients for general radiology as well as mri study. His referred specialists utilize diagnostic testing as well. For example, referred neurologists perform emg/ncv, eeg, and vng studies. Diagnostic testing can accurately, objectively determine injury and extent of the injury. It will also validate improvement and ultimately permanency.
In the treatment of all patients ESPECIALLY those injured in accidents, documentation is essential. Documentation enables Dr. Mollins to provide objective proof of the injury and assess a proper treatment regimen. It enables Dr. Mollins to quantitatively determine improvement and permanency. Remember, documentation (proof) may have a huge impact on the monetary compensation received by patients injured on the job (workers compensation). Patients injured in car accidents (no fault), slip and fall accidents, construction accidents or any accident where there is a lawsuit will be impacted greatly (in monetary compensation) with proper proof of injury.
Contact Dr. Jeff Mollins office today for more information on how his practice can help you with Injury Documentation by calling us at 718-802-0800.
Posted in: Injury Documentation, Injury Treatment
