In 2005, 78 000 British Columbians reported injuries from motor vehicle collisions to ICBC. The medical records of injured patients are an important component of the evidence in the adjudication of ICBC claims.
Patients injured in motor vehicle collisions can be more complex to manage than the average primary care patient. Some patients may have compounding issues beyond their physical injuries. Psychological factors, including home stresses, work issues, financial problems, or the worsening of pre-existing conditions can affect recovery.
Soft tissue injuries and, at times, the associated chronic pain are often difficult to assess and manage. Difficulty in gaining timely access to appropriate investigations and specialist consultations is frustrating for everyone involved. An objective functional assessment is typically outside the scope of a primary care physician, who often relies on a patient’s subjective self-assessment to determine his or her level of function and disability.
Physicians may also have to deal with litigation in which lawyers will attempt to make the best case for the patient by seeking financial awards for pain and suffering, past and future medical treatment, and past and future wage loss. Physicians may be uncomfortable in the adversarial litigation system where they are often caught between being patient advocates and defenders of the system.
For these reasons, in the event of a claim, medical records must be clear, accurate, and concise. They should be documented with the understanding that they will be made available to the patient and other parties.
The patient’s details of the accident should be documented in relation to the injury cause. It is good practice to record information on the force and direction of impact, the patient’s awareness of bracing before impact, and the area and severity of vehicle damage, which usually correlates to the nature and severity of the injury. The actual time of the onset of symptoms immediately after impact should be identified. Significant positive and negative findings such as head injuries, with or without loss of consciousness, should also be documented. Relevant pre-existing conditions or other conditions that may complicate recovery should also be noted.
Patient communication regarding the use of “regular” versus “as needed” medication, rest versus activity, graduated return-to-work duties and activities, and discrimination between hurt and harm are important aspects of directing care and should be documented. Patients’ descriptions of their physical limitations need to be reviewed and, if possible, verified by an objective clinical functional assessment performed by a trained physiotherapist or occupational therapist. Appropriately timed follow-up by a consistent primary care physician will provide the best patient outcomes.
The following are two common questions physicians have when dealing with medical record requests.
Q. If the records are illegible, whose responsibility is it to correct them?
A. Legibility of the medical record is paramount. It is the physician’s responsibility to provide insurers, legal counsel, or any other party with legible records. If the records are difficult to read, physicians should transcribe them with their initials to verify accuracy and attach them to the original records.
Q. How much time should be billed for producing records?
A. The fee is $77.90 per 15 minutes or portion thereof, plus the appropriate photocopying charges as per BCMA fee codes 0095 and 0096. If it will take more than 15 minutes, inform the requestor of the need to charge for additional time. Whoever requests the records is responsible for the cost, which should be reasonable and discussed in advance.
If you have other questions about medical record requests or concerns specific to ICBC cases, please contact me at martin.ray@icbc.com [2], 604 943-8344 (fax), or 604 943-6999 (phone).
—Martin Ray, MD
| SOAP method of record keeping
The SOAP (subjective/objective/assessment/plan) method of record keeping helps ensure that subjective complaints are clearly distinguished from objective findings. In cases where multiple or complex injuries have occurred, an ongoing problem list is useful. • Subjective details need to be identified by the source (e.g., patient, police report, or previous records). • Objective physical examinations should be both problem-based to focus on specific injuries and system-based to ensure that occult injuries are identified. Red flags related to specific problems should be noted as positive or negative. • Diagnoses need to be clarified as tentative, differential, or final. • Plans for further investigations, management, and follow-up should be clear and adhere to evidence-based practice guidelines. |