What’s relevant information for a WorkSafeBC claim file?

Issue: BCMJ, Vol. 51, No. 5, June 2009, page(s) WorkSafeBC
Peter Rothfels, BEd, MD, ASAM

Physicians have been asking us for examples of what is and is not considered relevant information for a claim file. Here are some examples.

In preparation for the May launch of WorkSafeBC’s new Claims Man­agement Solutions (CMS) elec­tronic adjudication system, two past articles have requested that all medical information you send for in­clusion in an injured worker patient’s claim file be relevant to the WorkSafeBC claim. The reason we request your diligence in this regard is that the new worker portal has been opened alongside our new CMS system.

While injured workers have always had access to their claim file, including medical information sent by their physicians, they now have online access to this information. With the new ease of viewing their claim file, more injured workers are reading their medical reports.

As a result, although we review all medical documents, it is more important than ever that you verify relevancy before sending information to us. Physicians have been asking us for examples of what is and is not considered relevant information. To clarify, we offer the following examples.

Scenario #1
The work-related injury
Your patient steps into a hole at work and twists his right knee. He reports immediate pain in the knee and within 2 hours the knee is swollen.

Your patient has a history of depression but for the past 3 years has been functioning well with no recurrence. He also had a meniscal tear in the right knee 4 years ago and had an MRI but no surgery.

You find AP laxity in the knee, suspect an ACL tear, and request an MRI and referral to an orthopaedic surgeon. There is no evidence of recurrent depression or somatization.

What’s relevant for the claim file?
At this point, the relevant information is the past meniscal tear, including how the injury occurred, and the MRI results.

What’s not relevant?
Information about the patient’s past depression is not relevant at this time.v

Outcome
Your injured worker patient is refer­red for an MRI and to an orthopaedic surgeon, who diagnoses an ACL tear. After surgery the patient recovers uneventfully.

There is no need for you to send any further information for the claim file.

Scenario #2
Same as Scenario #1 except that postsurgery the patient experiences extensive pain and complains beyond what you expect. Workup for complications such as infection or ongoing internal derangement is negative. The findings are in keeping with somatization and prolonged disability.

What’s relevant for the claim file?
At this point, the information regarding your patient’s past depression becomes relevant since somatization is linked to both depression and prolonged disability.

Scenario #3
The work-related injury
Your patient turns to the right while standing at work and develops knee pain. There are no objective findings. He complains of extensive pain and pain to light touch, is unable to perform any kind of work, and has the potential for prolonged disability.

Your patient has an extensive history of work-related knee injuries and other claims for disability, all with symptoms of prolonged pain and periods of atypically prolonged disability. There are other contributing factors in your patient’s history relevant to prolonged disability, including psychosocial issues.

What’s relevant for the claim file?
All information related to past knee injuries and claims, and prolonged pain and contributors to disability, are relevant to the current claim.

How to report information
Typically, you would report on a Form 8 or Form 11 or provide chart notes. Occasionally there are sensitive issues that are relevant to your patient’s claim and that we need to know to adjudicate the claim. However, we may not require every detail—for example, we may not need psychiatry consult notes. If you are reluctant to send relevant sensitive information to WorkSafeBC, please contact us and we may be able to provide options to copies of chart notes.

For more information
If you have any questions or concerns regarding information you should send to WorkSafeBC, please contact WorkSafeBC Medical Services at 604 244-6224 or toll free at 1 888 967-5377, extension 6224.

—Peter Rothfels, BEd, MD, ASAM
WorkSafeBC Director of Clinical Services and Chief Medical Officer

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