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Q: I think a potentially litigious patient with a back injury is malingering. How should I document my assessment? A: Record all the facts you observe as specifically and objectively as possible. Don't editorialize. You might write notes such as these: "Patient complained of severe pain in the lumbosacral area and had a positive straight-leg-raising test at 45 degrees on the right. Flexing the calf on the thigh made pain worse. He was able to arise and sit up with both legs extended, and his chin flexed on his chest without undue discomfort. He displayed no motor, reflex, or sensory deficits. While dressing after the exam, he easily bent over to tie his shoes. He walked normally as he left the office." Lee Johnson has twenty-five years of experience in healthcare law, risk management, claims management, risk malpractice defense litigation and general counsel advice to hospitals and other health care providers. She lectures to physicians, hospitals, bar associations and medical societies; produces internet programs, self-study programs, videos and audiotapes on risk management and the defense of medical malpractice litigation; and writes numerous articles, pamphlets and books on risk management topics. She is a contributor on risk management for Medical Economics magazine. You can learn about her at website. Occ. Med. Central is growing every day. There is so much useful information on the web there is no way we can know nor find it all. That's where you come in. Don't feel limited by our current category list. If you find the item useful, then your colleagues will want to know about it. Click on the "Contribute" button to send us your contribution.  |