The Importance of Accurate and Objective Documentation in Personal Injury Cases

Why Accurate Documentation is so Important

The biggest issue that has remained consistent throughout the history of personal injury claims is the documented evidence of a patient’s recovery, or lack thereof. This evidence affects many factors of the case, including whether or not a patient will receive disability benefits, the amount, if any, of a settlement, whether an insurance company will pay for the necessary treatment, and even liability when it applies.

Personal Injury Documentation

Dr. Bill Gallagher, a Contributing Editor at Attorney At Law Magazine with a column on personal injury case management, states that “Being able to treat any area is only half the battle. Unless we have objective documentation to deliver to you then you don’t have much to include in your demand letter. Case in point; unresolved cervical pain without supportive testing earns a Whole Person Permanent Impairment Rating of 0-3%. The same patient with findings of ligament laxity on CRMA will have a 23-28% impairment rating. Both may have the same symptoms and even the same problem but without the objective tests, you will be going after the insurance company….without the right ammunition.”

The statement sums up the blunt facts of any personal injury or disability case: without objective documentation, you have nothing. The laws of any state do not base claims on opinions or suppositions – and objectivity is crucial. In fact, it is mandated by both our current legal and healthcare system.

What this means is that, in terms of medical necessity, recording observations is no longer sufficient. To prove medical necessity, you must provide documented, objective data. Fortunately, technology is on the side of medical professionals, providing a number of options to not only prove medical necessity, but provide patients with an improved overall treatment plan, and more costeffective treatment.

In order to develop the proper recommendation for treatment, medical professionals are expected to evaluate a patient’s Range Of Motion (ROM) and muscle strength. Proper evaluation of joint ROM and muscle strength (volition) is crucial to successful patient management. Range of Motion and muscle testing are not only essential to developing a treatment plan, but important for the purpose of evaluation of progress. Success in these evaluations is based on use of accepted measuring methods.

In terms of personal injury cases, three important aspects need to be covered, backed by information that is both detailed and objective:

  • A definitive Treatment Plan that clearly outlines the duration
  • The anticipated results of the above Treatment Plan
  • The Treatment Objectives, which are statements in specific and measurable terms that describe what the patient will accomplish as a result of the treatment plan

When it comes to documentation regarding any aspect of a patient’s case, it should be done in such a way that is clear and will facilitate easy processing, whether to an attorney or an adjuster handing the case. Reports should be accurate, precise and objective, and provide clinically-relevant data which will provide evidence-based results that will affect both the patient and the third party payor.

Kennebec is one of the leading providers of products, including their revolutionary Proof Preferred system, which is essential to proving medical necessity as well as documenting loss and change in function. With two report levels that offer are consistent, reliable, and reproducible outcome assessments, Proof Preferred has all the right components for medical insurance reimbursement with the most innovative software to date. For more information on Kennebec and their Proof Preferred system, contact them to speak with an industry expert.