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Chiropractic News

March 2010

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The importance of proper report writing

By Mark Studin, DC, FASBE(C), DAAPM, DAAMLP, and Allison Bonk

Taking the time to make sure a report is in the proper format, well-written, and without grammatical mistakes is important for you, as well your patients.

Writing a report using such words as should, could, or might — when such words as will or does should be used — dramatically changes the context of an entire report.

A poorly written report with bad grammar, misspelled words, and necessary information missing reflects negatively on you, and suggests you didn’t take the time to write it well or didn’t have the know-how.

A poorly written report also implies you are not proficient or someone who strives to be the best-of-the-best. A written report may be the first impression a colleague has of you; is a hastily written report the impression you want to make?

Any report you write impacts more people than you may realize. It can impact the personal injury lawyer, the insurance company, the patient’s other doctors — not to mention your patient.

Personal injury lawyer

Your report can especially impact the personal injury lawyer. He or she will use your document to try to prevail for his or her client, and your report could become a crucial piece of evidence to do so.

A personal injury lawyer expects a thorough, well-written report, and may very well guarantee one by sending patients to someone that he or she knows can provide a useable report to win the case.

Are you someone a personal injury lawyer would use as a “go to doctor” in order to obtain reports that would help in court. Could you be?

Insurance company

Your report also needs to be well-written when it comes to the insurance company reading your reports. If your evaluation says: The patient’s past medical history reveals the following: Mrs. Smith has a history of a pre-existing bursitis in her right arm. She also suffered of several headaches for approximately 10 years. She was having no treatment for headaches since that time.

Several questions arise from the ambiguity: When was the 10-year period? When did it start or end. Is she or is she not being treated? Since when?

The paragraph should read: Mrs. Smith has a history of a pre-existing bursitis in her right arm that has continued to bother her until today, and has received no care for the bursitis for four to five years. She also suffered from several headaches for approximately 10 years that ended approximately five years ago, and hasn’t had any treatment over the last five years, where she has been asymptomatic.

Notice the difference? Being clearer in what you write can mean the difference in getting reimbursed or not.

Other doctors

Another group affected by the report is the other doctors the patient may be seeing or to whom you are referring patients to.

A well-written report portrays professionalism that will convey a sense of clinical competency to your peers. Not to mention, the

course of treatment that one doctor is following may impact that of another doctor or you.

Therefore, you must be careful to create a report that is clear, detailed, easy to read, and without errors. This will ensure everyone on the patient’s team is aware of what everyone else is doing, and will not proceed with any treatment that would be ill-advised.

In personal injury cases, there may also be an issue of workers’ compensation. A well-written report providing as much detail as possible regarding the impact the injury has on the patient’s ability to perform their regular daily tasks can be a major factor in the benefits the patient receives.

Take the time to examine what your patient does in his or her everyday life, and then clearly and articulately write your report to demonstrate the impact their injury is going to have on them.

Third-party claims examiners will read your report closely and if it’s full of grammatical errors, they can use that language to not  pay the claim.

Read and repeat

It’s crucial that reports be written in a professional manner and in American Psychological Association (APA) format, which includes being typed (a strong recommendation) and checked for grammatical mistakes and other errors.

This does not mean simply running a “spell check” on your document as certain typos are still words in the dictionary. Particular words, such as to, two, or too, may be spelled correctly, but the wrong variation of the word is typed.

Very often, a writer is so familiar with what he or she is trying to say that errors are not caught. You need to read and reread your reports, and have someone else read them as well. Another set of eyes is an invaluable tool.

After all, your patient’s well-being and your practice’s success can be at stake.

Mark Studin, DC, FASBE(C), DAAPM, DAAMLP, is the president of CMCS Management and consults chiropractors worldwide. He can be reached through www.CMCSManagement.com.

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Choose your words carefully

Choosing which words you use to write your report can be the difference in getting reimbursed and being denied. Three sentences that can get your claim denied include:

• Mrs. Jones was probably lifting a box at work, and hurt her back.

• Mrs. Jones allegedly lifted a box at work and hurt her back.

• Mrs. Jones was at work and her back hurt afterward.

The statement should read, “Mrs. Jones, while at work, lifted a box to put on the storage shelf, and during the process felt a sharp pain in her back, rated a seven on the visual analog scale of one to 10. The pain persisted during the day and worsened when she returned home.”

This statement contains no ambiguity and the wording clearly describes her problem. As a result, this claim has a greater chance at getting reimbursed.

 

 

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