Medical report writing series - by Dr John Wilson

Part 4 - Common traps with medical reports

Much of my workload consists of independent medical examinations which involve, not only the taking of a history and conducting an examination of the claimant, but reading the reports already provided to the insurer by the treating doctors. These portfolios of documents can sometimes run to hundreds of pages. The upside is that I get paid to read the material, and along the way I have been able to collect a library of raw material that I shall use by way of examples in this series of articles on medical-report writing.

This article is a sort of pot-pourri of traps and howlers that I have collected to date. My report readings are an infinite source of this material, and I expect that I will be able (editor willing) to do a future article or two that continues this theme.

Beware of involving third parties.
You may have an authority to divulge information about your patient, but it doesn’t extend to their families. Consider the case of Mr Young who has had a back injury and is seeking payment for home help, particularly as Mrs Young is unable to do home duties because she has multiple sclerosis. The chances are, even if you are Mrs Young’s treating doctor, that you don’t have authority to disclose information about her health condition. It is better to just report that Mr Young normally performs home duties as his wife has a disability.

For similar reasons sex is a topic best left out of medical reports unless the patient is particularly insistent that the insurer needs to know about sexual difficulties. It is best to first discuss with the patient exactly what should or could go in the report. In these situations it is worth cautioning the patient that once the report is signed and sent, there are no bounds as to where and when copies may go.

Many reports relate to employment issues, and therefore have the potential to be flavoured by the patient’s employment experiences and patients will commonly include derogatory comments about the boss. If your patient has described the boss a “delusional paranoid with a drinking problem” it is better to translate that into the report as “ my patient has reported a difficult relationship with the employer”

Proof- reading
If you dictate your reports for typing take special care to proof-read the document before signing it. What you dictate as “noted a tender lump” can come out as “no tender lump”. Those who use voice-recognition software need to proceed with extreme caution.

Take special care to avoid confusing left and right.

One of my colleagues tells of a greater disaster. He had a habit of interspersing his dictation with comments intended only for the typist. He lamented to the typist that the patient was a dreadful pain, and hoped that she would go away and find another doctor. The regular typist sub-contracted that job to another typist, who faithfully typed every word that was said. He missed it when he proofed the document!

Repeat the questions
Remember that copies of your reports will probably be distributed in many directions and possibly for many years afterwards. The same does not seem to occur with the letters that asked those same questions.

What I am saying here is to copy each question into your report, and then present the reply. Then, say a year or two later, if your report has been provided to me in the context of conducting an independent examination of your patient, I can be confident of understanding your replies.

Yes, I know that this involves more time on your part, and will probably evoke a squeal of protest from your typist, however if it is important to you that the decision-makers actually take heed of what you say, then repeat the questions.

And yes, I know there are many of you out there, who are two-finger typists that do your own reports. I do understand, and maybe, one day, the bean-counters will allow a higher fee for reports that have repeated the questions! Maybe!

Answer the questions
I know this may sound stupid, but there is one echoing sentiment that emerges whenever case-managers are asked to comment on the quality of medical reports. If only doctors would answer the questions!

When you are asked, for example, to provide a diagnosis, then provide a diagnosis. It is then OK to provide, if not separately asked, a paragraph or two outlining the possible alternative diagnoses, and the means by which you have arrived at the diagnosis.

And if you can’t answer the question say so, and why. It may be that the question is outside your field of expertise, or that you need more time to pursue investigations or referrals. It may even be in order to state that you do not presently have an opinion.

Don’t answer the question with a question
To illustrate the problem let me use an actual example that recently crossed my desk. We can only guess at the question.

Q4. More of the same. No surgery is planned. Rest. Analgesics. Massage. Physio. Gym. Exercises. Cannot afford Glucosamine and fish-oil capsules. Are you willing to pay for them?

Drafts and mistakes
Don’t fall into the trap of producing a draft report, and sending it to the claim administrator, to see if that is the sort of thing they are looking for. Drafts in files can get mixed-up with the real thing when it eventually arrives, and copies can inadvertently be passed on to the other side during the formal exchange of documents. Whether signed or unsigned, barristers (for the other side) love drafts, should the matter ever proceed to court.

Mistakes are a different matter. If you write a report, and later discover that it contains a mistake, do not ask for it back with a view to producing a corrected version. Write a brief letter or statement, correcting the error, and send it to the person who requested the original report.

Patient-generated reports
Be particularly wary about the patient who requests that you provide them with a formal report To whom it may concern. As a minimum, a formal report requires a formal request, ideally with specific questions to be addressed. The patient needs to be aware that there is no Medicare benefit for reports, and should also be quoted regarding the cost of the report.

Criticism of other practitioners
It is sometimes tempting, particularly where the patient has changed doctors or where there has been a report by an independent examiner, to be critical of that other doctor’s treatment or opinion. If such comment is necessary then tone it down. Don’t make comments like “Dr Wilson was clearly wrong”; it is better to say “I disagree with Dr Wilson” or “I do not understand Dr Wilson’s reasoning”.

In a nutshell. If you are a two-finger typist and do your own reports, avoid doing it over a glass of riesling for the sake of not wearing out the back-space button. If you do need to have your glass of riesling, make sure it is after you have done all the proof-reading of your reports.

In the next issue we are off to court. Every doctor’s nightmare – well nearly every doctor’s nightmare. Every time you write a medical report you are buying a lottery ticket for a trip to court. Understanding the court process helps you to write a better report.

Medical report writing series - by Dr John Wilson

Part 4 - Common traps with medical reports

Other articles in the Medical report writing series: