Dos & Don'ts: What the Judge Wants to See Part 2

Saturday, July 31, 2004 | 0

This is the second article in a series of six by San Diego Workers' Compensation Judge Susan England, reprinted here with permission from the California Society of Industrial Medicine (CSIMS). These articles were first presented as a single paper at the CSIMS conference held in San Diego, June 25-27, 2004. The first article reviewed the evidentiary status of medical reports in the workers' compensation system. This article reviews problems with treating reports. Earlier articles can be accessed by clicking on the title in the right side bar.

The opinions stated in this article do not represent the stance of the Workers' Compensation Appeals Board, its administration or any other person except the author.

Problems with Treating Reports

The Industrial Medical Council promulgated forms to be used by treating physicians, including a Doctor's First Report of Work Injury, a PR-2 (interim progress report), and a PR-3 on which to report permanent and stationary status and factors of disability. Although the forms undoubtedly save some time in the physician's office, they are frequently inadequate for the purposes of the determination of medical issues.

Addressing first some of the problems that occur with interim reports of a treating physician (PR-2 form or narrative):

A. We need to be able to determine the exact date upon which benefits ought to commence and ought to end. Language like temporarily disabled until the condition stabilizes or until permanent and stationary, or until the next appointment, is inadequate for the purpose of determining if an injured worker is or is not entitled to temporary total disability benefits. The temporary disability should be for a time certain, i.e. until June 1, 2003, or for thirty days.

B. If an injured worker is able to do any work for any period of time that ought to be reflected in the interim status reports with an accurate description of the temporary restrictions applicable. The ability to engage in some work activity is inconsistent with a total, temporary disability status. However, if the employer is unable to accommodate the temporary work restrictions then the injured worker will continue to draw temporary total disability benefits.

C. Changes in the treatment plan. The utilization of a PR-2 form is especially problematic when there is a change in treatment plan or some compensable consequence of the underlying injury becomes apparent and requires either a consultation with some other medical specialist, or treatment of a sort different from the original treatment plan.

It is inadequate to merely indicate that you wish to have the injured worker referred to a psychiatrist or psychologist or that he needs an internal consultation to determine if he has developed an ulcer, or that he needs therapy to the opposite extremity from the one injured, or that he now needs an MRI or other diagnostic test. The mere statement to that effect is not substantial evidence and, if the matter goes to trial on that report, the judge will have a difficult time utilizing that report as the basis for any decision.

In order to assure that your opinion will be substantial evidence, make sure you give the reasons for the referral or the tests or the treatment.

For example, the PR-2 says only that the injured worker needs to see an internist for evaluation of possible ulcer, since that is conclusionary it is insufficient to base a decision on. To create a report that would constitute substantial evidence upon which to base an award, you need to explain why the referral ought to be done on an industrial basis, for example:

"The injured worker has been taking anti-inflammatory medications for his left knee injury. Such medications are known to be causative or contributory to the development of peptic ulcer disease. The injured worker now has symptoms, which I suspect may be due to that disease process. I therefore request authorization to refer him to (name of physician) for an internal medicine evaluation and treatment."

Assuming the PR-2 utilizes language that says: "Request authorization for MRI" or "Request authorization for a surgical consult" or "Needs referral to a psychiatrist." None of these are substantial evidence. An explanation must be included that will explain the reason for the referral at this time as well as tendering your opinion as to how that referral is related to the underlying industrial injury.

The same thoroughness is required for a request for authorization for surgery. Don't just ask for authorization. Include in your report the type of surgery you feel is necessary, why it is necessary at this time, and how that relates to the industrial injury.

Remember that you are supposed to submit interim reports at least every 45 days. If you are using the PR-2 form it contains the 5703 language. But you must sign the report, personally. An agent cannot sign a declaration under penalty of perjury on your behalf.

The next article will discuss problems with P&S reports.

Contributed by California Workers' Compensation Judge Susan England.

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The views and opinions expressed by the author are not necessarily those of workcompcentral.com, its editors or management.