Dos & Don'ts: What the Judge Wants to See Part 3

Sunday, August 15, 2004 | 0

This is the third 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. The second article reviewed issues with treating reports. The next two articles review problems with P&S 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.

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

Problems with P&S Reports

Problems with permanent and stationary reports occur with great frequency. Some of the difficulties have been ongoing for years and some are of more recent development. Before beginning your assessment of disability, remember to clearly state that the injured workers condition has become permanent and stationary and the date upon which that status was achieved.

A. Descriptions of subjective complaints: (8 CCR 9727)

1. The patients description of subjectives is not adequate. You must assess the patients subjective complaints to place them in the proper rating category. A review of the terms that are ratable is always helpful:

a) A minimal or mild pain would constitute an annoyance, but causes no handicap in the performance of the particular activity. Minimal pain is not ratable.

b) A slight pain can be tolerated but would cause some handicap in the performance of the activity precipitating the pain.

c) A moderate pain could be tolerated but would cause a marked handicap in the performance of the activity precipitating the pain.

d) A severe pain precludes the activity precipitating the pain.

2. In describing subjective complaints it is important to describe when the symptom is present, its duration, if it precludes activities, and what relieves the pain. If the activity needs to be stopped for a period of time, how long must the rest period be. After that period of rest is the injured worker able to resume the activity. Sometimes it is helpful to know during what percentage of the workday the activity could be performed.

3. Watch your describers for both the level of pain and how often it occurs. For rating purposes the terms of frequency are taken to mean the following:

a) Constant - present 90% to 100% of the time.

b) Frequent - present about 75% of the time.

c) Intermittent - present about 50% of the time.

d) Occasional - present about 25% of the time.

A description of a back injury causing constant slight pain becoming constantly moderate is impossible to rate - there cannot be two disparate constant levels of pain.

A description of subjectives as being mild to moderate is too vague.

Watch your language to make sure you accurately describe the disability. For example the injured worker has frequent slight pain in the left hand and neck, becoming moderate with any overhead work. Does the pain in both the left hand and the neck become moderate, or only the pain in the neck?

The slide scale to assess subjectives on the PR-3 form is difficult for the disability evaluators to assess. It would be far better if you would write a narrative description of the subjective factors.

Try to describe the subjectives in terms of the words of art described and not other words that may not have a specific meaning. Phrases like very repetitive or very forceful may have meaning to you as you write them but will not have meaning to the disability evaluator.

B. Objective factors of disability:

1. Does the physical examination section of the report correlate with the description of objective factors of disability as contained in the permanent disability assessment portion of the report. If there is a discrepancy, the report should clearly identify the objective findings that pertain to the industrial injury and those pertinent portions should be replicated in the permanent disability section of your report.

2. Utilize the Packard Thurber book for reporting objective factors.

3. On upper extremity cases, where both are injured, estimated normals are required to make your report meaningful. Where an injured worker does not appear to be making maximum effort, an estimate of the loss should be given.

4. In hand cases, in addition to finger flexion and extension measurements, the distance by which the top of the finger fails to touch the mid-palm is needed to evaluate permanent disability.

5. Thigh atrophy should be measured at approximately 1/3 the distance between the upper pole of the patella and the umbilicus, or approximately mid-thigh. Measurements taken at 3 cm. above the patella in a tall individual is not adequate.

6. If an appliance is used the type of applicant needs to be described in detail and it must be specified that the appliance is a medical necessity. If the appliance causes a limitation of function or motion, to what extent is that so? How often must the appliance be worn?

7. If there has been an amputation, describe precisely where the amputation occurred, at what level on the particular body part. In the event the amputated part may be replaced by a prosthetic device, please so indicate.

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

Contributed by California Workers Compensation Judge Susan England.

-------------------