Suggestions for a Well-Drafted Doctor Letter

Sunday, June 22, 2003 | 0

While doctors have a responsibility to prepare an objective, thorough report, the best way for claims or legal specialists to enhance the outcome of their doctor's medical-legal evaluation in a workers' compensation AOE/COE, QME or AME is to prepare a well-thought-out Doctor Letter. In fact, the first inquiry MEDLink-affiliated doctors make prior to their medical-legal examination of an injured worker is: "Where is the Doctor Letter?" They are not referring to "generic letters" containing rubber-stamped questions void of claim details or identification of critical medical-legal issues.

However, receiving a comprehensive Doctor Letter does not get the evaluating doctor off the hook. The doctor is still responsible for conducting a complete history, performing a thorough examination, reviewing and summarizing pertinent medical records and preparing a consistent, logical, competent report. A customized Doctor Letter, containing a strategic presentation of issues, will spark doctors' interests and will assist them in developing factually supported conclusions. Of course, this requires some advanced planning, as preparation is essential to the outcome. This article discusses some prominent elements for creating a strategic Doctor Letter. Doctors do value your Doctor Letter, especially if it contains substantive information.

Elements of a Comprehensive Doctor Letter

There are two main requirements for your Doctor Letter: a prepared summary of the salient, factual points; and stellar questions covering the main issues doctors should address. Start by preparing what you determine the doctor will need by gathering discovery early. The claims administrator should make telephone contact immediately and get statements from both the employee and, if appropriate, the supervisor and coworkers. Most doctors look for collateral information, especially in a non-witnessed injury, or in psychiatric stress claims involving good faith personnel actions.

Get The Doctor's Attention: Introductory Requests and Instructions

The initial paragraph of your Doctor Letter should acknowledge the name of the applicant; date and type of exam (AME, QME, AOE/COE), applicant's occupation, employer date of hire, date(s) of injury(ies) and specific body part(s) or system(s) to be evaluated by doctor. Remember to list medical records enclosed or notify the doctor that medical records are forthcoming or unavailable.

The second paragraph should include special instructions in bold or underlined. For example:Rush Preliminary Status Report for AOE/COE causation or Mandatory Settlement Conference. There should be a notation if any other medical specialists are also evaluating the patient on certain dates to avoid multidisciplinary medical opinion overlap. Provide authorization for diagnostic testing or request doctor call for testing authorization. If indicated, authorize a medical or toxicological literature search.

Some have suggested that the type of discovery that doctors find helpful in preparing a comprehensive medical-legal report include: Doctor's First Report of Injury/Illness, Employer's First Report, past medical records, current medical records, treating physician notes such as hand-written entries of chiropractors, physical therapy reports and notes, diagnostic films (MRI, CT scan, X-rays), diagnostic test reports, and job analysis. For psychiatric claims, our psychiatric evaluators request past and current psychiatric records. If available, supply personnel records, statements from the supervisor and coworkers, and a summary of any investigation. List records you have enclosed or note they will be forthcoming once the injured worker signs a medical release.

Prepare a Summary of the Claim The body of the Doctor Letter should contain essential aspects of the claim and present the salient points. Prepare a brief, factual summary of the case to include: a summary of the injury, specific body part(s) or system(s) to be evaluated, and date(s) of injury/illness. This should include the date(s) of the injury(ies) and whether the injury is a specific or a cumulative trauma. Note whether the treating doctor or other specialists have already made determination of some issues such as temporary total disability, permanent and stationary status, permanent disability determinations, treatment provided to date, current work status, or when modified duty began. If available, provide a summary statement from the injured worker's supervisor or prepare an investigation summary. Note any past history of preexisting conditions or disability and/or prior awards.

Identify Specific Medical-Legal Issues You should then identify specific medical-legal issues the doctor should address. Comment on the most pressing issue and then delineate the remaining medical-legal concerns. Since claims may involve multiple injuries, numerous dates of injury, or various insurance coverage issues: detailed questions should be presented for each issue the doctor is to address. If certain medical-legal opinions are not at issue, such as vocational rehabilitation, you may request that the doctor not offer an opinion.

Listed below are specific medical-legal issues you should address:

*Diagnosis and Summary: Request that the doctor establish a proper diagnosis and prepare a brief summary of the case.

*Temporary Total Disability (TTD): Request doctor provide medically determined TTD dates and/or when modified duty commences. Also, instruct the doctor to comment on more global aspects of TTD issues, such as: if the doctor terminated TTD but the patient did not return to work, or if ongoing TTD is consistent with the injury and objective findings.

*Permanent & Stationary (P&S): Request that the doctor determine when the patient's condition became P&S or when s/he may anticipate patient will become P&S.

*Subjective Complaints: Request that the doctor characterize the frequency and intensity of pain per each body part, but only if the patient is P&S. (This does not apply to psychiatric evaluations.)

*Objective Findings: Request that the doctor delineate objective factors and ratable findings per each body part, such as: actual grip loss, range of motion loss, atrophy, amputation, scars.

*Permanent Disability (PD): Ask doctor determine whether, and to what degree, a worker has suffered PD, to render a final PD determination that includes subjective and objective findings, or, ask if PD will be anticipated. The doctor should also determine work restrictions if appropriate. Remind the doctor to use the Permanent Disability Rating Guide for injuries occurring on or after 4/1/97. For a psychiatric evaluation, the doctor would use the Psychiatric Work Function Tables.

*Causation: Request that the doctor provide a reasonable, substantive rationale regarding work related or disputed causation. Be sure to identify specific versus cumulative trauma injuries.

*Apportionment: Provide the doctor with any prior PD award information. If apportionment is an issue, identify facts that support it.

*Future Medical Treatment: If the injury was work-related and medical treatment is indicated, request that the doctor determine the nature and extent - as well as reasonable - and necessary future medical treatment. The doctor should specify type, frequency and duration of treatment. Also, if applicable, request that the doctor comment specifically if further treatment such as chiropractic treatment, physical therapy or surgery is necessary, and if current treatment is consistent with the treatment plan.

Vocational Rehabilitation: Request that the doctor determine, on a medical basis, when or if a patient is able to return to their usual and customary job, or to assign modified duty/restrictions on work-related activities as it correlates with the job analysis and findings upon examination. You may have the doctor opine as to whether employee will eventually be able to engage in occupation at time of injury.

Conclusion Request that the doctor prepare a detailed report to include the patient's history of injury/ illness, summary of records, physical exam findings with a factual basis for conclusions consistent with the facts of case, and findings upon exam. Instruct the doctor to comply with the Rules and Regulations in a statement at the end of their report. The doctor should attest and sign a report pursuant to Labor Code Section 4628, Industrial Medical Council Section 139.3, Workers' Compensation Appeals Board (WCAB) Rules 10606 and 10978, to include Declaration and Perjury Statements.

To allow the doctor time to prepare for the evaluation, submit the Doctor Letter, medical records and appropriate discovery documents to the doctor two weeks prior to the medical-legal examination. Ultimately, a well crafted Doctor Letter will allow you and the doctor to reach a common goal of providing medical-legal opinions accepted by judges, attorneys, insurance carriers, employers or medical providers that support fair compensation of legitimate injured workers.

Article by Janice Skiljo Haris R.N., President of MedLink, providing scheduling and management services for over 35 forensic physicians in Northern California. Ms. Harris has a Masters of Science in Occupational Health Administration from the University of California at San Francisco, and started MEDLink in 1992.

(c) 2001 MEDLink -- Reprinted by Permission. Additional articles may be read at www.camedlink.com . MEDLink affiliated QME physicians may be reached by e-mail at: camedlink@camedlink.com .