by Dr. Adam Richardson
Director of Physician Services
Claims Eval, Inc.
During the early part of my career, I had a plaque on my desk which read, “In God we trust, everyone else must document.” The plaque helped to remind me that I must detail my thought processes in my documentation. The saying remains equally important and applicable to the crafting of your determinations – a medicolegal document. It is equally important to avoid accentuating the “weaknesses” of your argument.
For example: when reviewing a request for a cervical epidural steroid injection in which the documentation notes radicular complaints that are supported by diagnostic testing but there is not objective evidence of radiculopathy on examination, please do not write, “Though the documentation notes radicular complaints which are supported by diagnostic testing…” as part of your non-certification determination. Why bring those points to the attention of the requesting physician, the injured worker the involved attorney and eventually – the presiding administrative law judge? Instead, please solely focus upon the positive aspects which support the logic of your determination – in this example, the lack of objective evidence of radiculopathy. In doing so, you will graphically see the “strength” or “weaknesses” of your determination(s).
You are an excellent group of reviewers. With slight reminders about presentation, I believe that our reports will be even more defensible. Keep up the great work!