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Medical Articles »Janice Skiljo Haris, R.N.
Suggestions for Preparation of a Well-Drafted Doctor Letter
Janice Skiljo Haris, R.N.
MEDLink Founder & President
While doctor has 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, Qualified Medical Evaluations or Agreed Medical Evaluations 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. 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 doctor's interest and assists 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. Doctor does 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 doctor should address. Start by preparing what you determine 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 / or coworkers. Most doctors look for collateral information, especially in an unwitnessed injury or in psychiatric stress claims involving good faith personnel actions.
Get 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 (Agreed Medical Evaluations, Qualified Medical Evaluations, 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 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 suggested discovery our 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, job analysis. For psychiatric claims, our psychiatric evaluators request past and current psychiatric records. If available, supply personnel records, statements from the supervisor / 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, date(s) of injury/illness. This should include the date(s) of the injury(ies) and if the injury is a specific or a cumulative trauma. Note if treating doctor or other specialists 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 workers' 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 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, detailed questions should be presented within each issue doctor to address. If certain medical-legal opinions are not at issue, such as vocational rehabilitation, you may request doctor not offer an opinion. Listed below are specific medical-legal issues you should address:
Diagnosis and Summary: Request 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 doctor comment on more global aspects of TTD issues, such as: if the treater 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 doctor determine when the patient's condition became P&S or when doctor may anticipate patient will become P&S.
Subjective Complaints: Request doctor characterize 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 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. Doctor should also determine work restrictions, if appropriate. Remind doctor use Permanent Disability Rating Guide for injuries occurring on or after 4/1/97. For a psychiatric evaluation, doctor will use the Psychiatric Work Function Tables.
Causation: Request doctor provide a reasonable, substantive rationale regarding work related or disputed causation. Be sure to identify specific versus cumulative trauma injuries.
Apportionment: Provide 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 doctor determine nature and extent as well as reasonable and necessary future medical treatment. Doctor should specify type, frequency and duration of treatment. Also, if applicable, request 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 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 doctor opine as to whether employee will eventually be able to engage in occupation at time of injury.
Conclusion
Request doctor to 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 doctor to comply with the Rules and Regulations in a statement at the end of their report. Doctor should attest and sign a report pursuant to Labor Code Section 4628, Industrial Medical Council Section139.3, Workers' Compensation Appeals Board (WCAB) Rules 10606 and 10978, to include Declaration and Perjury Statements.
To allow doctor time to prepare for the evaluation, submit the Doctor Letter, medical records and appropriate discovery documents to doctor two weeks prior to the medical-legal examination. Ultimately, a well crafted Doctor Letter will allow you and 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.
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