Report Writing: The Unwritten Rules
By Richard H. Adler
February 13, 1993
Much has been written about the importance of well documented records in meeting the needs of the patient, provider, insurer, and patient’s attorney in the area of personal injury and insurance law. Good documentation provides clear information of the care given to a patient; records the progress of treatment; enables the doctor to substantiate opinions on diagnosis, causation, and prognosis; is a source of the patient’s history and prior treatment; and justifies the reasonableness and necessity of care for the insurer and the patient’s attorney.
The same rationale for keeping good patient records also applies to preparing narrative reports. However, not much has been published for health care providers outlining some of the “unwritten rules” of report writing. Sometimes providers learn of these unwritten rules and expectations after the fact, which can create problems for the doctor, patient, insurer, and/or patient’s attorney. The following are factors to think about when responding to requests for personal injury narrative reports.
A. GENERAL CONSIDERATIONS
A well written report outlining the patient’s condition, diagnosis, impressions, and prognosis will be well received and builds your reputation as an expert in your field.
Well written reports keep you out of court.
Well written reports save time because they do not generate requests for clarification or additional information.
Effective reports aid in resolving cases.
Poor grammar, misspelled words, or incomplete sentences reflect poorly on the professionalism of the doctor. It indicates to the reader that you are either too busy to be careful or are not well informed.
B. USE OF COMPUTERS
Computers are almost a necessity for a business in the 1990’s. Computers can help an office create written procedures, streamline business operations, and generate insightful management reports if programmed properly. However, use of computer software to generate narrative reports runs the substantial risk of creating “cloned” or “boiler-plate” documents. Report writing needs to be controlled by the health care provider; time and thought are necessary ingredients. You cannot delegate report writing to a computer program without it coming back to damage your reputation in the long run.
Computer output is only as good as what you put into it. Computers cannot diagnose and they cannot reason.
Computer boiler-plate is easy to spot. Just as our law firm keeps track of doctors and the reports they write, insurance companies also keep track of reports that treating doctors write. If you say essentially the same thing over and over again in all cases, then your reputation and credibility may be called into question.
Format. The format of a report should be laid out with subheadings so that a reader interested in finding specific information does not have to read through the entire report.
Date. Most reports are not dictated, transcribed, and signed by the doctor the same day. The report should indicate when it was prepared and when it was signed. Once in a while, the gap between when a report is written and signed can cause problems. Consider the following example: a report was dictated on September 1, 1992, and signed on September 10, 1992. The report indicates that there were no pain problems remaining after the patient had been discharged. However, on September 8, 1992, there was a new injury and the patient was seen in the doctor’s office on September 9, 1992. The patient then makes a second claim under the second accident. The insurance company on the second accident claims the patient was not hurt from that accident because he was seen by a doctor and the doctor’s report one day later indicates there were no pain problems remaining.
Addressee. Use the full name and title of the individual to whom you are addressing the report. For example, if sending it to me, address it to Richard H. Adler, Attorney at Law, 401 Second Avenue South, Suite 600, Seattle, Washington 98104. If you are addressing it to an insurance adjuster, send it to Mr. No Cando, Claims Representative, Premiums Are Us Insurance Company, 1300 Policy Street, Our Town, Washington 98000.
Headers. At the top left of each page is the header. All pages should have a page number, patient name, and date of the report. This way, everyone handling, reading, or receiving this report knows how many pages are in the report and if any are missing.
Salutation. Salutations must reflect the professional relationship, not a personal relationship. Never address a letter to the adjuster or attorney as “Dear Richard,” rather it is best to say “Dear Mr. Adler.”
Do not prepare a report until it is requested in writing.
Don’t write a report unless you have a valid medical authorization.
Quick turnaround time in preparing a narrative report shows that you are on top of your practice and the particular case in question.
Approximately two weeks is a reasonable turnaround from the time you receive a request for a report.
E. CHARGING FOR THE REPORT
If you do not have a prior working relationship/track record with the individual requesting the report, you should advise that individual ahead of time of your fee schedule.
You may want to have the report fee in advance. In that instance, notify the requesting party of the prepayment requirement. Immediately upon receiving payment, the report should be completed.
To determine a reasonable report writing fee, consider how much time it takes you to prepare the report, how much you actually earn per hour, and what your peers are charging. The key here is to do what is “reasonable,” knowing that your patient ultimately pays for any report requested by an attorney.
F. LENGTH OF REPORT
Typically, a good narrative report ranges between three to seven pages in length, depending on frequency of treatment, the length of care, the number of interprofessional referrals made, diagnostic workup, etc.
Whenever an employee from Adler Giersch, P.S., requests you prepare a report for one of our clients, you are encouraged to call us and discuss any questions or concerns you have before you begin to write. The interests of the patient/client and health care provider are best served when the provider and patient’s attorney have effectively communicated the medical-legal informational needs of the case to one another.