PATIENT DETAILS



Dr. Eggleston recommends the following information be included in your narrative report.

He recommends using these EXACT headers.

Put them in THIS ORDER.

Generally Do NOT write in paragraphs except as shown below. Write an OUTLINE, just as you see it here.

August 10, 2008

Dear Mr. Eggleston:

I have concluded treatment of your client. This is a report of my evaluation and management of this patient, review of medical records, impairment ratings, prognosis, and future medical treatment.

PATIENT DETAILS

Patient Name: Mary Smith

Date of Birth: January 9, 1972

Gender: Female

Height: 5’5”

Weight: 192

Dominant Hand: Right

Address: 1234 Main Street

City, State, Zip Costa Mesa, CA 92626

ADDITIONAL DETAILS

Date of Accident: January 15, 2008

Date of First Treatment: January 15, 2008

Medical Specials: $7,517.52

Income Loss: $532.00 (one week of missed work)

Property Damage: $2000.00

Status: Office Treatment Completed, Home Treatments Ongoing

PHYSICIANS INVOLVED IN THIS CASE

Physician 1 Name: Bob Jones, D.C.

Type of Physician: Chiropractor

Billed Amount : $4,315.35

All Records Reviewed? Yes

Treating Physician? Yes

Physician 2 Name: Wilhelm Roentgen, M.D.

Type of Physician: Medical Doctor – Occupational Medicine

Billed Amount: $1,417.00

All Records Reviewed? Yes

Treating Physician? Yes

Physician 3 Name: Chad Warshel, D.C., DACBR

Type of Physician: D.C. – Radiologist

Billed Amount: $125.00

All Records Reviewed? Yes

Treating Physician? No

Physician 4 Name: Robert Thomas, DDS

Type of Physician: Dentist

Billed Amount: $560.67

All Records Reviewed? Yes

Treating Physician? Yes

Physician 5 Name: Phillip Whelen, M.D.

Type of Physician: Neurologist & Psychiatrist

Billed Amount: $1,100.00

All Records Reviewed? Yes

Treating Physician? Yes

INJURIES DIAGNOSED AND TREATED

Injury 1: Cervical sprain/strain

Physician who diagnosed it: Bob Jones

ICD-9 Code: 847.0

All CPT Codes used: 99203, 99213, 98940, 97124

Last DATE this injury noted: February 18, 2008

Injury TYPE: Muscle

Duration of this injury: 33 days

Prognosis: No complaints/No treatment recommended

Complaints with injury: ROM, HA, Dizziness, Spasm, Radiation, Anxiety, Depression

Office Treatments Done: Chiropractic adjustments, massage, ultrasound, exercises

Home Treatments Done: Bed rest, exercises, ice, stabilization, traction

Physician Who Treated It: Bob Jones

Last Date Treatment Noted: February 18, 2008

Intensity of Treatment: 3 days a week

Duration of Treatment: 33 days

Initial Treatment (1st 72 hrs)? Yes

Therapies Prescribed: Physical therapy, massage, acupuncture, self-exercise, gym

Tests done for this injury

Name of test: Cervical compression

Physician who tested: Bob Jones

Last date positive: February 18, 2008

Test type: Orthopedic

Test Result: Positive

Name of test: Cervical x-rays

Physician who tested: Bob Jones

Last date positive: January 15, 2008

Test type: X-rays

Test Result: Positive

Name of test: Cervical distraction

Physician who tested: Bob Jones

Last date positive: February 18, 2008

Test type: Orthopedic

Test Result: Positive

Injury 2: Occipitocervical Subluxation

Physician who diagnosed it: Bob Jones

ICD-9 Code: 739.0

All CPT Codes used: 99203, 99213, 98940

Last DATE this injury noted: February 18, 2008

Injury TYPE: Bone

Duration of this injury: 33 days

Prognosis: Complaints/Treatment Recommended

Complaints with injury: ROM, HA, Dizziness, Spasm, Radiation, Anxiety, Depression

Office Treatments Done: Chiropractic adjustments, massage, ultrasound, exercises

Home Treatments Done: Bed rest, exercises, ice, stabilization, traction

Physician Who Treated It: Bob Jones

Last Date Treatment Noted: April 21, 2008

Intensity of Treatment: 3 days a week

Duration of Treatment: 96 days

Initial Treatment (1st 72 hrs)? Yes

Therapies Prescribed: Physical therapy, massage, acupuncture, self-exercise, gym

Tests done for this injury

Name of test: Cervical x-rays

Physician who tested: Bob Jones

Last date positive: January 15, 2008

Test type: X-rays

Test Result: Positive

Complications for this Injury: Peripheral nerve injury

Injury 3: Cervicothoracic Subluxation

Physician who diagnosed it: Bob Jones

ICD-9 Code: 739.1

All CPT Codes used: 99203, 99213, 98940

Last DATE this injury noted: April 21, 2008

Injury TYPE: Bone

Duration of this injury: 96 days

Prognosis: Complaints/Treatment Recommended

Complaints with injury: ROM, HA, Dizziness, Spasm, Radiation, Anxiety, Depression

Office Treatments Done: Chiropractic adjustments, massage, ultrasound, exercises

Home Treatments Done: Bed rest, exercises, ice, stabilization, traction

Physician Who Treated It: Bob Jones

Last Date Treatment Noted: April 21, 2008

Intensity of Treatment: 3 days a week

Duration of Treatment: 96 days

Initial Treatment (1st 72 hrs)? Yes

Therapies Prescribed: Physical therapy, massage, acupuncture, self-exercise, gym

Tests done for this injury

Name of test: Cervical x-rays

Physician who tested: Bob Jones

Last date positive: January 15, 2008

Test type: X-rays

Test Result: Positive

Complications for this Injury: Peripheral nerve injury

Injury 4: Cervical Ligament Laxity

Physician who diagnosed it: Chad Warshel

ICD-9 Code: 728.4

All CPT Codes used: 99203, 99213, 98940, 72052

Last DATE this injury noted: April 21, 2008

Injury TYPE: Ligament

Duration of this injury: 96 days

Prognosis: Complaints/Treatment Recommended

Complaints with injury: ROM, HA, Dizziness, Spasm, Radiation, Anxiety, Depression

Office Treatments Done: Chiropractic adjustments, massage, ultrasound, exercises

Home Treatments Done: Bed rest, exercises, ice, stabilization, traction

Physician Who Treated It: Bob Jones

Last Date Treatment Noted: April 21, 2008

Intensity of Treatment: 3 days a week

Duration of Treatment: 96 days

Initial Treatment (1st 72 hrs)? Yes

Therapies Prescribed: Physical therapy, massage, acupuncture, self-exercise, gym

Tests done for this injury

Name of test: Cervical x-rays

Physician who tested: Bob Jones

Last date positive: April 21, 2008

Test type: X-rays

Test Result: Positive

Name of test: Cervical compression

Physician who tested: Bob Jones

Last date positive: February 18, 2008

Test type: Orthopedic

Test Result: Positive

Complications for this Injury: Peripheral nerve injury

(Repeat this format for each ICD-9 code used by every doctor in the case. If there are 63 diagnosis codes, you will have 63 injuries listed with this format. I know it’s long, but once you have a template, it goes quickly. Also, by doing cut and paste with similar body parts with similar CPT codes, treatments, therapies, testing, complications, etc., you can write these out fairly quickly. You can see that the only way you will ever have this much information to put into the report is to use the HBTI forms to gather it…)

PRIOR/SUBSEQUENT INJURIES

I ordered and reviewed the medical records of this patient’s personal medical doctor, Isaac Newton. I found no similar injuries to those described herein having occurred prior or subsequent to this accident. Therefore, I can say with reasonable medical certainty that all the injuries described above were caused by this auto accident.

(or)

I ordered and reviewed the medical records of this patient’s personal medical doctor, Isaac Newton. I found that this patient had an automobile accident in 1999, for which the diagnoses were cervical sprain, thoracic sprain, and lumbar sprain. These injuries resolved as of July, 1999, and there is no notation in the patient’s medical records of diagnosis or treatment for these injuries since that date. Therefore, I can say with reasonable medical certainty that all the injuries described above were caused by this auto accident.

(or)

I ordered and reviewed the medical records of this patient’s personal medical doctor, Isaac Newton, as well as her previous chiropractor, Louis Pasteur, and my own prior chiropractic records for this patient. I found that this patient had an automobile accident in November, 2007, for which the diagnoses were cervical sprain, thoracic sprain, and lumbar sprain. The patient was still under care for these injuries when the accident in question occurred. Therefore, I must apportion some of the injuries as follows:

Injury 3: Cervicothoracic subluxation

Apportionment: November, 2007 accident – minority

January, 2008 accident – majority

Injury 16: Lumbago

Apportionment: November, 2007 accident – majority

January, 2008 accident – minority

Injury 35: Sacroiliac subluxation

Apportionment: November, 2007 accident – majority

January, 2008 accident – minority

MEDICAL SUPPLIES PRESCRIBED

Item: Home cervical traction pillow

Type: Medical supply

Cost: $47.50

Item: TMJ splint

Type: Medical supply

Cost: $80.00

Item: Advil (3 bottles bought by patient)

Type: Medication

Cost: $24.00

Item: Ambulance Ride

Type: Ambulance

Cost: $850.00

(Note: there are only 3 “types” you can use, Medical supply, Medication, or Ambulance.)

DENTAL & ORTHODONTIC TREATMENT

I have reviewed the records of Dentist Robert Thomas, who diagnosed injuries #41, 42, and 43. He had to repair the upper front left tooth by placing a composite over the chipped area. His report is attached.

DISFIGUREMENT

There is no visible disfigurement on this patient.

(or)

There is a 1mm by 14mm scar on this patient’s right forehead as a result of the abrasion and cut she received in this accident.

(or)

The patient now has a disfigurement of the left upper front tooth, in that she no longer has a normal health tooth, but a damaged tooth repaired by a composite. Although the dentist did a good job matching the tooth color, composites tend to last only a few years and, especially on the front teeth, come off when biting certain foods. Each time this happens, the patient will again have the very visible chipped front tooth for a period of time until she can get to the dentist and have it repaired again.

IMPAIRMENT

Impairments were rated by Medical Doctor John Jones according to the AMA Guides to the Evaluation of Permanent Impairments, 6th Edition, and are as follows:

Cervical Impairment: 28% whole person

Lumbar Impairment: 20% whole person

Brain – Sleep Disorder: 13% whole person

Brain – Cognition: 6% whole person

Total Impairment: 53% whole person

In addition, this patient performed Duties Under Duress at Work and Domestically. Specifically, (list everything from these forms that apply to duties performed at work or home that patient had to do despite doctor’s order of disability)

Further, this patient Lost Enjoyment with the following: Work, Hobbies, Domestic and Household, and Sports. Specifically, (list everything from all the forms that apply to loss of enjoyment of life.)

DISABILITY

I placed this patient on temporary total disability for 33 days from 1/15/08 to 2/18/08.

I placed this patient on temporary partial disability for 63 days from 2/18/08 to 4/21/08. Limitations for partial disability included: Light work, no amusement park rides, and bed rest.

DEPRESSION/ANXIETY

This patient suffered depression and anxiety as a result of this car accident.

Condition: Anxiety

Physician who diagnosed it: Bob Jones

Last date Noted: April 21, 2008

Duration: 96 days and ongoing

Treatment prescribed: Exercise, meditation, counseling, avoid driving near accident scene, and referral to MD

Condition: Depression

Physician who diagnosed it: Bob Jones

Last date noted: April 21, 2008

Duration: 96 days

Treatment prescribed: Exercise, meditation, counseling, get out of house and socialize with friends even though she didn’t feel like it, and referral to MD

TMJ

The patient suffered TMJ sprain, pain, and muscle spasm following this accident. Treatment, testing, and prognosis were described earlier in the Injuries section of this report.

Office Treatments: Adjustments, massage

Physician who treated: Bob Jones

Last date noted: April 21, 2008

Duration: 96 days and continuing

Intensity of office treatments: 3 days a week

Intensity of home treatments: 7 days a week

Home treatments prescribed: Splint for home use, home exercises, restricted TMJ activity, relaxation exercises, and soft food/liquid diet.

INCOME LOSS

The patient lost $532.00 income because she missed one week of work as a result of this accident.

FUTURE MEDICAL

Future medical treatment was recommended by Medical Doctor Wilhelm Roentgen.

Surgical Option: $80,000. Stabilization surgery is an option to treat this patient’s ligament instability at C5-6. The cost of surgery is $80,000. Dr. Roentgen stated that this surgery is medically probable in the future to a certainty of 50-75%.

Non-Surgical Option: $54,000. Conservative, non-surgical treatment currently keeps this patient medically stable at a pain level that is currently tolerable. She chooses at this time to continue non-surgical treatments until a point that she can no longer tolerate the pain. Dr. Roentgen stated that the patient will require 12 treatments a year at a cost of $125 each. The patient is currently 42 years old and has a life expectancy of 78 years. Therefore, she will need these treatments either for 36 years OR until she has neck surgery. 36 years x 12 treatments x $125 = $54,000

Therefore, this patient’s future medical costs are between $54,000 and $80,000 in today’s dollars.

If you have any further questions about this patient, please contact my office,

Sincerely,

Bob Jones, D.C.

Enclosed: A complete copy of my chart for this patient

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