What can I say to the therapist or nurse if my case is in litigation?

When you treat for your accident-related injuries the nurse at your doctor's office will often meet with you before you see the physician or physician assistant. Typically the nurse is acquiring updated information from you regarding your limitations and restrictions and pain level from the injury. The same is also true for the physical therapist. In fact, you are probably seeing the therapist 2-3 times per week if this is what your doctor has prescribed. It is easy to become friendly with the nurse and, in particular, the physical therapist. After all, they chose careers in the healthcare field so that we can assume that they do care about your medical condition.



Despite the above, you must be careful how you choose your words. For example, you were hurt in an automobile accident 5 months ago. Recently you experienced a weekend of less pain than typical. However, you know that you are far from being healed. Yet the therapist asks you on Monday morning about your weekend. You said that you felt better with less pain, merely being forthright and trying to keep a positive attitude. However, the therapist records in your notes "Patient improved, less pain, reports that his weekend went well. Will continue with modalities. Expect full improvement." Obviously you did say you were feeling better but you were only making a comparison of the past weekend to the previous five months. You certainly did not mean to imply that all was better with your injury. However, someone reading this note could certainly infer this, especially a claims adjuster or insurance defense attorney.



Here are some tips if you are treating regularly for your accident-related injuries:



1. Always be HONEST. Never exaggerate any complaints of pain yet do not minimize your complaints, either. For example, if you say something such as "Oh, I guess I am doing better," this will be interpreted to mean that you are literally improving. In reality, you may be hurting more than ever but you do not want to be a complainer. Go ahead and complain but, just do not exaggerate.

2. Be careful of developing a friendship with your therapist or nurse. This may cause you to become too comfortable with what you say. For example, you may casually say that you watched the football game on Sunday with some friends and had a couple of beers. However, it is likely that your medical record will state "Patient reports no change in her condition. Drank beer over the weekend." Although there may be nothing wrong with enjoying a brew, do you really want this in your medical records?

3. The goal of the healthcare professional is to help you improve. This is admirable, we want this from our healthcare professionals. However, an overzealous healthcare professional may use any opportunity to increase his batting average. Thus, unless you truly are improving and have no doubt that you will be 100%, do not give anyone ammunition to state in your records you are healed if this is not accurate.

Simply put, it may be better to state "I see some improvement but not enough" or "I still hurt a lot but the last couple of days seem somewhat better," if this is actually the case. Remember, your words will be recorded literally and, at times, stated inaccurately. Thus, like all of life's situations, be careful what you say and how you say it. If you are careful, you will not have to worry about something being taken out of its proper context. Attorney Doug Stoehr