Opinion by Tanielle Ridley: (Tanielle is responsible for assessing and resolving the production and technical matters relating to medical legal reports for experts, attorneys and patients that use Fundamedical Administration Services.)
How should a medical legal expert approach the following issues after completing the medical legal report?
- The attorney queries an alleged exclusion of an injury in a medical legal report?
- The attorney queries the alleged omission of a patient complaint relating to his or her accident?
Firstly, the expert must establish the reason for the issue surfacing. In the above examples, this could be:
- The patient has complaints, however they cannot be linked to the accident due to insufficient proof, or
- The patient actually has no complaints which fall under the expertise of the specialist in question
Complaints with Insufficient Proof
In general, experts submit letters with the best of intentions of preventing the completion of unnecessary reports. However, this could expose the attorneys to liability under settlement because it seems as if they have not considered the injury or complaint.
The majority of the experts have requested that this scenario be handled in the following manner:
- Before submitting the report or letter, identify the evidence or documentation required to find the nexus between the accident and alleged injury.
- Request the documentation from a FundaMedical representative.
- If this new information can be obtained and it changes the conclusions in the report – include it and submit the report accordingly.
- If this information cannot be obtained, still mention in the report or letter that the claimant reports a specific injury, however, there was insufficient evidence to support it. If new relevant documentation becomes available, an addendum medico-legal report may be completed.
A patient was seen by a neurosurgeon and a psychiatrist. The neurosurgeon reviewed the psychiatrist’s report, which mentioned a possibility of the patient developing hypoxia in hospital (due to severe burn wounds).
There were no ICU records available and as a result, the neurosurgeon was unable to support this possibility. The neurosurgeon subsequently submitted a letter stating that the patient had no neurosurgical complaints and that a neurosurgical medico-legal report was not recommended.
The attorneys queried the fact that the patient had no complaints and whether the neurosurgeon had considered all possibilities or just went on what the patient stated. On investigation it appeared that the neurosurgeon had indeed considered the possibility of hypoxia but required the following evidence:
- Proof of a clear period in the hospital records during which the Sats took a dip and were under 90, or
- Proof of a prolonged period of loss of consciousness, during which the patient was not intubated (the patient was intubated on arrival).
FundaMedical was able to assist by requesting the above. Once the ICU records were obtained it was established that the link could still not be found and the letter was amended to read:
“There is a possibility that the patient developed hypoxia in hospital, however there are insufficient records available to support this. If the relevant information is made available, a neurosurgical medico-legal report may be completed.”
This allowed all possibilities to be considered, prevented the attorneys from being liable for under-settlement and still allowed the expert to only stand by a diagnosis that could be supported by objective evidence.