The Eloquent Physician - a Medical Record Software Program. Sample Doctor’s Chart Note

In my opinion (fullName) has reached maximum medical improvement from the injuries that (he_she) sustained on (dateOfInjury), and has sustained a 5% permanent physical impairment to the whole person as a result of the lumbosacral injury sustained on that date. This is categorized as a lumbosacral DRE II as per the AMA Guides to the Evaluation of Permanent Impairment, 4th Edition, page 110. As I understand this patient's specific situation, (he_she) had no symptoms referable to the low back prior to the incident of (dateOfInjury). Further, I understand that (he_she) has complained of symptoms in the lumbar spine region more or less continuously since the injury. Additionally, as I understand the mechanism of injury, I believe that the accident in question is a competent producing cause of (his_her) low back injuries. Based, in part, upon this information, as well as the physical examination findings during the course of treatment in this office I, again, believe that the accident in question has caused a permanent injury with a permanent physical impairment as above noted. The physical examination findings which support this conclusion include limited range of motion of the lumbosacral spine as well as muscle spasm in that region. These findings have been noted by me and have been persistent over the course of at least six months since the accident. Thus, I believe that this patient fits all of the criteria for a DRE II, as noted on page 110 of the Guides. Notwithstanding my opinion stated above that (firstName) has reached maximum medical improvement as it relates to the lumbosacral injury sustained on (dateOfInjury), it is my opinion that (he_she) will require palliative medical treatment in the future. While it is impossible to be certain of the exact degree of symptoms that are going to be experienced at any one particular time in the future, it is still quite clear that it is likely that (he_she) will have periods of exacerbation and remission over the ensuing months and years. This is quite typical for patients who have experienced lumbosacral injuries such as that experienced by this patient. Diagnostic studies such as X-rays and/or MRI's will be required in the event that there is continued symptomatology over the years. X-ray studies would cost around $350 and each MRI of the lumbosacral spine would cost approximately $1200. Similarly, in the event that radicular symptomatology were to be a prominent component of (his_her) symptoms in the future, neurodiagnostic studies, such as EMG / NCV should be undertaken as well as, potentially, therapeutic epidural steroid injections. During periods of exacerbation therapy will be beneficial. Typically a series of {one time weekly | two times weekly | four times weekly | five times weekly | six times weekly | seven times weekly | | three times weekly} therapy sessions per week for {1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10} consecutive weeks will be satisfactory to allow for improvement of the symptoms. It is my opinion that sequences of therapy sessions with this frequency should be undertaken for exacerbations, and that this will be required {two | three | four | five | six | seven | eight} times annually. Therapy sessions typically cost between $100 - $125 per session. Massage therapy has been noted to give temporary relief in many patients who have injuries such as these. In the even that massage is seen to be of assistance, I would be of the opinion that massage, up to once weekly, should be undertaken. Non steroidal anti-inflammatory medications have been found to be particularly helpful in situations such as this. I would recommend that they be utilized, as needed, unless contra-indicated by allergies, ulcers or other reasons. In addition to the therapies mentioned above, trigger point injections may prove useful. Again the frequency cannot be determined with precision. However, it is common that patients with injuries such as those sustained in this instance would require between 3 and 4 trigger point injections per year. Each of these injections is likely to cost $150. Finally, occasional office visits to a physician should be undertaken. Depending upon the degree of symptomatology in the future, annual or bi-annual visits would be appropriate. It is unlikely that a surgical procedure in the lumbosacral region would be of assistance in this particular instance. However, it is impossible to rule this possibility out entirely. Because of (his_her) injuries I believe that some degree of work limitation is present. I believe that (he_she) is capable of working. However, I would recommend restricting the work to {light duty | moderate duty | heavy duty}. { | Because of the injury to the spine this patient is capable of light duty work only. Occasional lifting and carrying of up to 20 pounds, and repetitive lifting and carrying of up to 10 pounds is acceptable. In addition, the patient should avoid strained | In my opinion the patient is capable of moderate duty work. Lifting and carrying of up to 50 pounds on an occasional basis and of up to 20 pounds on a repetitive basis is acceptable. This patient should avoid any continuous bending, stooping, or kneelin | In my opinion the patient is capable of heavy duty work. Lifting and carrying of up to 100 pounds on an occasional basis and of up to 50 pounds on a repetitive basis is acceptable. This patient should avoid any continuous bending, stooping, or kneeling.}