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Medical Records: Predicting The Future

Kenneth I. Kolpan, JD (Editor)

EVERYONE INVOLVED with a patient who has a head injury wants to know how that person's future will be. The patient wants reassurance that he or she will return to premorbid condition despite having suffered a closed head injury. The family needs to know what to expect. The patient's attorney, insurance company, and defendants who may be responsible for the injuries are concerned about the patient's future.

The medical model promotes the notion that treatment will make the patient better, and rehabilitation programs foster this notion. Despite the hope of everyone involved that the head injury patient will return to his or her preaccident level of functioning, reality is often otherwise. Medical prognosis reports for patients with head injury are fraught with this contradiction.

A written opinion regarding a patient's prognosis can have significant consequences for many patients who are involved in litigation. A report stating that the patient has an excellent chance for full recovery or that the prognosis is excellent (without any further explanation) will be used by the other side in a lawsuit to prove that the plaintiff has no compensable injury. Medical reports are written at a time when providers may be unaware but should realize there is potential litigation. Even if the writer of the report is unwilling to be involved in testifying on behalf of a patient, the written medical report will find its way to insurance companies, counsel, and a jury.

Opinions regarding the outcome of a head injury are misunderstood because of the context in which they are written. For example, neurosurgeons who save the lives of traumatically injured patients have a different perspective on the patients' outcomes. The neurosurgical opinion regarding prognosis may appear to be optimistic when it is really a statement about a head-injured person's survivability and condition after neurosurgical intervention.

Statements by subsequent treating physicians about the patient's recovery are similarly misunderstood. A recent physician's report stated that a patient with a serious brain injury had an excellent chance for full recovery. When he was finally deposed, the physician explained that he was referring to her full recovery from neurological injury; he agreed that she had not recovered from and still had significant cognitive deficits. Had he not been deposed, the medical report standing alone would have suggested strongly that the patient's condition at trial was allegedly due to malingering rather than an injury sustained 3 years earlier.

Other medical reports speak optimistically of the patient's improvement and recovery because the report may be read by the family and the patient. Those who are familiar with head injury know that families must be educated about the subtle effects of a head injury so they can deal realistically with the injured person's limitations. A realistic description of the patient's future rather than a simply optimistic one allows the family to obtain appropriate rehabilitation services in order to maximize recovery. In the case cited above, the physician's statement of full recovery was written so as to discourage the teenage patient from dropping out of high school (the physician feared that she would if she read a more realistic note). The patient took the physician's encouragement and optimism and used them in denial of any significant injury. The defense counsel in the patient's lawsuit will use the physician's note as evidence that there is no injury.

Though prediction of outcome after head injury cannot be made with certainty, it is important that medical reports describe the patient's prognosis within the context in which the patient is seen. Medical reports will be in the hands of persons who may be responsible for the future care of the head-injured person (e.g., insurance agents or jurors). They will be looking to the medical experts for statements of the patient's future condition. Well-written, well-documented, and clear descriptions of prognoses will, in the end, serve all head-injured patients.