8 rules for taking the perfect workers’ comp patient history

This article is intended for medical providers who need to write a history of a work-related injury.

The quality of a patient’s injury history can make or break the accuracy of an impairment rating. Read our eight rules on conducting a complete patient interview,  including how to let silence be your friend, and the one comment that every good medical history should include.

Follow these 8 simple guidelines, and you will end up with a complete patient history that has all the right answers to the right questions.

  1. Let the patient tell the story without interruptions. Hold your specific questions until after they’ve had their say. Don’t worry—most patients will not speak for more than 5 minutes.

  2. As you listen, draw a timeline. As the patient mentions each event related to the injury, plot them on the line in relation to one another.

  3. Ask the employee what he or she was thinking at the time of the work injury. This is important to collaborate with other informational sources as to what actually happened.

  4. Figure out how the employee feels about the incident. Notice off-handed remarks about interactions with players in the story, and clues about what prompted their decisions. What are their expectations? Do they want to be recognized? Do they want respect from their employer? Do they just want to be taken care of? Do they feel as though they’ve been cheated or not heard?

  5. Get a picture of the magnitude of what the employee perceives as their loss. Listen carefully for subtle impacts that the injury has had on their daily life, relationships, income, and spouse.

  6. Close the interview by asking the injured worker two questions:

    1. “Do you believe I have heard your entire story?”

    2. “Is there anything else you feel you need to tell me?” Try a 15 second pause here; it will seem like two hours. Remember: let silence be your friend.

  7. After the employee has had their say, show them your completed timeline. Tell the story back to them, and have them confirm that your notes are correct.

  8. In your written report, write a comment at the conclusion of the employee’s story that affirms that the history is fair, correct, and complete. For example: “After obtaining the history, the content was reviewed by the employee and confirmed to be complete and accurate.” This simple sentence will place your report above all others regarding believability and sincerity.

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