In the event of a car accident, nothing is as important as your health. But the other side of the med-legal coin is the way your doctors and attorneys document your progress. Usually, when you have an accident, your documentation is going to show a progression of painful movement, to hopefully a gradual improvement of symptoms to a full resolution. And full function. One of your chiropractor's jobs is to document your symptoms and function along the way.

Initial intake form to describe the injury

As with any doctors office, the initial intake form is a very important part of documentation. The intake form will talk about your injuries before and after the accident. The intake form should also describe what had happened during the collision, and what type of collision. Personal injury intake forms sometimes also include details such as seatbelt use, head restraint position, and awareness of the injury as it happened.

An intake form will be followed by the doctors notes. As we do an examination on you, we are doing an orthopedic, neurological, and spinal examination. We are testing your range of motion. We are documenting pain with range of motion. If you bend your neck to the left and you feel pain, but you bend your neck to the right and you do not feel pain, we need to document that.

Disability Questionnaires

Another important part of your documentation is filling out disability or outcomes questionnaires. These questionnaires are standardized, and they include several questions that talk about your ability to perform tasks at home, and whether or not pain interferes with that activity.

Outcomes questionnaires are filled out on the initial intake, during re-examinations in the course of care, and at the end of care. Every outcomes questionnaire can be scored, and the score can be put into a spreadsheet where it can be graphed, demonstrating your progression through the initial injury to discharge

Analog or Numerical Pain Scale

If you ever been to the doctors office because of pain, the medical assistant or the chiropractor might have asked you what level of pain you are experiencing on a scale of one to 10. Zero being no pain, and 10 being the worst pain you could ever imagine. When you are asked to put a number to your pain level, this is called a numerical pain scale.

Less common is the analog pain scale. With an analog pain scale, you are asked to rate your pain on a line on a piece of paper. This line might be 10 mm long. The doctor then takes a ruler to the line to measure where you put your mark. So, if you put a mark somewhere to the right of the middle, it might be 7 mm. This is just like having a 7/10 on the numerical pain scale.

The numerical pain scale is heavily criticized, but it is one factor within the whole intake process. It helps to paint the overall picture of your current pain level, disability, and severity of injury.

Computerized Range of Motion Testing

We have a computerized range of motion system in our clinic. This objective measurement of your range of motion of an injured body part is also another important piece of the injury puzzle. Injured patients who come to our office receive this computerized mention motion test, and this provides a written report for the medical record.

Computerized Functional Movement Testing

Our office also includes a computerized kinetic functional movement evaluation. This is done to injured patients when they are starting to feel better on their road to recovery, and are no longer in acute pain. This functional movement evaluation tests balance, coordination, symmetry in the lower limbs, strength, and mobility. Again, this computerized evaluation is put into a report, and becomes part of the medical record.

Functional X-rays

In many cases, it is necessary to perform flexion and extension x-rays of the neck or low back to document the severity of injuries. With a whiplash injury, it is common to tear the ligaments in the neck, which can leave you with some degree of instability within the bones of the neck. A flexion and extension x-ray can be taken by one of the local imaging centers, and we can send that out for a report from a radiologist who will measure the instability that may occur.

Other types of Imaging

Some injuries are so severe that they require an MRI to image the soft tissues of the spine. Other types of injuries require diagnostic ultrasound. This is done on a case-by-case basis.

Special Tests

And yet still more severe injuries may require a referral to a neurologist to perform other special tests. Special testing by neurologist may include nerve conduction velocity test or electronic muscle testing.

If you have been involved in a car accident or other type of injury, it is important to good get in to see your chiropractor right away. In Petaluma, our office has a special interest in whiplash injuries caused by car accidents. We are located at Chiropractic Care.

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