Taking a Great Medical Legal History

15 March 2012 / Impairment Physical Exam / Comments Off on Taking a Great Medical Legal History

Know your historian.

Before the doctor even begins the exam, he or she needs to assess the validity of the applicant. Is the applicant reliable? How clearly does the applicant recall the injury? Is there adequate understanding? Should and interpreter be present?

These considerations are all too commonly overlooked. I cannot tell you the number of times I have had applicants bring their children as interpreters, sometimes as young as six years old!

If dealing with a head injury and complaints of memory loss, bring in the spouse or adult children to help with the history. Lay ground rules regarding speaking in turn for the overly helpful spouse who want to talk for the applicant. Make it easy on yourself and the applicant.

Set up the history for success, not failure, early on in the process. If the collection of the history is flawed from the beginning, how accurate do you think the conclusions will be?

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