1. Initial Intake Documentation
2. Progressive Documentation
3. Communications with the Attorney
4. Deposition of Health Care Professionals and Medical Experts
5. Trial Testimony of the Health Care Witness
6. The Health Care Professional employed as an Expert

A) History:

1. Identify other health providers.
2. Inquire as to past claims (workers compensation, personal injury: with or without lawsuit).
3. Set forth the "what" "when" "where" "why" & "how" of the mechanics of the injury AND the symptoms and complaints. Read back what you record to the patient for acknowledgment of accuracy

B) Preliminary Diagnosis:

1. Identify intended treatment regimen to be applied both in your office and by the patient at home.
2. Record expected nature and timing of improvement and/or referrals.
3. Identify other treating doctors.
4. Determine nature and timing of needed or possible referrals.
5. Initiate and maintain TEAMWORK with other doctors providing patient care.

C) Obtain past films and/or take good quality films as needed

D) Obtain lien and authorization for information release:

1. Have lien signed by patient and patient's attorney.
2. Require prompt notification by patient and attorney if a new attorney is acquired.
3. State that you are providing the lien as an accommodation to the patient to defer payment but that it should NOT be construed as an engagement of the attorney to collect money owed to you by the patient or a third party because you are not engaging the attorney in any capacity.
4. An attorney cannot directly/ indirectly pay, agree to pay, or guarantee payment of a client's medical bills. (However, an attorney can lend money for such a purpose, to a client provided the loan is based upon a written promise to repay the loan). California Rule of Professional Conduct 5-104(A).
5. Consider the option of filing a lien notice with the court case and/or with the defense insurance carrier.

2. Progressive Documentation

A) Develop good reporting habits and train your staff to record accurately, thoroughly and clearly:

1. Review the entries of your staff.
2. Make entries legible, thorough and specific.

B) Act as though a defense IME is looking over your shoulder.

C) Record all symptoms, complaints and exacerbating events (who, what, when, where, how, why as to each):

1. Repeat/read back to patient what [s]he reports.
2. Do not omit information that you fear to be problematic; instead, acknowledge it and try to rule it out as a problem [perhaps over time].
3. Do not be cheap with paper: Be thorough, try to keep from writing about one visit on two sheets, use a whole new sheet.

D) As to EACH treatment provided (state the type, duration, strength and location of application of each modality):

1. Clearly distinguish the location of symptomatology from the treatment site.
2. Perform and document periodic review of diagnosis, treatment regimen, and outside referral needs.
3. Be certain to chart note all telephone consversations with the patient and other treating physicians.

E) It is the Plaintiff's duty:

1. To seek necessary medical treatment of his/her injuries (BAJI 14.67).
2. To follow his/her doctor's reasonable and proper advice and instructions regarding treatment, care, and activities (BAJI 6.28).
   *The doctor should monitor the patient to see that [s]he is following the advice given.

3. Communications with the Attorney

A) Help determine early on:

1. Who all the potential defendants are
2. Whether there is a valid claim vs. third part[ies]
3. Theories of liability
4. Consultant[s] regarding the foregoing, advise the attorney regarding the competence, courtroom presentability, and reputation, of each so as to counter the anticipated defense IME.

B) Recommend books and treatises on the pertinent ailment, organize a study group library and updated bibliography.

C) Provide reports requested by the attorney:

1. The doctor should only prepare medical reports IF they are requested. There is a risk that early written reports will be overly optimistic and offer premature conclusions. Further, there is a cost for such reports that may not need to be incurred.
2. Be careful about: communicating with the plaintiff's attorney by letter or recording telephone communications with the attorney in the chart notes or saving message memos.
3. Note that it is improper for the defense attorney to unilaterally contact the treating doctor to privately discuss injuries, treatment, prognosis (Torres v. Superior Court (1990) 22 CA3 181).
4. Discuss the report contents and any problems in advance so as to be thorough, and to cure/ameliorate and/or candidly confront problems.
5. Discuss and prepare reply report to defense IME report.

D) Prepare attorney to effectively depose and/or cross-examine the defense expert.

E) Prepare with the attorney for your deposition or arbitration or trial testimony.

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