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Request from Lawyer for Soap Notes

I am looking for advice on this. This is new territory for me.

Recently I have seen a client who had been in a car accident. I saw this person several times. This person had been to a doctor after the accident but prior to seeing me was given the OK to resume normal activies, sports and live life in general. After a while this person realized they had more extensive health concerns relative to the accident than originally thought. Now they are sueing the driver of the other car to cover their medical expenses. This includes recouping the cost of the massage therapy as well.

I have been asked by their lawyer (and given the appropriate signatures and documentation) to turn over copies of my notes, etc. My question is. Do I, in this case simply need to copy and provide the lawyer with copies of my Client Intake form and copies of my SOAP notes, or am I expected to take the time to transcribe my soap notes into sentence format for each of the session we had which would be time consuming? I do put a lot of effort into keeping good soap records, and where I have not written out the info in full sentence, I did use the standard medical shorthand we were taught in school. Also, I had a phone conversation with this person prior to their first session. Am I expected to provide written detail regarding that conversaton as well?

I would love some feedback from anyone who has more experience in this area. What do you think?

Replies are closed for this discussion.

Replies to This Discussion

Permalink Reply by Dawn Lewis on September 27, 2011 at 2:41pm

Hi Jeanne - I have been doing insurance billing for many years, and have had to provide notes to lawyers at least a half a dozen times, plus I used to teach SOAP notes to massage students. Send copies of your original SOAP notes, along with the client intake form, and a cover letter simply stating that if they need more info, they can contact you. Sometimes attorneys want you to write out a prognosis, but since this client's doc had already released them for most activities, it does not sound like they are asking you for that. And you do not have to modify or add to your notes in any way.

Permalink Reply by Jeanne Riley on September 27, 2011 at 2:58pm

Thanks Dawn. That is good to hear from you.

Permalink Reply by Linda LePelley, RN, NMT on September 28, 2011 at 9:03am

And I bill the lawyer for the copies and time spent on the matter.

Permalink Reply by Jody C. Hutchinson on September 29, 2011 at 8:46am

Jeanne,

I agree with the Linda and Dawn. Send copies of the notes along with an invoice for $25.00 and your contact info. I have never had an attorney ask for more documents. Best of luck.

Permalink Reply by Kay Warren on September 30, 2011 at 7:56am

Here's my take. Are you required to make it pretty for the lawyers. No. Should you? Yes. Most of them don't understand our terminology or abbreviations, and it doesn't "reach" them, and doesn't help them get a settlement. Your notes also record what they told you about their condition, and possibly when & how they realized that they weren't in as good a shape as they thought, the "decision tree" that helped you assess their condition and determine your course of treatment, and of course, your results. Detailed conversational notes are a good thing. I'd do it.

The other question is how you found about about this. Did the client tell you they were still having problems? did they tell you they were planning on seeing an attorney because the injuries weren't resolving? Or did you just get a letter from the attorney?

Another guy here posted about injuries than can be missed by X-Ray or MRI, and posted a video link. Go have a look.

http://www.youtube.com/watch?v=GCtVKwO65mQ&feature=player_embedded

if the client is still having serious problems, yo might want to share the link, and ask them to speak to their doctor about the possibility of using this diagnostic tool.

good luck.

Permalink Reply by Jeanne Riley on September 30, 2011 at 10:40am

Thanks Linda, Jody, I love it..good idea.

Hi Kay, Thanks for your thoughts. This is new territory for me so I am still trying to sort out how I feel on this but I think I am a little more with Jody, Linda and Dawn on this one. I agree with you that the lawyer would probably not understand the terminology without taking the time, or hiring someone to have the notes transposed. Although, if he specializes in this type of work, maybe he does know how to read these as is.

Generally, it would be my inclination to go the extra mile and and make things pretty and nice for others. I am drawn to help people and that is why I do the work I do. But, it is hard enough to find time to fit in everything it takes to get a business up and running to spend a great deal of my time making life easier for a lawyer I have never met, who is I would guess getting paid well for his time. I am thinking that if the roles were reversed I would get his notes nicely typed out but with a bill for an amount way over $25. Even my childrens' doctor charges $5 for a copy of the annual health history needed for school. I need to be smarter about my own time management so I have sent off my response with simple photocopies of my intake and soaps and a nice letter inviting them to let me know if they need anything further. I hope I do not hear from him. And I hope he is successful in helping this person out. But if I do hear from him, I think I will bring up the topic of time is money prior to spending more of my time on this.

It's always an interesting journey isn't it. Thanks everyone for your advice and input.

Permalink Reply by Jeanne Riley on September 30, 2011 at 10:51am

Wow, Kay. I watched that video. Thanks. It was very interesting. If I get in an accident I am going to this person for a consult.

Permalink Reply by Gordon J. Wallis on September 30, 2011 at 11:49am

I have given treatment notes to attorneys many times in the past...You just give it too them... and thats it...They hold little importance compared to the Docs notes..Thats what they really look at...And they know the terminology.. They dont read them in court.. They are just submitted....