Question

Case Study:

A 50-year-old male delivery driver presented to a walk-in clinic complaining of back pain after having fallen from his truck earlier that day. On physical examination, there was tenderness of the lumbo-sacral spine, and limited range of motion in all directions. His neurological exam was normal. The physician prescribed analgesics and recommended follow up with the patient's own family physician and also a referral to a physiotherapist.

During the visit, the patient asked the physician to complete a work-related injury form. When the physician suggested the patient take the form to his own family physician, the patient became argumentative. Feeling intimidated, the physician authorized modified work duties for a period of two weeks. Unable to reach his family physician, the patient returned six days later asking the physician to extend the disability period. When the physician declined, the patient became verbally abusive and threatening. He requested and was given a copy of his medical record.

Sometime later, the physician added the word ‘today' to the medical record of the first encounter to confirm the timing of the initial injury. He wanted the patient's medical record to be accurate should the workers' compensation agency question the worker's entitlement to benefits and request precise details concerning the date of the injury.

A few weeks later, the patient complained to the College about several aspects of the physician's care. In the course of the College's investigation, the patient's copy of the medical record was compared with the doctor's copy, and the addition, the word "today," was discovered.

• Discuss what the addition of the word "today" means in the legal process of keeping a health/medical record. Determine if this was in violation of any laws and be sure to justify your decision with supportive resources.
• Also analyze how the physician at the walk-in clinic handled the situation. What are your thoughts on the refusal to extend the disability period?
• Write 4-6 Paragraphs about the questions/topic above.

Answer 1

Answer :

Here 50 years old male is complaining tenderness in lumbo sacral region with limited range of motions and neurological assessment was normal . So there is no that much seriousness for the patient and physician prescribed the analgesics and physiotherapy as needed. But patient not satisfied with the treatment and he needed some more days to take rest

The medical record help to provide evidence of injury and treatment for worker's compensation .so the old man asked the doctor to extend the medical leave Gud physician not obeyed for that and has arguments between both physician and patient and finally physician added the "today" word to the patient medical record .it tells about the first day of consulting of patient to clinic and it is violation of laws and regulations

Patient dont have major injury and it can be relieved by some analgesics and physiotherapy .thats why only physician refused to extend the disability period .