As part of an Independent Medical Exam , I am asked the get a “History of Injury” . A medical history of injury is very similar to a story. Information gathering typically consists of the Five Ws: Who, What, Where, When, Why, and as many of us also learned, sometimes How .
Interestingly, the origin of these elements are attributed to Aristotle . Rudyard Kipling memorialized these elements in a poem:
I keep six honest serving-men
(They taught me all I know)
Their names are What and Why and When
And How and Where and Who.
The “History of Injury “ is usually documented as provided by the patient (claimant) at the time of the examination and thus may vary from the history provided in the medical record. I try to get the claimant to describe the injury as the understand it . Oftentimes, I will have them carefully demonstrate what happened. In the case of an auto accident , we will often draw a diagram of the vehicle positions to get a better picture of how the accident occurred. As an Independent Medical Examiner, I consider both the history as provided by the claimant and the history in the medical record in providing an opinion “to a reasonable degree of medical certainty”. I will discuss “reasonable degree of medical certainty” in my next post.