Records, What Do We Request and When Do We Need Them?

Many times we are asked what documents or records we request to conduct a Vocational or Life Care Plan Assessment. At times we are asked if we “want” everything or can a summary or a few documents suffice. We are even asked when we want to receive the records.

Our answer is always a steadfast “we would like to see everything that is pertinent to our role in the evaluation of the case” and “we would like to see it as soon as practical”. To help define what that would include, the following is a discussion of requested documents and records. Please keep in mind that cases vary and some of the records may not exist, so we take what is available.

Regarding the issue of when to review them, it is better to have extra time than to have to rush through them, which increases the chance for error by missing something important.

• Medical reports, Independent Medical Exams and Other Expert reports:

  • We would like to receive for review any treating and/or consulting physicians’ narrative reports, particularly those that address diagnosis, prognosis, current medical status, physical or mental restrictions or limitations, surgical reports, and in the Vocational case any statements discussing return to work capability.

  • For Life Care Plans we prefer to consult with or meet the physician(s) to determine future medical care based on medical necessity, after reviewing the documents. As a method, we consider all opinions in a case.

  • Of particular importance is the receipt of any Vocational or Life Care Planning Expert, so that we can critique any strengths, weaknesses, opportunities and problems with the assessment. Other expert reports can include Psychologists, Physical Therapists, and FCE reports.

  • This group also includes forensic economist reports as well. If the plaintiff has participated in State and Federal Vocational Rehabilitation programs this information is also important. From this we determine a vocational profile and participation with rehabilitation planning and goals.

  • In Longshore and Defense Base Act Cases, the OWCP-5 is extremely important because it outlines physical limitations.
    

• Depositions, Accident Reports, and IRS/Social Security Records of Wages:

  • There is much information found in depositions of the plaintiff, physicians, and other experts, such as psychologist, economists, and other rehab experts.

  • Because we are not involved in the determination of liability, but are more involved in the damages portion of the case we do not usually need depositions or statements of fact witnesses, depositions or reports of others experts such as biomechanics, product failure or accident reconstruction.

  • It is important to review Workers’ Compensation records, particularly First Report of Injury.

  • IRS records tell wages, however in the case of contract or self -employed workers, gross earnings, expenses and net earnings are very important. We prefer the Social Security reports in most cases.
    

• Notice of representation, Signed Release of Information, Interrogatories and Responses:

  • Whether engaged by the plaintiff or the defense we need to know who is involved; who represents whom.

  • In the case of co-counsel or multiple defendants, we need to know all who are involved in the case.

  • Due to HIPAA and HYTECH it is increasingly important to obtain the plaintiff’s signed authorization for the release of information. If you are going to share protected medical information you should have a release.

  • We obtain the releases to consult with other experts involved in the case, however when engaged by the defense we do not believe that we are to communicate with treating physicians or other treating professionals outside the presence of the plaintiff or their representative.

  • Interrogatories and responses contain useful information regarding the plaintiff’s history and the damages sought in the case.
    

• Social Security Disability and Medicare Set Aside Plans:

  • Although the rules of “disability determination” differ between legal venues and types of cases, it is often helpful to review decisions and conclusions reached in SSDI cases, to consider facts considered in the decision.

  • Many times Life Care Plans are used to develop Medicare Set Aside Plans, however when a Set Aside has been developed before a Life Care Plan, we can use the Set Aside to help develop the Life Care Plan.

  • When developing Life Care Plans and researching costs, we follow the standard method of researching costs in the relevant geographic area for medical services, supplies and equipment.
    

To schedule a complimentary consultation concerning a "hypothetical matter" with one of our experts at Stokes & Associates, please call David Barrett at 504-454-5009 or email dbarrett@stokes-associates.com

Larry S. Stokes, Ph.D.
Aaron Wolfson, Ph.D.
Todd Capielano, M.Ed., LRC, CRC, LPC, CLCP
Lacy Sapp, MHS, CRC, LPC, LRC, CLCP