Do you read those PT records? No? Hmmm …

Let me tell you a story. Some details have been changed to protect … well, you know. Once upon a time I was asked to review some records on a young man, about 32, who sustained many fractures in an accident. Let’s call him Charley. Now, several years later, he’d been back to his regular job as a waiter in a busy downtown restaurant. Well, the attorney was happy because there was a physician note from a pain management clinic opining that lifelong physical therapy was a good idea; the associated physical therapist thought so too. And after all, if a doctor says so, it has to be true, right? What could go wrong? Asked for Charley’s PT records, he said, “What do you want those for? You can’t ever read those things anyway.” Please, I said. It turned out that Charley did have quite extensive rehabilitation. After he got out of the hospital, he had outpatient PT for months. As the attorney foretold, the PT flow sheets were poor copies of largely illegible scribbled codes in tiny boxes, all scrambled up and hidden in a pile of unrelated material. However, as I anticipated, the admission and discharge evaluations were typed and clear: Charley had done well in PT, been adherent to a good home exercise program, and was discharged having met all of his therapist’s functional goals.  Ten months later a new physician sent him to a different PT because he had stiffness and joint pain. After eight weeks of care, he had again met all his discharge goals, including demonstrating an appropriate home exercise plan. This therapist noted particularly...