Q: How thorough do I need to be in determining my client’s use of over the counter medication, supplements and CAM treatment? (Part two)

A: Last month’s newsletter discussed some of the common over the counter medications and supplements that can cause significant bleeding complications, particularly when used in combination with prescription blood thinners. Since Coumadin is affected by vitamin K and liver metabolism a large number of OTC medications and herbal supplements can alter bleeding times and lab values. Other blood thinners, such as Plavix, Xeralto , Pradaxa and Eliquis work by a different mechanism and are not affected by as large a number of supplements. Medications (aspirin, ibuprofen) and herbals (St. John’s Wort) can cause problems with Plavix and the newer blood thinners as well.

The fact that the use of OTCs and herbals may not show up in medical records was also discussed. People often do not tell their doctor they are taking them. More distressing, there is evidence that providers are not asking about them. What else may not be documented in the treating physicians records?

Issues of causation are frequently difficult to extract from medical records. The reasons for this are varied and sometimes inadvertent. The change over to Electronic Medical Records (EHR) and the time constraints placed on physicians are both implicated here. EHRs with their templates and drop down boxes often result in very generic descriptions of injuries and symptoms. A busy physician may use these tools to streamline the office visit and record keeping process. Unfortunately, important details can be left out during this process. There can also be a presumption on the part of the treating physician that a patient on his or her schedule for a work injury has already had a claim accepted. This can lead to a limited statement in the records, often no more than a sentence; “John is here today for an injury to his shoulder that happened at work.” Many physicians are more focused on treating the patient and coming up with a plan of action than going into detail about the events surrounding the onset of an injury or illness.

When asked weeks, months or even years later to make a definitive statement of causation the treating physician may have minimal documentation to fall back on. Collecting information from other sources can fill in the necessary details. Chiropractor and physical therapy notes can be very helpful with injury cases since they typically contain more details about the mechanism of the injury. Notes from acupuncturists and massage therapists can also be useful. Naturopathic and holistic providers can be more focused on causes of injury or symptoms than allopathic providers and their records are not always included in medical cases. Naturopaths are frequently not M.D.s or D.O.s and, for better or worse, their opinions usually do not carry as much weight in a court of law so their records can be overlooked.

CAM provider records can also be useful in cases of illness rather than injury. Environmental exposure causing allergic, respiratory, and neurologic illnesses, to name a few, can be difficult to pin to a specific cause. People experiencing more subtle symptoms may not go to their physician right away. They may try a number of home remedies, OTCs and herbals before seeking medical care. The internet being the wealth of misinformation that it is can lead people to try various treatments. Holistic and naturopathic providers may be the first line of treatment for some people and their notes can provide details of symptoms, dates of onset and treatments already tried. This information can be valuable, especially in cases where there is a delay of weeks or months in seeing a physician. By then the details of early symptoms and onset may be fuzzy in the persons memory.

Issues of ongoing disability and pain can be elucidated in CAM provider records as well. People in chronic pain (low back, neck, myofascial) frequently seek out multiple avenues of treatment and ongoing symptoms can be documented. Another serious issue that can have CAM treatments come into play is that of delayed or missed diagnosis. Keep an eye out for more on these topics here in the future.