When a patient comes in to be evaluated following a motor vehicle accident, it is important to provide detailed documentation. Patients will often need these reports for their lawyer and car insurance if they have med pay coverage. Remember, private insurance usually does not pay for motor vehicle accidents, so the patient may have to pay out of pocket.
Document all body parts that were injured, no matter how small (abrasions, cuts, minor aches and pains). The most common injuries are muscle sprains and spasms to the back and neck, along with bruising/contusions and concussions.
Make sure you or the MA complete the entire MVA box in the context section.
Add as many details as possible about the accident such as weather conditions; time of day; who was in the vehicle; describe what happened; who got the ticket; the extent of the damage and where it is on the vehicle; if the patient was ambulatory at the scene; ER visit and findings and how the patient was transferred (POV vs EMS); if the seatbelt was used; if the airbag was deployed; if EMS was on the scene; if any prior injuries to injured body parts.
Ask about loss of consciousness (LOC). Was there an initial brief LOC followed by a lucid phase and then another LOC episode or focal change? This indicates a bleed, and the patient should be sent to the ER for further workup and CT imaging.
Regarding the timing of symptoms, remember that fractures and torn ligaments or tendons result in immediate pain. Neck and back pain from muscle spasms, which most MVAs will have at some point, are gradual over 24 to 48 hours. If the patient states there was no pain on the day of the accident and the pain came the next day, this can reassure that the patient is most likely experiencing a muscle spasm rather than fractures or something torn. You still must do a thorough workup.
The most important part of evaluating a patient in an MVA is the physical exam. Examine all areas injured, including the skin.
One of the most important exams you can do for an MVA patient is to check reflexes when there is concern for a spinal injury, like a disc herniation. If the reflexes are reduced, then the patient is more likely to have a herniation or nerve compression on the affected side.
Look for red flags for back pain and send to the ER if present. There is a big difference between paraspinal muscle pain and posterior spinous process pain. Anyone with posterior spinous process pain should have a CT of that area, as 50% of spine Fx can be missed on plane film. Anyone without spinous process pain and just paraspinal muscle pain can have an X-ray with any tenderness over the affected area.
Look for signs of burns if an airbag was deployed.
If there was blunt force trauma to the head or LOC, do a thorough neuro exam and look for signs of a concussion (Concussion Impact Questionnaire) or subdural/epidural hematoma.
Blunt force trauma to the chest and/or chest pain and should be sent to ER if:
Blunt force trauma to the abdomen:
For symptomatic patients do a UA and look for blood, a pregnancy test for child-bearing women, and an abdominal ultrasound for any of the above.
Make sure you provide specific diagnoses for all body parts injured, and not just pain to a body part. It is preferable to use codes for contusions, sprains/strains, abrasions, etc.
It is good to include a diagnosis for the type of accident itself. For example, there is a general code for an encounter for the exam and observation following a transport accident (Z04.1). There are specific V codes for the type of accident as well. The code for a person injured in an MVA is V89.2xx. However, you can be more specific as to the type of vehicle and if the patient was the driver or the passenger. For example, you can use V86.05 for the driver of 3-4 ATVs injured in a traffic accident.
Document the management plan for each injury. Refer to specialists, physical therapy, imaging, and the ER appropriately. Inform patients that it may take 24 to 72 hours after an accident before new pain develops or the current pain worsens.
Manage pain by alternating OTC Tylenol and Ibuprofen every 4 to 6 hours, which will also help reduce inflammation in strained muscles. Consider muscle relaxers for suspected muscle spasms; most will develop this over the first 24 to 48 hours.
Stretching exercises should be provided to increase blood flow and oxygen to the muscles.
Apply heat to relax muscles and topical analgesics like Bio Freeze or Icy Hot.
Follow appropriate rules for determining if X-rays are needed:
Refer to the ER if the patient had a brief LOC/concern for a bleed, focal neuro signs, was involved in a high-impact collision, or the vehicle was totaled.
Any patient not sent to the ER should have another follow-up visit in the clinic no later than 48 hours. This is the time when all the inflammation and muscle spasms will occur but at its max. You should re-evaluate them then.
Send to the ER if the patient has now or develops at home:
Check out the September 2009 edition of the Journal of Urgent Care Medicine for more on the topic of assessing patients after a motor vehicle accident.
E-mail: kmanlovesimmons@peachtreemed.com
