Shared by Sigmund Miller, DC: webinfo@ChiroViewPresents.com
2/01

What Do You Mean Prognosis Is Guarded?

Author: Sigmund Miller, DC

As some of you know, I was involved with running a national utilization review company 
called ChiroView for more than 15 years. In that time, I supervised chiropractors, medical 
doctors, and physical therapists in reviewing more than 250,000 chiropractic, physical 
medicine and physical therapy claims. 
I could never understand, when reviewing charts, why next to "prognosis" the treating 
clinician's response was often listed as "guarded". This occurred mostly when reviewing 
chiropractic records. 
Let me get this straight. Here I am reviewing chiropractic records that 1] were being 
submitted by someone who I believe is the most skilled in diagnosing and treating 
musculoskeletal conditions, 2] who just completed one of the most extensive consultations 
and examinations, and 3] who submitted a diagnosis that is reasonably accurate. And now 
when it comes to providing an opinion as to how this patient is likely to respond to 
treatment, the doctor, at best, can only offer a guarded prognosis!
I always believed one primary objective when treating patients was to improve the quality 
of their lives. That might mean any number of things to you and your patients. But more 
times than not, in all my years treating, patients simply wanted to feel better so they could 
return to the kinds of activities of daily living they enjoyed most. My patients typically 
would rate the quality of their lives largely upon whether they were capable of performing 
some, if not all, of their more enjoyable daily activities.
You and I know that in the clear majority of cases, chiropractic treatment offers a prognosis 
that is excellent for full recovery; or in more chronic conditions, will reduce discomfort to a 
level allowing patients to return to a more active and enjoyable lifestyle. 
I firmly believe a guarded prognosis is often submitted because doctors believe being vague 
and ambiguous will then open the door for more extensive treatment. Nothing could be 
farther from the truth. Clinical opinions that remain 1] non-committal relating to the amount 
of treatment anticipated or 2] ambiguous regarding "likelihood of a favorable response" will 
simply be "red flagged" and subjected to the utilization review process.  
When patients are paying cash, how can they not be upset, if after spending all this time 
and money following initial work-up, the chiropractor is vague in 1] offering an opinion as 
to how they are likely to respond to treatment, 2] how long treatment will last, and 3] 
approximately how many visits are required?
Whether you're treating a patient paying cash, or filing a workers compensation or personal 
claim, or even submitting a claim covered by the patient's insurance company, I 
recommend you communicate clearly and decisively on these issues. Most importantly, 
remember it's your clinical judgement, and if you're incorrect early on, then update those 
opinions in follow-up reports. It's that simple. 
For example, I recommend that following initial evaluation and during the acute stage, you 
report to the patient and/or payer at 2-week intervals. That can increase to 4 week periods 
as the patient continues to respond favorably. During my 23 years of treating patients and 
following initial work-up, I would typically inform the patient or conclude my report to the 
payer as follows:
"Based upon initial evaluation and diagnosis submitted, the patient presents as an 
appropriate candidate for a course of chiropractic treatment. Initial course of treatment will 
extend 2-4 weeks. I anticipate visits being scheduled multiple times weekly, and then 
tapering as patient responds favorably. Re-evaluation completed at approximately two-
week intervals will include outcome assessment tools. Treatment effectiveness will be 
based mostly on the patient's ability to return to more normal activities of daily living."
You also need to be clear in your reporting when managing workers compensation or 
personal injury claims, especially if you believe the patient has reached a clinical level that 
is permanent and stationary or is at maximum improvement. I assume when you've made 
that determination, patients have already explored and completed all appropriate diagnostics 
and other treatment alternatives, and now has residuals.  
If future care is necessary in supportive fashion then consider outlining the amount of 
treatment you believe is required over 12-month intervals. Consider the example below 
when concluding your report under the heading of "Future Treatment": 
"Given residual symptoms patient will require future care characterized as supportive in 
nature. It is within reasonable clinical probability that up to four flares in symptoms are 
likely to occur during the course of a 12-month period based upon the patient's present 
activities of daily living. I anticipate 3-5 visits being required for each episode. As a result, 
visits ranging up to 20 are recommended annually. To evaluate in the future efficacy and 
amount of treatment being recommended, I suggest this patient and records be reviewed at 
12-18 month intervals." 
Well enough said on this topic. Let me know what you think and please consider rating this 
article 1 to 5 where 1 = You're putting me to sleep and 5 = great stuff!
Cheers!
Sigmund Miller, DC 
Chiroclinix - Director of Community Relations