The Vanishing Baseline
You are assessing a 54-year-old client referred after a workplace injury. The referral notes state she has "no significant prior history." During the interview she mentions, almost in passing, that she had six weeks of physiotherapy for the same shoulder two years ago and was told then that she "might need surgery eventually." She is keen to return to work and says the earlier problem "was nothing, it sorted itself out." Her employer's insurer is paying for the current assessment and has asked for a "clear causation opinion." The current presentation is consistent with either a new injury or an exacerbation of the old one.
1. How should the earlier episode change your assessment and your report?
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It changes both the reasoning and the wording. The referral's "no significant prior history" is now known to be inaccurate, and a causation opinion built on it would be unsafe.\n\nIn the assessment: obtain details of the earlier episode (dates, treating clinician, imaging, outcome), and compare the mechanism and symptom pattern then and now. This is what distinguishes new injury from exacerbation of a pre-existing condition - a distinction with real consequences for the insurer and the client.\n\nIn the report: state the prior history explicitly, note that the referral summary omitted it, and frame the opinion as provisional if records are unavailable. Avoid a definitive causation statement you cannot support. The client's minimisation ("it was nothing") is common and understandable, but it is data to weigh, not a reason to omit the history.
2. The client asks you not to mention the earlier problem because it might affect her claim. What do you say?
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Acknowledge her concern without agreeing to conceal. Something like: "I understand why that worries you. I can't leave it out, because an opinion based on incomplete information could be overturned later - and that would be worse for you. What I can do is make sure the report explains the earlier episode accurately and doesn't overstate its relevance."\n\nThe principle is honesty and completeness: reports must be accurate and not misleading, and the omission would mislead the payer. You can offer to show her the relevant section, or to include her explanation in her own words, which serves her interest fairly.\n\nIf she withdraws consent for the assessment on that basis, document the request and its refusal and follow your organisation's process. You do not alter the record.