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Reliable Historian

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Hi group,

I am struggling with wording/documenting the fact that I do not believe a new

patient I am seeing is a truly reliable historian- liar :) - of his case or

history.

Pedestrian hit by a car. This is the second time, first in 2007. He reports

being beat up in 2009 but would not provide details. He contradicted himself in

recalling the few details of the accident he " remembers " . He was reluctant to

give me information about his past conditions. Told me I did not need to see the

police report. I nicely assured him I needed all the information available to

help him to the best of my abilities.

My treatment is going to be EXTREMELY conservative until I feel more comfortable

with the details behind the case.

I want to document this and do a good CYA, but I also do not want to report

something that may negatively impact his medical/legal future.

Any suggestions on how to nicely call this guy a liar without doing any

potential future damage to a potential case? Where is the appropriate spot in

the notes for this? a narrative, soap? Should I even be worried about this?

Thanks in advance!

a Lehman, DC

Corvallis

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