Using Medical Records to Your Client’s Advantage in Hearings.
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Transcript of Using Medical Records to Your Client’s Advantage in Hearings.
Using Medical Records to Your
Client’s Advantage in Hearings
A Poll! A Show of Hands, Please
How many of you represent clients’ in certification hearings?
Riese hearings? How many of you routinely review nursing notes;
doctor’s orders, admission summaries; seclusion/restraint records; laboratory results, etc. in preparation for hearings?
The Importance of Record Review
Advocates have an ethical obligation to provide the best representation possible to their clients
Reviewing the record: …allows you to better anticipate and prepare for facility representative testimony; …allows you to prepare your client for any embarrassing or angering testimony that might be offered by the facility representative; …allows you to ask your client for his/her version of “negative” events prior to the hearing; …allows you to draw out and expand upon documentation that is helpful to your client’s case.
Another Poll!
How many of you routinely ask for client consent before reviewing the medical record to prepare for hearings?
Consent to Review Client Records
Traditionally, Advocates reviewed client medical records without requesting consent from the client, often without even haven spoken to the client before hand.
In recognition of, and respect for, client self-determination and privacy (or in response to facility policy), many advocacy programs now have policies requiring advocates to obtain client consent for review of records prior to hearings.
Can we have some volunteers from the audience?
Asking for client consent dialogues…
(pages 4 to 5 in your handout)
The Medical Record
The medical record is a medicolegal document
Content and organization of medical records are not uniform, but can vary somewhat from facility to facility
Sample Contents of Medical Records
Emergency Department Records, if any Intake Forms
Face sheet Conditions of Admission, Consents, Involuntary Commitment
Assessments & Evaluations Psychiatric History and Physical Nursing Social Services Pharmacology Nutrition Education
Sample Contents of Medical Records, con’t.
Consults MD Orders Medication Administration Record Care Plan
Problem list Treatment planDischarge plan
Sample Contents of Medical Records, con’t.
MD Notes Interdisciplinary Notes (IDNs)
Nursing notes Non-licensed Staff Notes Ancillary Staff Notes- Social Work, RT, OT, Nutrition
Restraint/Seclusion Records Labs & Radiology
Sample Contents of Medical Records, con’t. Graphics
Vital signs Height & weight Intake & output
Legal Papers Informed consent Involuntary commitment Conservatorship papers
Discharge Summary/Death Papers Old Medical Records
Electronic Medical Records: The Pluses More than one user at a time Can be retrieved instantaneously Cannot be lost or damaged like traditional
paper records Legibility Ease of review for hearing preparation
Electronic Medical Records: The Minuses Access issues for Advocates
Requires computer terminal be available for Advocate’s use
Requires access codeRequires training in the software programRequires the cooperation/understanding of
facility Health Information Management staff and/or facility legal staff
Audience Participation Time!
Has the facility you work in converted to electronic health records?
Do you have access to the electronic for or do you have to rely on staff to print them out for you?
Share your experiences good and bad!
Record Review for Certification Hearings
Note not only do the circumstances that lead up to the client’s detention, but also the description of the client’s condition on arrival at the facility.Calm, cooperative behavior? Improvement in conditions since admission?Positive descriptions of condition and/or
behavior?
Record Review for Certification Hearings, con’t.
Note other indicators that the client’s condition has improved over the course of hospitalization Has prn (as needed) medication administration
discontinued or decreased? No emergency medication ever given? Or, emergency
medication discontinued, or decreased administration?
Has client consented for regular medication or ECT? Other indicators of appropriateness for voluntary
treatment either on an inpatient or outpatient basis?
Record Review for Certification Hearings, con’t.:
Grave Disability Note of any documentation in the record of
family support and/or financial support. Sources: Social Services assessments and evaluations Discharge planning documents.
Note positive physical health reports. Sources: History and physical, Patient graphics Lab results.
Record Review for Certification Hearings, con’t.:
Lab Results
Advocates don’t have to be medical experts to use information about their clients’ normal lab results in hearings.
Lab results generally list the substance or component being tested, the patient’s result, the standard or normal range or reading, the units, and an indication if the result is outside normal limits:
Component Results Standard Range Unit
Magnesium 1.8 1.7 - 2.3 mg/dL
Record Review for Certification Hearings, con’t.:
Lab Results You do not have to, nor would most
Advocates be comfortable, proclaiming the client healthy based on a lay interpretation of lab results.
Can we have some volunteers from the audience? Sample hearing dialogue about lab
results…
(page 10 in your handout)
Record Review for Certification Hearings, con’t.:
Procedural Due Process Check the record to ensure that the client has been
given the following information: A copy of the 14-day certification form. The
statement in the lower portion of the form pertaining to advising the client of due process rights should be signed.
Has the 14-day certification been signed by two authorized persons?
.
Record Review for Certification Hearings, con’t.:
Procedural Due Process Is the 72-hour evaluation form present and signed? Is
the upper portion completed to indicate that either proper advisement was given or the reason why it wasn’t?
Have the legal time constraints regarding detention been exceeded?
Do the narratives on the 72-hour hold and 14-day certification forms substantiate each commitment criteria indicated?
Is the Involuntary Patient Advisement form completed and present in the chart?
Record Review for Certification Hearings, con’t.:
Procedural Due ProcessDoes the date of signatures on the 14-day
certification coincide with the initiation? Pre-signed or post-signed certifications should not be acceptable
Hearing Record Review: An Opportunity for Informal Monitoring
Use hearing preparation as an excellent opportunity to perform routine monitoring of the facility’s compliance with patients’ rights law related to:Denial of rights;The use of seclusion and restraint;Medication consent, etc.
Medical Terminology
Most medical words are derived from Latin or Greek. They are generally made up of the following word parts:
A Combining Form which gives the word its main meaning, either a body part or medical concept (e.g. psych/o-, cardi/o-, hepat/o-, etc.),
A suffix which modifies or clarifies the medical meaning of the Combining Form and specifies disease, condition, or procedure (e.g. –al, -itis, -osis, etc.); and sometimes
A prefix which modifies or clarifies the medical meaning of the Combining Form and specifies location, time, number, etc. (e.g. bi-, eu-, dys-, trans-, etc.).
Medical Terminology
When trying to decipher an unfamiliar medical term, you being with the suffix, then the prefix if any, and then the combing form.”:
Tachycardia
suffix meaning prefix meaning combing form meaning
-ia (condition) + tachy- (fast) + Cardi/o- (heart)
Psychosis
suffix meaning prefix combing form meaning
-osis (condition/abnormal condition) ----- Psych/o- (mind)
Medical Terminology
Other resources related to medical terminology are included in the Appendices
Thank you!