Medical Legal Consulting News, Summer 2013
IN THIS ISSUE:
- Listening to the blues
- Vocabulary Quiz: Psych/Mental health record abbreviations and terminology
Greetings! Welcome to the summer issue of Medical Legal Consulting News from MLCS, Inc. Continuing with our musical theme for 2013, MLCS’ Greatest Hits, this issue is devoted to the “blues,” those medical record reviews involving allegations of psychiatric injury or a component of pre-existing mood disorder, such as depression.
Let us help you improve your “blues” listening skills through our article on reviewing psych records and by taking our psych terminology quiz. Look for our “Broadway musical” issue later in the Fall when we will highlight examples of very large reviews that have everything!
We welcome your feedback and appreciate any suggestions for articles for upcoming newsletters. You will have an opportunity for feedback on medical record reviews through our client survey, which is emailed periodically.
Linda Luedtke, RN, MSN
President and Director of Consulting Services
Listening to the Blues
Review of medical records with psychiatric diagnoses
Medical record reviews of “blues” claims involving psych allegations can be challenging for a number of reasons. Psychiatric testing, medical management and psychotherapy records are typically less familiar to the layperson. There can be the appearance of no objective data. Common sense and life experience suggest to us that there can be many causes for psychological, emotional and cognitive distress, but at the same time, it can be hard to exclude the possibility that a trauma could be a source of symptoms.
The MLCS legal nurse consultant listens closely to the “blues” file to hear melody patterns that point to a pre-existing psychological condition or the situation in which the trauma has been a factor in the post-accident psychological distress. The MLCS nurse is trained to review psychiatric and counseling records and is aware that references to prior psychiatric treatment and counseling may not be prominent in the records but tucked away or cryptic, sometimes within a past medical history or social history of the record.
The provider may not be identified by name, or if the provider is identified by name, the specific reason for the prior psych-related treatment may not be given. Detective work of looking up diagnostics and treatment codes may be required. In some cases, the only clue to a prior relevant psychological condition is a listing of current or prior medications, which reference psychotropic medications. As with allegations of physical injuries, the MLCS nurse analyzes records to see if psych symptoms are reported consistently and consistent with the diagnosis offered.
Analysis of a “blues” file also includes investigation of non-traumatic alternative explanations for the symptoms. Examples of this could include significant concurrent stressful family psychosocial situations and suspected or newly diagnosed systemic medical conditions, such as hypothyroidism, which can be associated with psych symptoms.The legal nurse consultant listens to the “blues” file to hear if there has been resolution or recovery of symptoms as demonstrated by the individual’s functional status. For example, PTSD symptoms related to an auto accident may be questioned if the individual is driving the same vehicle on the same road without report of PTSD-specific symptoms.
Do these abbreviations create a melody you can clearly hear, or dissonance you can’t make sense of? Knowing them will be music to your ears when it comes to understanding medical records.