Using Medical
Records to Your
Client’s Advantage in
Hearings
A Poll! A Show of Hands, Please
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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
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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
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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 selfdetermination 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
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Sample Contents of Medical Records
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Emergency Department Records, if any
Intake Forms
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Face sheet
Conditions of Admission, Consents, Involuntary Commitment
Assessments & Evaluations
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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 plan
 Discharge plan
Sample Contents of Medical Records,
con’t.

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MD Notes
Interdisciplinary Notes (IDNs)
 Nursing
notes
 Non-licensed Staff Notes
 Ancillary Staff Notes- Social Work, RT, OT, Nutrition
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Restraint/Seclusion Records
Labs & Radiology
Sample Contents of Medical Records,
con’t.
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Graphics
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Legal Papers
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Vital signs
Height & weight
Intake & output
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
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Electronic Medical Records:
The Minuses
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Access issues for Advocates
 Requires
computer terminal be available for
Advocate’s use
 Requires access code
 Requires training in the software program
 Requires 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!
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Record Review for
Certification Hearings
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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
 Discharge planning documents.

evaluations
Note positive physical health reports. Sources:
 History and physical,
 Patient graphics
 Lab
results.
Record Review for
Certification Hearings, con’t.:
Lab Results
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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
Magnesium
Results
1.8
Standard Range
1.7 - 2.3
Unit
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
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.
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?
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Record Review for
Certification Hearings, con’t.:
Procedural Due Process
 Does
the date of signatures on the 14-day
certification coincide with the initiation? Presigned or post-signed certifications should not
be acceptable
Hearing Record Review: An Opportunity
for Informal Monitoring
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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
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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
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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
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Other resources related to medical
terminology are included in the
Appendices
Thank you!