Using Medical Records to Your Client’s Advantage
in Hearings*
Patients’ Rights Advocacy Training (Basic Track)
February 6, 2013
*Credit:
Some of the information this handout was originally presented by Jeanne Matulis, Theresa
Nelson, Melissa Daar and Leslie Morrison.
1
1.
The Importance of Record Review
2.
Respect the Client - Obtain Consent
(a)
3.
Sample Dialogues
The Medical Record
(a) Content
(b) The Electronic Medical Record
4.
Record Review: Certification Hearings
(a) Note the Negative as Well
(b) Special Considerations: Grave Disability
(c) A Note on Lab Results and Graphics
(d) Procedural Due Process
5.
Notes on Medical Terminology
Appendices
Medical Abbreviations
Medical Words: Singular and Plural Nouns
Medical Words: Common Suffixes and Prefixes
*Credit:
Some of the information this handout was originally presented by Jeanne Matulis, Theresa
Nelson, Melissa Daar and Leslie Morrison.
2
1.
The Importance of Record Review
Reviewing written documentation is fundamental to adequate hearing
representation.
Advocates have an obligation to provide the best
representation possible to their clients. Reviewing the record allows you to
ask the client to give his/her version of “negative” events in the record and to
expand on reports of behavior that may be helpful to his/her case. It also
helps you verify that the information offered by the facility representative is
actually documented in the record. Advocates who rely on the facility
representative to provide a fair and balanced representation of the
information in the record and fail to read the record themselves do their
clients a disservice by placing their clients at a disadvantage vis-a-vis the
facility. You should not lose sight of the fact that certification and Riese
hearings are adversarial in nature despite being informal.
2.
Respect the Client - Obtain Consent
Explain to the client that to provide them the best representation, you will
need to know what evidence the facility plans to present at the hearing by
reviewing what the staff has written in his/her medical record. Obtain the
clients consent to review their medical record. If the client refuses
consent, explain that it will hamper your ability to effectively assist them,
but if the client still refuses, the advocate must respect this decision.
Note: Advocates are entitled to a copy of the Notice of Certification without
client consent. (W&I Code, section 5253).
*Credit:
Some of the information this handout was originally presented by Jeanne Matulis, Theresa
Nelson, Melissa Daar and Leslie Morrison.
3
(a)
Sample Dialogues
Wrong way to ask for consent:
A:
Hello Ms. Rodriguez. I’m the Patients’ Rights Advocate. I don’t
work for the hospital; I work for the Patients’ Rights Advocacy
Program. I’m here to represent you in your hearing today. Can I
look at your medical record?
C:
No!
Better way to ask for consent:
A:
Hello Ms. Rodriguez, may I speak with you for a moment?
C:
Sure.
A:
My name is Linda Chan, I am a Patients’ Rights Advocate and I
work for the Patients’ Rights Program; I do not work for the
hospital. I’m here today to help you with a hearing. Did you
know that you are scheduled for a hearing today?
C:
Yea, the nurse told me.
A:
Great. The hearing is about whether the doctor should be able to
keep you here up to 10 days longer or whether you should be
free to leave the hospital. Can you tell me how you feel about
being here; do you want to stay in the hospital or do you want to
leave?
C:
I want to get out of here!
A:
Okay. That’s what the hearing is all about. At the hearing there
will be a hearing officer who decides whether the doctor can
keep you here any longer. The (doctor/nurse/social worker) will
be at hearing to represent the hospital; she will explain why
(she/the doctor) wants you to stay in the hospital. The facility
*Credit:
Some of the information this handout was originally presented by Jeanne Matulis, Theresa
Nelson, Melissa Daar and Leslie Morrison.
4
representative speaks first because she has the burden of proof.
Then we’ll get to explain why we feel you should be able to
leave.
3.
C:
Okay.
A:
Have you seen this? (Notice of certification).
C:
Yes, the nurse gave me a copy.
A:
Okay, so you can see it says the doctor believes you need to
stay here because she thinks you are suicidal and dangerous to
others. Do you know why the doctor might think this?
C:
Well, I was suicidal when I first got here, but I’m not anymore,
and I’m NOT dangerous! I’ve never been dangerous to anyone!
A:
Okay then, what I’d like to do now then is go take a look at your
medical record so we’ll have a better idea about why the doctor
thinks you’re dangerous and still suicidal. That way we’ll be
better prepared to respond to what the facility representative
might say in the hearing. Is that okay with you?
C:
Okay, will you talk to me again before the hearing?
A:
Yes, of course. As soon as I have had a chance to review your
record, I’ll come back and talk to you about it says. Okay?
C:
Sure.
The Medical Record
The medical record is a medicolegal document, meaning that the documents
in the record are not only medical documents, but also legal documents that
may be used in court. The information presented by the facility
representative should be documented in the medical record. If the facility
representative presents evidence during the hearing that you did not see in
*Credit:
Some of the information this handout was originally presented by Jeanne Matulis, Theresa
Nelson, Melissa Daar and Leslie Morrison.
5
the record during your review, it is quite appropriate to say, “Can you please
show me where that is documented in the record?”
(a) Content
The medical record varies somewhat in content and organization from one
mental health facility to another, but typically contains the following items:
1. Emergency Department Records, if any
2. Intake Forms
a. Face sheet
b. Conditions of Admission, Consents, Involuntary Commitment
c. Discharge plan
3. Assessments & Evaluations
d. Psychiatric
e. History & Physical
f. Nursing
g. Social Services
h. Pharmacology
i. Nutrition
j. Education
4. Consults
5. MD Orders
6. Medication Administrations Record
7. Care Plan
k. Problem list
l. Treatment plan
m. Discharge plan
8. MD Notes
9. Interdisciplinary Notes (IDNs)
a. Nursing notes
b. Non-licensed staff notes
c. Ancillary Staff notes- Social Work, RT, OT, Nutrition
10.
Restraint/Seclusion Records
11.
Lab & Radiology
12.
Graphics
a. Vital signs
b. height & weight
*Credit:
Some of the information this handout was originally presented by Jeanne Matulis, Theresa
Nelson, Melissa Daar and Leslie Morrison.
6
13.
14.
15.
c. intake & output
Legal papers
a. Informed consent
b. Involuntary commitment
c. Conservatorship papers
Discharge Summary/Death papers
Old Medical Records
(b) The Electronic Medical Record
The traditional paper medical record is being phased out in many facilities
and replaced with electronic medical record. Paper records have several
disadvantages: only one healthcare provider can access it at a time; it can
become lost or damaged, and; it can take hours or days to retrieve a
patient’s past medical records that are stored off site. The electronic record
has mixed reviews from advocates, however.
The main problems
advocates have encountered have to with accessing the records.
Reviewing electronic records requires that a computer terminal be available
to the Advocate, that the advocate have an access code for the record, that
the Advocate have training on the medical records software, and that the
Advocate have the cooperation and understanding of the facility Health
Information Staff that even though the Advocate is not a facility employee,
he/she requires and is entitled to access the record.
Once these access problems are resolved, however, Advocates report that
electronic medical records have made preparation for hearings more
“effective,” “easy” and “less time consuming” and they find the electronic
record “clearer” and more “legible,” and “understandable.”
*Credit:
Some of the information this handout was originally presented by Jeanne Matulis, Theresa
Nelson, Melissa Daar and Leslie Morrison.
7
4.
Record Review: Certification Hearings
Pay particular attention to the documentation of the circumstances that lead
up to the client’s detention, e.g. that on the 5150, but also the description of
the client’s condition upon arrival to the facility.
For example, review the ED records, if any, the intake sheet and initial
nursing notes and look for the following:
 Any statements that the client was calm or cooperative on admission;
 Any statements that the client’s condition has improved since
admission;
 Any positive descriptions of the client’s condition or behavior;
 Any other signs of improvement, e.g. if the client was initially on oneto-one staffing when admitted, was this discontinued? If so, can it be
inferred from this that the staff no longer feels the client’s behavior
requires this level of care any longer? In other words that they are no
longer acutely suicidal or dangerous?
Pay attention to other indicators that the client’s condition has improved over
the course of hospitalization, e.g. review the physician’s notes, physician’s
orders, medication record and consent forms and look for the following:
 Was the client been prescribed any prn (as needed) medication at
admission or early in the hospitalization? If so, has the medication
been discontinued or has administration of the prn decreased? Note
the date last prn medication was last given.
 Has the client received emergency medication? If so, has the
incidence of the use of emergency medication decreased or stopped
over the course of hospitalization? Note the date last emergency
medication was last given.
*Credit:
Some of the information this handout was originally presented by Jeanne Matulis, Theresa
Nelson, Melissa Daar and Leslie Morrison.
8
 Has the client consented to regular medication or ECT? If so, is there
an argument that the client may be able and willing to accept treatment
on a voluntary basis either in the hospital or on an outpatient basis?
(a) Note the Negative as Well
Review seclusion and restraint records, nursing notes, and doctors orders
It is important that you know about your client being placed in seclusion or
restraint any other negative incidents involving your client in the facility so
that you can respond effectively if the facility representative raises them in
the hearing. During preparation for the hearing, ask your client his/her
perspective on what lead to seclusion or restraint, or other negative
incidents. Ask your client what if anything he/she would do differently if the
same situation arose in the future.
(b) Special Considerations: Grave Disability
It’s helpful for all clients, but particularly for those certified as gravely
disabled, to make note of any documentation in the record of family support
and/or financial support. Information regarding these aspects of your client’s
life is often found in Social Services assessments and evaluations and
discharge planning documents.
Note positive physical health reports. You may be able to argue that the
client’s alleged inability to provide for food, clothing and shelter is not
adversely affecting his or her health. Information regarding the client’s
health status can be found in the history and physical, patient graphics, and
lab results. Documentation that the client has been eating and sleeping well
while in the facility may be found in nursing notes and patient graphics.
(c) A Note on Lab Results
Most Patients’ Rights Advocates do not come from a medical background
and are therefore understandably reluctant to make pronouncements about
the health of their clients. The client’s physical health or lack there of, can
sometimes play a pivotal role in certification hearings where the client is
alleged to be gravely disabled. Lab results generally provide the patients’
*Credit:
Some of the information this handout was originally presented by Jeanne Matulis, Theresa
Nelson, Melissa Daar and Leslie Morrison.
9
value, the normal range or reading for that substance, the units, and some
sort of notation when the patient’s values fall outside the normal range. For
example:
Within normal limits:
Component
Results
Red blood cells count
4.05
Hematocrit
Standard Range
Unit
3.60 - 5.70
36.5
M/uL
34.0 - 46.0
%
Outside normal limits:
Component
Magnesium
Results
1.6

Standard Range
1.7 - 2.3
Unit
mg/dL
In other words, the Advocate generally does not need medical training to know
whether the client’s lab values may be problematic. Rather than proclaiming in a
hearing that the client’s lab results indicate that he or she is perfectly healthy, the
Advocate may want to consider something like this:
Sample Dialog
Advocate:
You testified that Mr. Roland’s mother reported that he was not
eating for days prior to being admitted?
Facility Rep:
That’s right. That’s what she said.
A:
I noted that it looks like all Mr. Roland’s lab values appear to be
within normal though. Is that correct?
F:
I’ll have to check; let me see. Yes. Yes that’s correct.
*Credit:
Some of the information this handout was originally presented by Jeanne Matulis, Theresa
Nelson, Melissa Daar and Leslie Morrison.
10
(d) 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?
 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?
 Does the date of signatures on the 14-day certification coincide with
the initiation? Pre-signed or post-signed certifications should not be
acceptable.
6.
Hearing Record Review: An Opportunity for Informal Monitoring
In the post-HIPAA era, conducting a formal monitoring project, in which
random medical records are pulled at a facility and reviewed without client
consent, is becoming increasingly difficult for many county advocates. Many
county counsel and/or private hospital council fail to recognize the
Advocate’s authority as designee of the local mental health director to
access records for the purpose of monitoring. Reviewing clients’ medical
records in preparation for certification or Riese hearings provides an
excellent opportunity to conduct informal monitoring of denial of rights, the
use of seclusion and restraint, medication consent, etc.
*Credit:
Some of the information this handout was originally presented by Jeanne Matulis, Theresa
Nelson, Melissa Daar and Leslie Morrison.
11
6.
Notes on 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.).
When trying to decipher an unfamiliar medical term, you being with the
suffix, then the prefix if any, and then the combing form.”
Examples:
Tachycardia
suffix
meaning
-ia
(condition) +
prefix
meaning combing form meaning
tachy(fast)
+
Cardia
(heart)
Psychosis
suffix
meaning
prefix
-osis (condition/abnormal condition) -----
*Credit:
combing form meaning
Psych/o-
(mind)
Some of the information this handout was originally presented by Jeanne Matulis, Theresa
Nelson, Melissa Daar and Leslie Morrison.
12
Appendices
*Credit:
Some of the information this handout was originally presented by Jeanne Matulis, Theresa
Nelson, Melissa Daar and Leslie Morrison.
13