Using Medical Records to Your Client’s Advantage in Hearings

1. Using Medical Records to Your Client’s Advantage in Hearings

2. 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?

3. 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.

4. Another Poll! • How many of you routinely ask for client consent before reviewing the medical record to prepare for hearings?

5. 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.

6. Can we have some volunteers from the audience? • Asking for client consent dialogues… (pages 4 to 5 in your handout)

7. 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

8. 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

9. Sample Contents of Medical Records, con’t. • Consults • MD Orders • Medication Administration Record • Care Plan • Problem list • Treatment plan • Discharge plan

10. 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

11. 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

12. 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

13. Electronic Medical Records: The Minuses • 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

14. 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!

15. 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?

16. 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?

17. 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.

18. 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

19. 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.

20. Can we have some volunteers from the audience? • Sample hearing dialogue about lab results… (page 10 in your handout)

21. 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? .

22. 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?

23. Record Review for Certification Hearings, con’t.:Procedural Due Process • Does the date of signatures on the 14-day certification coincide with the initiation? Pre-signed or post-signed certifications should not be acceptable

24. 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.

25. 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.).

26. 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 suffixmeaning prefix meaning combing form meaning -ia (condition) + tachy- (fast) + Cardi/o- (heart) Psychosis suffixmeaning prefix combing form meaning -osis (condition/abnormal condition) ----- Psych/o- (mind)

27. Medical Terminology Other resources related to medical terminology are included in the Appendices

28. Thank you!