Reading your own patient records can rekindle that lack of trust and those feelings of vulnerability that brought you to therapy. The discrepancies, falsehoods, and what sometimes seem to be personal attacks can be shocking and add to the trauma that you work through. Honest considerations of certain personality disorders and mental health diagnoses, if not framed appropriately, can end or greatly limit careers prospects. Patients and clinicians should make an effort to review records periodically. If not reviewed, records can have decades of inconsistencies that will interfere with disability claims, that can change how providers treat patients and can lead to further injury, traumatization, and possibly end careers.
Cherry Picking Moments of Joy in a Troubled Life
Working in the military, in private practice and for a large medical system I have had the opportunity to work with patients claiming disability and workman’s compensation for their physical and mental health concerns. In all of these settings I have witnessed the devastation that notes in patient records can have on lives. During disability evaluations the disability evaluators comb through records to determine appropriate compensation. Many times it seems that their goal is to cherry-pick the words and phrases that will help them deny or limit compensation. Providers’ notations that celebrate successes or healthy behavior, if not framed correctly, can be found in disability decisions as evidence of functioning and to decrease or deny a claim.
Success and healthy behavior should always be framed in terms of a patients diagnosis or illness. There have been patients worried that insurance investigators were spying on them trying to catch them doing something that their disability should limit. Similarly, disability evaluators find nuggets of healthy behavior in health and mental health records to use as ammunition against a claim. Clinicians want to record successes in therapy but should also consider how their records may be used in the future.
The health record should entrench successes and positive, healthy behavior within the greater experience of the Veteran’s diagnosis. When being evaluated for disability the patient has to frame their positive experiences to ensure their disability is fully appreciated. The health record and individual patient records/notes need to be written the same way. It’s further traumatizing and can even cause a rift in therapeutic relationships when a note about the patient “sailing again” or some other positive/healthy activity, is used to show that the patient is functioning well enough to deny or limit compensation.
When a Veteran goes to a compensation and pension exam they are often coached to present their worst day. A patient may feel good on evaluation day and want to present as healthy. People often hide their symptoms from others and especially in front of strangers and strange doctors. In a compensation and pension exam you don’t want to be an optimist or wear rose colored glasses. You want to entrench your life in your diagnosis. This isn’t an exaggeration of your symptoms it is an attempt to give a down-and-dirty window into how they affect you.
Yes, you are taking care of your kids and your mom is helping. That sounds great. Make sure you say you can’t keep a job and that your at your moms because your on a break with your wife. Add that your mom “helps” because both your mom and your wife don’t trust you with the children because your memory is bad or because you can’t control your angry outbursts.
Yes, you are going on a skiing trip… You were just doing a dolphin encounter last week… You just started sailing and are looking forward to go on a SCUBA adventure next month… Make sure you say that the ski trip is for disabled Veterans and you will have escorts helping you down the mountain at all times. That the SCUBA encounter is for disabled Veterans and accommodations are made depending on the disability. Tell the evaluator that the dolphin encounter is part of your “recreation therapy” prescribed by your therapist to help with your social isolation and your loss of ability to find enjoyment in things.
Patient records should similarly include the context that healthy behavior and treatment success occurs. It’s important to celebrate progress. It is also important to show that progress does not mean “cured” or without impairment.
The Specters of Possible Career Ending Diagnoses
Diagnoses in patient records can limit or end careers, they can change how healthcare providers receive and interact with patients, and once a diagnosis is in the record it is almost impossible to remove the specter of having been labeled by it. Providers often consider diagnoses and note them in the record to rule out. These rule-out diagnoses sometimes don’t get appropriately assessed afterword and diagnoses such as “bipolar” or “borderline personality disorder” linger for years in patient records. Often a provider will carry the diagnoses from previous clinicians records without further assessment or consideration. These habits and concerns change how patients are treated and can have devastating effects on their lives and careers.
Consider the military reservist who is having symptoms of Post-Traumatic Stress (PTS). Without experience and specialized training many seasoned therapists and psychiatrists may see their symptoms as possible bipolar illness or even schizophrenic processes. The diagnoses are seen by a military evaluator during a periodic health assessment and a red flag is raised. These are possible career-ending diagnoses for service members. The patient now has to try and get second opinions or find ways to have their providers change their diagnoses.
A new clinician/provider may be unwilling to take the risk of reversing a diagnosis made by another provider. If the diagnosis is changed and the patient’s symptoms lead to adverse circumstances, such as suicide or homicide, the new clinician may be on the hook. The tragedy is that even if a provider does take the risk and changes the diagnosis, the patient will always have the diagnosis in their history. “A history of bipolar…” can be just as bad as the diagnosis itself. In the military and with law enforcement agencies changing a diagnosis can mean approving the use of fire arms and being around explosives. Who is willing to take that risk?
“How do you treat a borderline? Refer them out.” The diagnosis of borderline personality disorder (BPD) has a stigma among almost all professionals. With the advent of shared medical records diagnoses are often on a “problems list” and can be seen by all healthcare providers serving a patient. If you have a diagnosis of BPD in your record professionals often treat you different. PTSD, bipolar and other mental health diagnoses can also draw similar treatment differences. Monitoring patient records and ensuring rule-out diagnoses are actually ruled out in the record could avoid much of this trouble. Reviewing your own patient records and ensuring you are confronting diagnoses that can have such an impact could also help you avoid trouble. With the advent of shared records diagnoses can have a huge impact on regular treatment and we need to make sure records are as accurate and current as possible.
A diagnosis can end careers and change how a health team treats a patient. Frequent review of the record and the diagnoses can help avoid trouble with a patients career. It can also help patient avoid being treated based on a stigmatized diagnosis. It is hard to change a diagnosis and almost impossible to remove it from a record completely. Once written into the patient record there will always be a history of the diagnosis, a specter of the diagnosis, that can continue to affect the patient’s life and career.
When Providers Attack
One of the most devastating and long-lasting corruptions of a patient record is the attack. Patients and providers do not always get along. Patients are not that pleasant sometimes. Certain mental health diagnoses are known to not be pleasant. In exploring a patients record you can sometimes read the discomfort, anger, frustration and genuine dislike of a patient written in descriptions of behavior or assessments of their personality. This can happen within a regular patient/provider relationship but it is also seen during insurance and disability evaluations where no other treatment relationship is maintained. Attacks are important to catch and confront by both providers and patients as they can lead to negative consequences.
Providers are human and subject to the same irrational behavior as any other human. They too can suffer their emotions and have bad days. They can have their biases and although we hope they do not affect care, their prejudices. Sometimes providers start out with these issues and sometimes they become cynical and judge mental over their practice. In any case, their issues, biases and beliefs affect the patient record. Clinicians are often advised to have their own therapy so that their issues and transference do not affect treatment.
When a patient is already disliked, periods of tardiness or cancellations can be framed negatively by the provider. A patient who is distraught in traffic and drives slow may be framed as “frequently late” without explanation or exploration. Cancellations can also be framed in a way to make it seem the patient does not want care or is not sufficiently treatment compliant. A more liked patient may be understood for how their symptoms interplay with their ability to participate in treatment. In these cases the providers own issues preclude a thoughtful exploration. This can lead disability claims being denied, court ordered treatment being extended, patients being returned to jail for non-compliance, or administrative action by clinics and hospitals to remove the patient form active status.
Confronting providers when records demonstrate these attacks can also be an issue. It is best to get the support of another provider or a patient advocate in the clinic/hospital system. There is a good chance that you will need to change providers if possible. In rare circumstances everything may be a misunderstanding and this will be an opportunity to repair a rift in the therapeutic relationship and may even improve treatment. Most of the time it may be the end of the therapeutic relationship and an opportunity to create a new one.
But I did have Cancer
Mistakes in records need to be corrected and fast. Copying and pasting is a common provider mistake. It makes life easier for a provider to copy and paste things that usually don’t change from one note to the next but it could lead to missing something and making or perpetuating grave errors. If for none of the previous reasons, you should frequently monitor patient records for incorrect or outright false information.
Diabetes I is a different animal than diabetes II. The dangers can be different and the treatment is different. It is an easy mistake to leave off that “I” but can have devastating effects. I have seen this mistake personally so I know it can happen. With patients that have to constantly monitor their health a mistake like this can affect the trust the patient has in their providers. These mistakes can cause anxiety and develop feelings of hopelessness. Patients need to trust their providers to get their conditions correct, incorrect treatment can mean certain death.
Not having a history of cancer is different than having a history of cancer. This is true especially when it led to major surgery and had significant effects on self perception, self confidence and how one lives their life. A male that had their prostate removed and is having incontinence and erectile issues has different health and mental health needs than one that didn’t. Similarly a female that has spent her entire life judged by her appearance, who has cried as her hair fell out, her nails became brittle and break, and her breasts removed has different health and mental health needs than one that has not. These simple omissions or careless false declarations of “no history of cancer” can cause further stress and lead to a lack of distrust in providers and their healthcare.
Mistakes happen. Monitoring patient records needs to be a common practice by providers and patients to ensure patients aren’t further traumatized or victimized by what is written or omitted. The discrepancies, falsehoods, and personal attacks need to be confronted and remediated regularly. Helping patients with this can increase trust within the therapeutic relationship and also ensure appropriate health and mental health care is provided the patient. A patient’s record can impact their health, careers and disability evaluations. Patient’s do not need to be further traumatized by their record.
Timothy Vermillion, DSW, LCSW