How are those of you who see WC/NF patients documenting aberrant drug related behavior (mainly "hard" indicators such as illicts on tox or doctor shopping) in their chart? I ask because on the one hand, I feel that there should be some form of documentation of rationale for discontinuing medications or discharging the patient. On the other hand, I could imagine how documenting something like having cocaine in their system or obtaining meds from several doctors could have a devastating impact on their WC/NF cases. Sure it would be easy to just say that these patients "reap what they sow" but this could also cause potentially violent behavior directed towards us a ex-providers. Anybody have any suggestions about how best to go about this?
documenting aberrant drug related behavior in workers comp / no fault patients
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I find the truth quite comforting. Failure to document the events and facts is a felony on most states and depending on what transpired can get you a visit with the DEA.
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if they are "stupid" enough to be caught with cocaine or heroin in their system, i have no sympathy for them.
I dont want society's hard earned money to pay for someone's cocaine habit.
and yes, there has to be documentation for the reasons to discharge a patient from the clinic.
I dont want society's hard earned money to pay for someone's cocaine habit.
and yes, there has to be documentation for the reasons to discharge a patient from the clinic.
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Document what you see and what you know. CYA.
You don't make the legal rules about the consequences of their actions.
Hiding facts from the chart to "protect" the patient can only come back and bite you ni the @$$.
You don't make the legal rules about the consequences of their actions.
Hiding facts from the chart to "protect" the patient can only come back and bite you ni the @$$.
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I get your point, you don't want to be the recreational drug use police. But you MUST get in their business if you prescribe opiates because the DEA will expect you to be monitoring for misuse, mixing with illicits and diversion. It's part of your responsibility as a provider of controlled substances.
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Uh, document EVERYTHING!
Doesn't matter if it is a WC, MC, private ins, a judge, lawyer, clergy...........
Doesn't matter if it is a WC, MC, private ins, a judge, lawyer, clergy...........
I hear what you guys are saying, and I completely agree with having no sympathy for people engaged in illegal and dangerous behavior. What I am more concerned about is the potential for violence directed towards us as ex-providers if they believe we are the cause of damaging their case. What are your thoughts?
FYI, I have been documenting all bad behavior thus far. I am the most thorough in being vigilant of aberrant drug related behavior in my practice. I'm just beginning to worry as my list of wrongdoers continues to grow ever longer
FYI, I have been documenting all bad behavior thus far. I am the most thorough in being vigilant of aberrant drug related behavior in my practice. I'm just beginning to worry as my list of wrongdoers continues to grow ever longer
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We adopt the philosophy, "It is what it is". If they have cocaine in the urine, it definitely will affect the care I deliver to them, and it should be noted in their chart. The mal-effect on their legal case is an issue for lawyers, since it could well be argued there was no cocaine in their bodies at the time of the accident/injury. But it is not my problem, and I am responsible only for their treatment in the same manner I treat anyone else.
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On the flip mode of this: pt has a + cocaine in their UDS (or whatever ), and you fail to document appropriately.
This pharmaceutical treasure trove then hits someone in their 18 wheeler while they are gorked ; police pull them over, and pt has your narcs on them + illicit substances.
Uh-0h. Better call Saul.
Even if you haven't scripted narcs - considered reporting to DMV?
i find that i actually prescribe very little if zero narcs to WC or NF patients. The ones i see get sent just for the procedure, and the 12 doctors on the case are handling everything else. I dont prescribe opiates never much anyway, but I almost never have WC patient asking me for MEDs, they are asking me to be off work, to fill this crap out, to lie, etc. but rarely for meds...
So that being said, if i dont prescribe medications to them, i dont urine test them, because it doesnt impact what i wont be prescribing them.
the same with NF. its all about the case, getting the settlement. Most dont even really have pain, so they dont really want meds, they just want the settlement...
So that being said, if i dont prescribe medications to them, i dont urine test them, because it doesnt impact what i wont be prescribing them.
the same with NF. its all about the case, getting the settlement. Most dont even really have pain, so they dont really want meds, they just want the settlement...
Interesting. I see a lot of NF/WC and the vast majority of these patients request pain meds from me. Sometimes I think it's because they are trying to build their case by showing that their injuries are severe enough to warrant pain medications. If only there were an algometer (or a BS meter) that I could use to sort them all out!
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On a sort of related note: Do you peeps give reduced rates (payment plans) for workers asking for med / legal letters relating to work issues ? Obviously they have to pay for this themselves, and almost always these workers are of the blue collar variety.
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i once told a lawyer that i was convinced the pt was malingering for work comp and in fact had no injury at all - he told me that if i put that in the chart, he would do his best to destroy me professionally....
so not only will the pt be mad at you, but then you will also have a lawyer mad at you...
cases that have any litigation component (pot of gold at the end of the rainbow for lawyer and the patient), I will excuse myself as soon as I smell any smelly stuff with the following statement: "I am unable to clearly delineate the source of pain" "Due to the complexity of the case" "I have nothing else to offer" and walk away....
so not only will the pt be mad at you, but then you will also have a lawyer mad at you...
cases that have any litigation component (pot of gold at the end of the rainbow for lawyer and the patient), I will excuse myself as soon as I smell any smelly stuff with the following statement: "I am unable to clearly delineate the source of pain" "Due to the complexity of the case" "I have nothing else to offer" and walk away....
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I am a little more direct when lawyers are involved: "The patient was discharged for engaging is substance abuse and drug diversion. He will not be seen in our practice again under any circumstances". The lawyers never ask me for anything after that.
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If the the claimant is using illicit drugs, then that is an ipso facto contraindication to chronic opioid therapy.
Also, if a claimant is using illicit drugs, you should help them get treatment for their disease of addiction. Make a referral to an addiction specialist.
I explain to all my patients that I suspect (or admit to) using ilicit drugs. Ilicit drug use and chronic opioid therapy do not mix. I am happy to continue to see them for nonpharm pain management, but they'll have to go elsewhere for meds.
Also, if a claimant is using illicit drugs, you should help them get treatment for their disease of addiction. Make a referral to an addiction specialist.
I explain to all my patients that I suspect (or admit to) using ilicit drugs. Ilicit drug use and chronic opioid therapy do not mix. I am happy to continue to see them for nonpharm pain management, but they'll have to go elsewhere for meds.
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I urine screen everyone on first visit.
Had a WC pt, who's UDS was pos for THC. I saw her for f/u, she was livid that I had checked for it. I told her that I do that for everyone, additionally, she had signed paperwork indicting we do urine test,etc on everyone and she had given it voluntarily.
She was obviously very concerned that 'people at work would find out and be judgemental' and was told me why I couldnt just have 'taken her word and if something happens" it would be her fault.
I told her that I have to document these things, and if something were to happen, then they could always as, "so Dr did you bother to check the urine on patinet X".
Needless to say, she walked out of my office and was furious that I wouldnt change her 'results'.
Personally, I think one's work has no business knowing about what illicits,etc they are doing. The workman's comp people really should get notes,etc on the work injury itself,etc. However, since I have to put ALL my findings on the chart, that's what I do....
Had a WC pt, who's UDS was pos for THC. I saw her for f/u, she was livid that I had checked for it. I told her that I do that for everyone, additionally, she had signed paperwork indicting we do urine test,etc on everyone and she had given it voluntarily.
She was obviously very concerned that 'people at work would find out and be judgemental' and was told me why I couldnt just have 'taken her word and if something happens" it would be her fault.
I told her that I have to document these things, and if something were to happen, then they could always as, "so Dr did you bother to check the urine on patinet X".
Needless to say, she walked out of my office and was furious that I wouldnt change her 'results'.
Personally, I think one's work has no business knowing about what illicits,etc they are doing. The workman's comp people really should get notes,etc on the work injury itself,etc. However, since I have to put ALL my findings on the chart, that's what I do....
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Actually, it's time to be more careful than that. WC and employer should only get info relating to the injury. PMH, FH, SH, ROS and other unrelated things should not go to them. Our EMR allows us to do this with the click of a button.
Problem is that if you want to document reason for discharge (aberrant drug related behavior) this would go in the HPI or Assessment and Plan section which the WC board would see.
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I have never had anyone waiting in the parking lot, wc or not, after discharge. It all depends on how this is done. Documentation is a mandatory requirement of our profession so that is a given. Discharges can be framed in that "the state considers the activity precipitating the discharge to be a felony. My license is at stake here, and I simply cannot risk it. But on the other hand I won't be reporting this felony to the police either." This is disarming to the drug addict since they feel they are being shown some latitude by not being reported to the police, and they don't want to do anything that might change your mind about reporting to the police.
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Interesting.
But then does the reviewer at the WC realize that your note that you are forwarding to them is 'incomplete'?
Furthermore, you would have to foward them your Assessment/Plan. Usually my assessment would include verbage like , "Nicotine Depedence, Marijuana Use, Back pain likely facetogenic in nature" etc.
Otherwise you would have to leave out "marijuana' use in teh Assessment part.
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as far as patients waiting for you in the parking lot: maybe you should start parking in the nursing parking lot and drive a beat up car --- and then carefully dart from car to car, with a baseball cap on, a fake beard - once it is dark outside...
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or just dont leave the hospital.
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Back to your initial concern (about doing your job and a patient becoming violent)
1. There's crazy everywhere you could get stabbed at the mall. Nothing can avoid random crazy.
2. For managing "situations" there are actually modules and lectures on de-escalating a violent situation. If you have hospital privileges I'm sure you could find a class on it. Most of it is about identifying a potentially bad situation, and defusing it before it goes bad. I never get into a shouting match in my office, because long before the shouting starts, I have calmly asked the patient to leave. Then I walk out of the room so they can walk themselves out the front door and not have me or my staff staring at them or in their physical space. 99% of the time they go without even stopping at the desk. If they don't leave in 15 minutes go back to the exam room and tell them (calmly) if they don't go you will call the police to escort them out. But I've never had to call the cops, they all go once I've told them to leave.
These people are everywhere. I have a good friend who is a seamstress who gets rich ladies calling her motherf%^& and screaming at her, sometimes shoving or throwing things at her because their pant hems were done wrong.
1. There's crazy everywhere you could get stabbed at the mall. Nothing can avoid random crazy.
2. For managing "situations" there are actually modules and lectures on de-escalating a violent situation. If you have hospital privileges I'm sure you could find a class on it. Most of it is about identifying a potentially bad situation, and defusing it before it goes bad. I never get into a shouting match in my office, because long before the shouting starts, I have calmly asked the patient to leave. Then I walk out of the room so they can walk themselves out the front door and not have me or my staff staring at them or in their physical space. 99% of the time they go without even stopping at the desk. If they don't leave in 15 minutes go back to the exam room and tell them (calmly) if they don't go you will call the police to escort them out. But I've never had to call the cops, they all go once I've told them to leave.
These people are everywhere. I have a good friend who is a seamstress who gets rich ladies calling her motherf%^& and screaming at her, sometimes shoving or throwing things at her because their pant hems were done wrong.
I like that approach, but are you liable for NOT voluntarily reporting it to the police?
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I believe there is a federal "Need to Know" requirement with reports to employers. Maybe it's just state.
For WC, I would not include social diagnoses, as they do not have bearing on the WC injury. They may affect the outcome, but WC does not want to know that. It's a crazy situation and more reason why WC is not compatible with pain management.
Well, I don't want to belabor thus too much or appear paranoid, but I do believe that there is also such a thing as "organized crazy."
Case in point, I saw a very nice patient for follow up yesterday that I had recently just begun to see. The patient had an IT pump placed many years ago for FBSS by another physician in another state that caused him severe side effects and he wanted it out. The patient said that the physician who placed the pump left the practice, "but oh, my family found him alright. My family is something you don't want to mess with!" and smiled as he left the room. This was obviously not intended as a threat to me, but I sure did not want to know any more details about what happened to that poor doctor!
What makes you think that I don't already do this? Well at least the part about the beat up car.
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I once had a pt who was injecting narcs (Oxycontin of course), and dispensing to his friends. His family joker (ahem I mean MD) was scripting him the fentanyl patch.
Needless to say, I recommended stopping it. Said pt wasn't impressed.
He showed up the day after I sent the consult note yelling in the office, and threw a sticky slushy drink in the hallway.
I guess it could have been a heck of a lot worse!
