MH Records and continuity of care

[Shikima]

What are people doing/saying when it comes to cross sharing of medical records and releasing records back to the referring physician?

My understanding is that the days of needing a release for each little detail are no longer applicable as HIPPA allows for services to cross communicate either in the inpatient or outpatient setting and that the parity laws did modify this further as not to impede with this process?

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[F0nzie]

Sometimes I ask the patient how they would feel if I provided their PCP with a status update. I am not required to ask them, but depending on how they respond it may offer some insights on how they feel about treatment or how they feel others may perceive them.


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[Shikima]

I can appreciate in asking, but in terms of laws and momentarily discounting courtesy, then releases are a thing of the past.

 

[TexasPhysician]

I'm against sharing physical records in general. Support staff may fax to the wrong phone number, personal information may be improperly handled at the receiving location, etc.

I make an effort to call the other treating physician and discuss the care. It improves relationships with other physicians, and it is often more helpful than a ton of paper.

 

[Shikima]

I'm against sharing physical records in general. Support staff may fax to the wrong phone number, personal information may be improperly handled at the receiving location, etc.

I make an effort to call the other treating physician and discuss the care. It improves relationships with other physicians, and it is often more helpful than a ton of paper.

Unfortunately with MU and other bogus measures, phone call isn't one of the options. Agreed with the team building spirit....

 

[TexasPhysician]

MU?

 

[Shikima]

Meaningful Use - CMS nonsense - which I heard was going to be terminated for something more nefarious this year?

 

[TexasPhysician]

Meaningful Use - CMS nonsense - which I heard was going to be terminated for something more nefarious this year?

Ah. I run a cash practice. Thanks

 

[Guyton]

In the systems where there is a an integrated electronic health record, my notes are routinely shared with other providers. The patient can access their session notes and labs through the online portal at one of my clinics.

 

[Shikima]

Ah. I run a cash practice. Thanks

If I could get away with the same earnings for a cash practice, I would. Not where I live as everyone relies on insurance and lives on paychecks. Many are in the arears due to unpayment of copays.

 

[milesed]

What are people doing/saying when it comes to cross sharing of medical records and releasing records back to the referring physician?

My understanding is that the days of needing a release for each little detail are no longer applicable as HIPPA allows for services to cross communicate either in the inpatient or outpatient setting and that the parity laws did modify this further as not to impede with this process?

HIPAA still applies as always. If there is no special circumstance, the patient must consent for release of PHI. I got cursed out by a cardiologist over this recently when the patient (he referred to us) did not want to release anything.

 

[Shikima]

HIPAA still applies as always. If there is no special circumstance, the patient must consent for release of PHI. I got cursed out by a cardiologist over this recently when the patient (he referred to us) did not want to release anything.

My understanding is that HIPPO allows for continuity of care. This includes allowing EHR to cross communicate and every one can see all notes. I also believe ACA further defined this and allowed it to be easier to cross communicate without any written authorization.

 

[WisNeuro]

My understanding is that HIPPO allows for continuity of care. This includes allowing EHR to cross communicate and every one can see all notes. I also believe ACA further defined this and allowed it to be easier to cross communicate without any written authorization.

Yep. HHS has defined purposes where a ROI is not needed in continuity of care circumstances. We get outside records from non-VA hospitals all of the time under this provision. Granted these are records that only pertain to a certain set if guidelines and does not constitute their whole chart (e.g., ED admission and care associated with TBI). And, I usually get the patient's consent to get the record, generally verbal consent before my evaluation.

 

[HIPAAHasOneP]

Long time lurker. Anyway, I'm a nurse who works on the regulatory side of things in a hospital and I have a particular interest in patient privacy. The move toward releasing patient information without obtaining consent concerns me. I know it's allowed, but I think it's disrespectful. I work in a hospital where psychiatric records are part of the general medical record, and I'm appalled at some of the information that's available for everyone to read. Does the lab tech need to know a patient is a victim of incest? The dietician? The dermatologist? The nurse? Does the patient understand that information they shared in confidence is available to everyone who accesses their record? Some may understand this, but I'm not sure all of them do. If we are not careful about protecting patient privacy, patients are going to quit talking to psychiatrists and therapists. I'm not a psychiatric patient, but if I were I would be pissed if a psychiatrist shared sensitive information about me without my consent. We're not going to have continuity of care if the patient feels we betrayed their trust and doesn't come back.

 

[TexasPhysician]

Long time lurker. Anyway, I'm a nurse who works on the regulatory side of things in a hospital and I have a particular interest in patient privacy. The move toward releasing patient information without obtaining consent concerns me. I know it's allowed, but I think it's disrespectful. I work in a hospital where psychiatric records are part of the general medical record, and I'm appalled at some of the information that's available for everyone to read. Does the lab tech need to know a patient is a victim of incest? The dietician? The dermatologist? The nurse? Does the patient understand that information they shared in confidence is available to everyone who accesses their record? Some may understand this, but I'm not sure all of them do. If we are not careful about protecting patient privacy, patients are going to quit talking to psychiatrists and therapists. I'm not a psychiatric patient, but if I were I would be pissed if a psychiatrist shared sensitive information about me without my consent. We're not going to have continuity of care if the patient feels we betrayed their trust and doesn't come back.

Agreed, but most systems are not like you describe.

In my past academic center, psych notes were labeled "sensitive" and unavailable to non-psych staff. We could unsensitize notes we deemed appropriate to coordinate care.

In my private practice, I call to coordinate appropriate information with other docs.

I've never worked at a facility that allowed non-psych faculty to view all psych notes. I'm sure they exist though.

 

[HIPAAHasOneP]

TexasPhysician, it's good to hear that not all EMRs are like the one where I work. If you unsensitized notes did you have to unsensitize the entire note, or could you block out certain parts that maybe you felt the other physician didn't need to know. For example, I could see where diagnosis and treatment would be important for the internist, but I don't think the internist has any business knowing about the patient's affair or that the patient's parents are going through a divorce or a whole host of other things patients may tell a psychiatrist. I think it should be up to the patient to decide who gets what, but unfortunately HIPAA says otherwise.

 

[Salpingo]

What are people doing/saying when it comes to cross sharing of medical records and releasing records back to the referring physician?

My understanding is that the days of needing a release for each little detail are no longer applicable as HIPPA allows for services to cross communicate either in the inpatient or outpatient setting and that the parity laws did modify this further as not to impede with this process?

You are correct: http://www.hhs.gov/hipaa/for-profes...ent-payment-health-care-operations/index.html

Written consent was never part of HIPAA, it's a standard various institutions put in place to CYA. Right now, I do whatever my institution tells me to do, but I would probably be more lax if I had my own practice (i.e. get verbal consent so the patient isn't caught off guard, give them opportunity to identify information they are worried about being made public, which more often than not isn't even in the chart).

 

[Salpingo]

Long time lurker. Anyway, I'm a nurse who works on the regulatory side of things in a hospital and I have a particular interest in patient privacy. The move toward releasing patient information without obtaining consent concerns me. I know it's allowed, but I think it's disrespectful. I work in a hospital where psychiatric records are part of the general medical record, and I'm appalled at some of the information that's available for everyone to read. Does the lab tech need to know a patient is a victim of incest? The dietician? The dermatologist? The nurse? Does the patient understand that information they shared in confidence is available to everyone who accesses their record? Some may understand this, but I'm not sure all of them do. If we are not careful about protecting patient privacy, patients are going to quit talking to psychiatrists and therapists. I'm not a psychiatric patient, but if I were I would be pissed if a psychiatrist shared sensitive information about me without my consent. We're not going to have continuity of care if the patient feels we betrayed their trust and doesn't come back.

One thing I've learned in training is just how much stuff doesn't belong in the record. That's something that should be taught at the very beginning of school. Providers who are putting this stuff in the chart should be taken to task and explain why they think this level of detail is medically relevant.

But outside of psychotherapy, putting psychiatric information (or HIV or reproductive health) behind a firewall is just furthering the stigma around mental health.

 

[HIPAAHasOneP]

You are correct: http://www.hhs.gov/hipaa/for-profes...ent-payment-health-care-operations/index.html

I think that's the problem. Some hospitals aren't limiting "disclosures of, and requests for, protected health information for payment and health care operations to the minimum necessary." Some hospitals are sharing much more than the minimum necessary. I think a hospital would be hard pressed to defend that it was necessary for the internist to know the patient had an affair, for example, yet that kind of information and more is shared by the psychiatrists at the hospital where I work (hopefully, this is not common).

 

[TexasPhysician]

TexasPhysician, it's good to hear that not all EMRs are like the one where I work. If you unsensitized notes did you have to unsensitize the entire note, or could you block out certain parts that maybe you felt the other physician didn't need to know. For example, I could see where diagnosis and treatment would be important for the internist, but I don't think the internist has any business knowing about the patient's affair or that the patient's parents are going through a divorce or a whole host of other things patients may tell a psychiatrist. I think it should be up to the patient to decide who gets what, but unfortunately HIPAA says otherwise.

The diagnosis and medications are available outside the note but within the emr (everyone can see them).

We unsensitized the note when we felt another field should address something and avoid providing therapy note material in those notes. It worked quite well.

 

[smalltownpsych]

i get more and more requests for records every day. As a result, I am putting less and less in the record. I have always been circumspect, but now I am charting biographical info, symptoms, and vague statements such as hx of trauma. I really don't feel that all ofh these people requesting information should get it even with signed consent. Schools, probation officers, other medical clinics where I have no idea who has access. I agree with Tex, if another doc wants info about a patient, then I'll talk to them personally. What they need to know that is relevant to them probably isn't readily available from the chart anyway.

 

[Shikima]

i get more and more requests for records every day. As a result, I am putting less and less in the record. I have always been circumspect, but now I am charting biographical info, symptoms, and vague statements such as hx of trauma. I really don't feel that all ofh these people requesting information should get it even with signed consent. Schools, probation officers, other medical clinics where I have no idea who has access. I agree with Tex, if another doc wants info about a patient, then I'll talk to them personally. What they need to know that is relevant to them probably isn't readily available from the chart anyway.

This then begs the question - I know you're not an MD and this basically goes out to the others in the forum. Perhaps OPD and others in academia (sorry forgot names which are at the tip of my tongue) can further elaborate how much and what kind of details are necessary for E&M coding as that's what we're doing now.

I have see that 'little printout' on how to stratify the diagnostic coding from a 913 vs 914 vs 915, but in practicality, how is this reproduced in a setting where information is detrimental. The stigma still carries forward....

 

[Salpingo]

This then begs the question - I know you're not an MD and this basically goes out to the others in the forum. Perhaps OPD and others in academia (sorry forgot names which are at the tip of my tongue) can further elaborate how much and what kind of details are necessary for E&M coding as that's what we're doing now.

I have see that 'little printout' on how to stratify the diagnostic coding from a 913 vs 914 vs 915, but in practicality, how is this reproduced in a setting where information is detrimental. The stigma still carries forward....

I know you didn't necessarily direct this to me, but this is from my internal billing dept, so take with a grain of salt:

99213 – Two out of the 3 components

• Expanded problem focused history (HPI with 1-3 problem-focused elements, 1 problem pertinent ROS, no past/family/social history)
• Expanded problem focused exam (at least 6 elements of a MSE)
• Low decision making
  • Low complexity (2+ self-limited/minor problems or 1 stable chronic illness)
  • Acute uncomplicated illness/injuiry (limited # of dx/management considered, limited tests/documentation reviewed, low risk of complications)

99214 – Two out of the 3 components

• Detailed history (HPI with 4 or more elements, extended ROS w/ 2-9 elements, pertinent past/family/social history w/ 1 history area)
• Detailed exam (at least 9 elements of a MSE)
• Moderate decision making
  • Moderate complexity (1+ chronic illness with mild exacerbation/progression or side effect of treatment, 2+ stable chronic illnesses, undiagnosed new problem)
  • Multiple # of diagnoses/management options considered, moderate test/documentation review, moderate risk of complications, morbidity & mortality

99215 – Two out of the 3 components

• Comprehensive history (extended HPI with 4 or more elements, complete ROS w/ 10 elements, complete past/family/social history w/ 2 or 3 history areas)
• Comprehensive exam
• High complexity medical decision making
  • High complexity condition (one or more chronic illness with severe exacerbation/progression or side effect of treatment)
  • Acute/chronic illness or injury that may pose a threat to life or bodily function
  • Extensive # of diagnoses/management options considered, extensive test/documentation review, high risk of complications, morbidity & mortality

It seems you can hit most of the requirements with a detailed MSE and A/P. If you're treating someone for depression, you can conduct half of a HAM-D (the half with physical symptoms), then ask them about their job (or their attempts to find one), and you already have enough for a detailed history. I'm not saying that's all an encounter should be, but I don't see why you would need to document at a more personal level than that.

 

[HIPAAHasOneP]

i get more and more requests for records every day. As a result, I am putting less and less in the record. I have always been circumspect, but now I am charting biographical info, symptoms, and vague statements such as hx of trauma. I really don't feel that all ofh these people requesting information should get it even with signed consent. Schools, probation officers, other medical clinics where I have no idea who has access. I agree with Tex, if another doc wants info about a patient, then I'll talk to them personally. What they need to know that is relevant to them probably isn't readily available from the chart anyway.

I appreciate all of the responses which help me understand that others are being more careful than what I have been seeing. I think they need to come up with a way for information to be redacted within a note in the EHR to prevent information from being shared that others have no business knowing. It's not just the patient's privacy I worry about but also others who may be mentioned in the notes. The spouse who is listed as a an alcoholic in the record or the family member with mental illness never signed a consent for treatment and yet their personal information is shared with anyone who gets the records, and they don't even have a clue. In my opinion sensitive information about other people should be removed before those records leave the MHP. These things weren't such a big deal when the records stayed at the psychiatrist's or therapist's office, but I think it's an issue now with increased access and sharing of records.

 

[Shikima]

I know you didn't necessarily direct this to me, but this is from my internal billing dept, so take with a grain of salt:



It seems you can hit most of the requirements with a detailed MSE and A/P. If you're treating someone for depression, you can conduct half of a HAM-D (the half with physical symptoms), then ask them about their job (or their attempts to find one), and you already have enough for a detailed history. I'm not saying that's all an encounter should be, but I don't see why you would need to document at a more personal level than that.

Still doesn't explain what a note looks like for content when it comes to a 913 vs 4 vs 5.

 

[Shikima]

I appreciate all of the responses which help me understand that others are being more careful than what I have been seeing. I think they need to come up with a way for information to be redacted within a note in the EHR to prevent information from being shared that others have no business knowing. It's not just the patient's privacy I worry about but also others who may be mentioned in the notes. The spouse who is listed as a an alcoholic in the record or the family member with mental illness never signed a consent for treatment and yet their personal information is shared with anyone who gets the records, and they don't even have a clue. In my opinion sensitive information about other people should be removed before those records leave the MHP. These things weren't such a big deal when the records stayed at the psychiatrist's or therapist's office, but I think it's an issue now with increased access and sharing of records.

The areas which you espouse concern over, is covered in the FHx and past psych history of the H&P.

 

[HIPAAHasOneP]

The areas which you espouse concern over, is covered in the FHx and past psych history of the H&P.

I get that it's important that you know it, but I'm not sure it's necessary that everyone who accesses the record knows it. It's definitely not necessary for me to know it, yet I have access to it. I only need to know about treatment, diagnosis, toxicities, but not information about family members or anyone else. I also don't need to know about past history of sexual abuse. I think that smalltownpsych's way of keeping it vague and just mentioning trauma without being specific is a good way to handle it.

 

[HIPAAHasOneP]

Here's a real example that I am aware of. A patient reported a history of abuse and named the person, except the psychiatrist inadvertently wrote the wrong name down because the patient was talking about more than one person and the psychiatrist got confused. It was not a large city and a lot of people knew the person who was named in the record. That record was then shared with other doctors at that hospital in the name of continuity of care. The problem was that person who was named as an abuser didn't do anything wrong yet their name was dragged through the mud. What if that was your name that was incorrectly named as an abuser (or an alcoholic or whatever else) and passed around, or my name? I think we have to consider more than just the patient's right to privacy. We also have to think about other people and their right to privacy. An attorney got involved in this case. Harm to that other person would have been minimized had that record stayed in the psychiatrist's office, but it didn't.

 

[michaelrack]

I do mainly inpt; would never put someone else's name in a chart. It is necessary to mention things like abuse, but I try to keep it factual: " the patient alleges that her husband sexually molested their 5 yo daughter, and is having trouble coping" is something I might put in an H and P. I wouldn't put "the patient is sucidal due to the stress of dealing with her husband's molesting their 5 yo child". Of course, inpt is a different issue than outpt- there are a lot of people (psychologists, Social workers, etc) who rely on accurate documentation by me.

However, a lot of times things can be kept general: "the patient reports physical abuse by an ex-boyfriend" or "the patient has a history of physical abuse in relationships" rather than "john doe beat the patient 2 years ago"

 

[Shikima]

Must we put in 'allegedly'? Isn't it a presumption that w're reporting what's being told as we aren't eye witnesses?

 

[notdeadyet]

Same thing. As long as you say that the patient reported, claimed, stated or alleged, you are indicating that you are mentioning only what you are told, not statement of fact. You don't have to say allegedly if you say something was told: it's one and the same.

 

[hamstergang]

Must we put in 'allegedly'? Isn't it a presumption that w're reporting what's being told as we aren't eye witnesses?

If you are going to put into writing that someone did something wrong, it's good practice to attribute that info to your source. Else, you become the source and if it turns out to be not true, that would just be a problem for you that you could have easily avoided.

Plus, it emphasizes that you should be documenting facts. "The patient was raped" is not something I know to be true. "The patient reports having been raped" is true.

 

[smalltownpsych]

This then begs the question - I know you're not an MD and this basically goes out to the others in the forum. Perhaps OPD and others in academia (sorry forgot names which are at the tip of my tongue) can further elaborate how much and what kind of details are necessary for E&M coding as that's what we're doing now.

I have see that 'little printout' on how to stratify the diagnostic coding from a 913 vs 914 vs 915, but in practicality, how is this reproduced in a setting where information is detrimental. The stigma still carries forward....

I could be wrong, as I don't actually need to do this (thank goodness ), but I would think that a template with little checkboxes would probably be the best way to capture the various levels for e&m codes. From what I have seen of the little printout, that would be what I would want or if I had to, then design it myself. We actually keep two different records a template that contains the minimum required info for billing purposes and a progress note that has info that is more highly protected and no one (except the other licensed mental health people in our clinic) has access to that document without my authorization.

 

[smalltownpsych]

I appreciate all of the responses which help me understand that others are being more careful than what I have been seeing. I think they need to come up with a way for information to be redacted within a note in the EHR to prevent information from being shared that others have no business knowing. It's not just the patient's privacy I worry about but also others who may be mentioned in the notes. The spouse who is listed as a an alcoholic in the record or the family member with mental illness never signed a consent for treatment and yet their personal information is shared with anyone who gets the records, and they don't even have a clue. In my opinion sensitive information about other people should be removed before those records leave the MHP. These things weren't such a big deal when the records stayed at the psychiatrist's or therapist's office, but I think it's an issue now with increased access and sharing of records.

As a rule, I never put anyone else's name in the record. I have even begun to not say "pt. reported dad used to physically abuse them". Instead, I'll say "pt reported experiencing abuse as a child". The more I see records going out, the less I feel needs to go in there. Also, I have had other mental health people with access comment to my patients about what is in the records and my patients feel violated. The privacy is the patients and I work damn hard to uphold it for therapeutic reasons. In an inpatient setting its a bit different but it should still be limited to the individual's treatment team.

 

[Shigella73]

Error

 

[HIPAAHasOneP]

I do mainly inpt; would never put someone else's name in a chart. It is necessary to mention things like abuse, but I try to keep it factual: " the patient alleges that her husband sexually molested their 5 yo daughter, and is having trouble coping" is something I might put in an H and P. I wouldn't put "the patient is sucidal due to the stress of dealing with her husband's molesting their 5 yo child". Of course, inpt is a different issue than outpt- there are a lot of people (psychologists, Social workers, etc) who rely on accurate documentation by me.

However, a lot of times things can be kept general: "the patient reports physical abuse by an ex-boyfriend" or "the patient has a history of physical abuse in relationships" rather than "john doe beat the patient 2 years ago"

I can see the need to document these things and to share with the psychologists and social workers because in that case it is pertinent to the care of the patient. I guess my question is how would you answer a patient who is upset and asking you why in the world you shared a note with the hospitalist who is treating her pyelonephritis or pneumonia that she reports she was sexually abused by her father as a child? I can see the need for collaboration regarding diagnosis and treatment, but some of the other sensitive information you collect? Why would they need access to that type of information in the note in order to treat the patient's pneumonia? I don't think in that case the minimum necessary to care for the patient would have been shared, and I think that is where potential problems could arise. Even if the alleged abuser isn't named if it is documented that the patient said it was her father that person could still be identified and might not be too happy to know that this record was then handed to the hospitalist and other doctors (and nurses and whoever else) who needed access to that record. (I don't have any interest in protecting abusers, but then that information is not always true either). My beef is not at all with psychiatrists or therapists. I get that most of you are stuck with the EHR you have. I guess my beef is with the powers that be who pick out the EHR and who don't consider how the sharing of information may impact the patient and other people noted in the record. Holistic, collaborative care is a great idea, until it's not.

(Sorry I have two new screen names as I had forgotten the first one when I registered yesterday). Apparently now I remember but will stick with this one. I deleted the previous post so as to not confuse things).

 

[TexasPhysician]

I can see the need to document these things and to share with the psychologists and social workers because in that case it is pertinent to the care of the patient. I guess my question is how would you answer a patient who is upset and asking you why in the world you shared a note with the hospitalist who is treating her pyelonephritis or pneumonia that she reports she was sexually abused by her father as a child? I can see the need for collaboration regarding diagnosis and treatment, but some of the other sensitive information you collect? Why would they need access to that type of information in the note in order to treat the patient's pneumonia? I don't think in that case the minimum necessary to care for the patient would have been shared, and I think that is where potential problems could arise. Even if the alleged abuser isn't named if it is documented that the patient said it was her father that person could still be identified and might not be too happy to know that this record was then handed to the hospitalist and other doctors (and nurses and whoever else) who needed access to that record. (I don't have any interest in protecting abusers, but then that information is not always true either). My beef is not at all with psychiatrists or therapists. I get that most of you are stuck with the EHR you have. I guess my beef is with the powers that be who pick out the EHR and who don't consider how the sharing of information may impact the patient and other people noted in the record. Holistic, collaborative care is a great idea, until it's not.

(Sorry I have two new screen names as I had forgotten the first one when I registered yesterday). Apparently now I remember but will stick with this one. I deleted the previous post so as to not confuse things).

Your beef is with the government who requires EHR for meaningful use, and 1 reason why I am private.

No academic center has staff with time to censor records when requested. The government wants all records to be available to medical staff to "improve" care. They aren't concerned about the info you are discussing.

Only more expensive EHR's have the ability to "sensitize" notes.

If someone wants completely private psych notes, avoid academic centers and see someone private who aims to keep records private. Sometimes you do get what you pay for.

 

[notdeadyet]

In fairness, from reading lots of medical records for forensic cases, cash practice psychiatrists seem to have far more inappropriate charting. I'd personally fear what goes into my chart from the cash only guy in solo practice than the guy at the medical center.

 

[HIPAAHasOneP]

Your beef is with the government who requires EHR for meaningful use, and 1 reason why I am private.

No academic center has staff with time to censor records when requested. The government wants all records to be available to medical staff to "improve" care. They aren't concerned about the info you are discussing.

Only more expensive EHR's have the ability to "sensitize" notes.

If someone wants completely private psych notes, avoid academic centers and see someone private who aims to keep records private. Sometimes you do get what you pay for.

Good point. If I'm ever in need of psychiatric care I will look for a private practice psychiatrist who still uses pen and paper and files my record in a dusty cabinet.

 

[Salpingo]

I can see the need to document these things and to share with the psychologists and social workers because in that case it is pertinent to the care of the patient. I guess my question is how would you answer a patient who is upset and asking you why in the world you shared a note with the hospitalist who is treating her pyelonephritis or pneumonia that she reports she was sexually abused by her father as a child? I can see the need for collaboration regarding diagnosis and treatment, but some of the other sensitive information you collect? Why would they need access to that type of information in the note in order to treat the patient's pneumonia? I don't think in that case the minimum necessary to care for the patient would have been shared, and I think that is where potential problems could arise. Even if the alleged abuser isn't named if it is documented that the patient said it was her father that person could still be identified and might not be too happy to know that this record was then handed to the hospitalist and other doctors (and nurses and whoever else) who needed access to that record. (I don't have any interest in protecting abusers, but then that information is not always true either). My beef is not at all with psychiatrists or therapists. I get that most of you are stuck with the EHR you have. I guess my beef is with the powers that be who pick out the EHR and who don't consider how the sharing of information may impact the patient and other people noted in the record. Holistic, collaborative care is a great idea, until it's not.

(Sorry I have two new screen names as I had forgotten the first one when I registered yesterday). Apparently now I remember but will stick with this one. I deleted the previous post so as to not confuse things).

A few possible answers:

1. History of trauma is an important part of your mental health, and thus, an important part of your general health. For example, a depressed patients with hx of trauma respond better to psychotherapy than medication. If a future provider (which could be in any specialty) is worried you are depressed, they should then look to refer you to someone who can give therapy, to provide the best possible care
2. We are always making sure that victims of abuse are safe. Often, abusers refuse to leave the room during interviews, and the patient is too nervous to speak freely without repercussions
3. Knowing your personal history is important to deliver sensitive care. Some victims of abuse are uncomfortable disrobing or with invasive exams in general, and it's good for us to be aware of that.
4. I'm sorry the hospitalist brought up this information in a way you felt had nothing to do with your medical care. They may have had good intentions, but clearly it felt like an invasion of your privacy. Would you like to talk about it?

Agree with all of the above to minimize identifying information of other people/patients, but family history is important. For awhile, HIV+ was considered privileged information, but I could never imagine keeping that out of chart now

 

[Salpingo]

Good point. If I'm ever in need of psychiatric care I will look for a private practice psychiatrist who still uses pen and paper and files my record in a dusty cabinet.

The easiest thing to do would be to intermittently ask to see and review the records, and have an open discussion of what's in there.

I agree that there's a hypothetical danger to reckless distribution of records, but there's a much more real danger when people are over protective. Look at the Virginia Tech shooting.

 

[TexasPhysician]

In fairness, from reading lots of medical records for forensic cases, cash practice psychiatrists seem to have far more inappropriate charting. I'd personally fear what goes into my chart from the cash only guy in solo practice than the guy at the medical center.

My experience shows the exact opposite. Poor charting is probably pretty rampant though.

Cash practices in my area often won't release records to anyone but the patient/guardian, and coordinate care much better. No faxing of records at all.

 

[HIPAAHasOneP]

3

A few possible answers:

1. History of trauma is an important part of your mental health, and thus, an important part of your general health. For example, a depressed patients with hx of trauma respond better to psychotherapy than medication. If a future provider (which could be in any specialty) is worried you are depressed, they should then look to refer you to someone who can give therapy, to provide the best possible care
2. We are always making sure that victims of abuse are safe. Often, abusers refuse to leave the room during interviews, and the patient is too nervous to speak freely without repercussions
3. Knowing your personal history is important to deliver sensitive care. Some victims of abuse are uncomfortable disrobing or with invasive exams in general, and it's good for us to be aware of that.
4. I'm sorry the hospitalist brought up this information in a way you felt had nothing to do with your medical care. They may have had good intentions, but clearly it felt like an invasion of your privacy. Would you like to talk about it?

Agree with all of the above to minimize identifying information of other people/patients, but family history is important. For awhile, HIV+ was considered privileged information, but I could never imagine keeping that out of chart now

You make good points. It just seems like there are more and more people these days with their hands in patients' medical records. I wonder if it's going to get to the point where a patient says I'm not telling the psychiatrist that because the hospitalist is going to know, and the dermatologist is going to know, and whoever falls under the "health care operations" area will know, etc. Then, we have these health information exchanges which include optometrists and podiatrists and public health people and the fire department, and on and on, and pretty soon the patient's sexual abuse history is all over the place. My understanding is that with the health information exchanges some states are opt in, some are opt out, and some states it's left to the institution. Patients may not fully understand just how many people can get access to their information if they agree to it (or fail to opt out). But then again, it may be that the patients who care about privacy know to avoid academic centers altogether and know to avoid health information exchanges, and the ones who visit academic centers and who join health information exchanges don't care much about privacy. I think we may be going down a dangerous road, though.

 

[Armadillos]

As mentioned above as far as billing goes you hardly have to document anything to meet the criteria. So when people are constantly over documenting HPI its because they think it's helpful.

Pretty sure that the following would meet and exceed the history criteria needed for pretty much any billing level and then A/P to justify medics decision making would need to match up as well.

Ccepressed
HPI ; 40 yo male w/ suicidal ideation. Depressed for 2 months, poor mood, disturbed sleep, poor concentration, decreased appetite and SI.Worsened by social stressors. Prozac not helpful.

ros: per HPI, all other systems reviewed and negative
PmHx: HTN, depression
fmHx: mother depressed, father bipolar
Social: single, accountant, denies etoh/illicits

 

[michaelrack]

I can see the need to document these things and to share with the psychologists and social workers because in that case it is pertinent to the care of the patient. I guess my question is how would you answer a patient who is upset and asking you why in the world you shared a note with the hospitalist who is treating her pyelonephritis or pneumonia that she reports she was sexually abused by her father as a child?

There are several different models of taking care of a psych patient's medical problems. Hospitalists see very few of the patients at the 2 psych wards I practice at (my regular job and my weekend locums position). When I am consulting on a medical ward (usually for alcohol/drugs/suicidality), I dont put sensitive information in the note, or use very general terms if absolutely necessary. My regular job is a rather unusual situation; non-disclosure agreements prevent me from saying more, other than that I am boarded in both psychiatry and internal medicine.

 

[michaelrack]

many psych wards/hospitals are not associated with medical hospitals/wards

 

[HIPAAHasOneP]

many psych wards/hospitals are not associated with medical hospitals/wards

True, I'm mainly thinking about the academic centers were a patient may be seeing multiple physicians. I think that's where the bigger concern is. And, as long as patients know and agree to where their information is going I don't have a problem with it. I'm just not entirely sure some of them do.

 

[HIPAAHasOneP]

A few possible answers:

1. History of trauma is an important part of your mental health, and thus, an important part of your general health. For example, a depressed patients with hx of trauma respond better to psychotherapy than medication. If a future provider (which could be in any specialty) is worried you are depressed, they should then look to refer you to someone who can give therapy, to provide the best possible care
2. We are always making sure that victims of abuse are safe. Often, abusers refuse to leave the room during interviews, and the patient is too nervous to speak freely without repercussions
3. Knowing your personal history is important to deliver sensitive care. Some victims of abuse are uncomfortable disrobing or with invasive exams in general, and it's good for us to be aware of that.
4. I'm sorry the hospitalist brought up this information in a way you felt had nothing to do with your medical care. They may have had good intentions, but clearly it felt like an invasion of your privacy. Would you like to talk about it?

Agree with all of the above to minimize identifying information of other people/patients, but family history is important. For awhile, HIV+ was considered privileged information, but I could never imagine keeping that out of chart now

I was thinking more about what you wrote, and I can't think of a single time when I had my dermatologist, my internist, or the endocrinologist ask about a history of sexual abuse (or a legal history or some of the other things a psychiatrist may ask about) in their paperwork. This suggests to me that maybe information like this is not necessary for those physicians to have in order to treat the patient. I have seen that question asked in the paperwork at the gynecologist's office - which makes sense.

I like Armadillo's way of documenting. Much more discreet than the kind of notes I'm seeing.

 

[TexasPhysician]

I was thinking more about what you wrote, and I can't think of a single time when I had my dermatologist, my internist, or the endocrinologist ask about a history of sexual abuse (or a legal history or some of the other things a psychiatrist may ask about) in their paperwork.

Maybe you are just asking the wrong questions. When was the last time you asked your dermatologist about the black/red thing hanging out down there? Maybe that hypothyroidism affecting dryness/libido at endo office? You never know when the business becomes the doctor's business.....

 

[SeniorWrangler]

A lot of EHR's now also have open records which the patient can see at any time. This has really changed my charting practices, a lot of the stuff I was taught in residency does not look or sound good to the layperson. My notes are less biographically specific and use a lot less psychiatric jargon than previously. This is probably a good thing overall.