The trickiest bit I anticipate is when i would really like to communicate concerns about a feigned component to presenting symptoms and documentation of external motivations relevant to treatment. Not everyone is willing to take calls/respond to emails relevant to care coordination so I am not sure how to go about this now. Any suggestions?
Well those people who arent interested in care coordination are also not reading your notes. 75+% of my patients are those with FND, somatization, factitious disorder and other things on the abnormal illness behavior spectrum. I also see the patients feigning in the ED etc. I rarely include malingering as a diagnosis and only mention this where there is clear reason to do so (e.g. wanting to avoid hospitalization in recalcitrant antisocial patients). instead what I do is clearly document all the inconsistencies I have noted from chart review, collateral, patient comments, subjective vs objective observations, psychological testing etc. Typically I might use some phrase like "it is my opinion x is not accurately reporting their symptoms."
Most patients have incentives for being ill (and this is particularly true for my pts) and I discuss with them frankly during the first session. "No one wants to be sick and suffering the way you are, but sometimes it can be hard to imagine getting better and there are always barriers that get in the way of recovery. That can be things like not having to work in a toxic environment, your partner being nicer to you, getting disability, avoiding certain obligations and so on. It is important for us to identify what factors might get in the way." And usually I have them complete some sort of pros and cons of staying the same vs changing. So I absolutely include these things including financial incentives etc in my notes. I also tell patients "you can have treatment or you can have disability, you cannot have both." [of course there are obvious exceptions like pts w/ psychosis but you know what I mean].
For patients with factitious disorder who are hurting themselves through medical procedures or inducing illness, that's covered by the physical harm exception in the 21st century cures act. So they don't get to see their records.
For other patients who I think might have factitious disorder, I discuss this with them openly saying I don't know but it is one thing on the differential.
There will always be (and always have been) patients who object to what you put in the medical record. For the most part the bar is very high to prevent patients accessing their records, but for those patients who definitely should not, the law provides enough latitude to prevent them from seeing their notes in real time, and to redact or limit the release otherwise. I have changed nothing except more mindful of not copying forward things since we moved to open notes.
