ER telepsych

[thepoopologist]

Talking to a company about it for some extra monies. Any drawbacks? The shifts are 4 hours, there is no prescribing. Its 160/hr. 45 min/patient.

They have shifts in a crisis stabilization unit that are 180/hr that does have prescribing.

A somewhat related question, are more concise notes more protective liability wise in settings like these? I'm at a state run facility currently and I write really comprehensive notes right now

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[wolfvgang22]

Sounds like a sweet gig. I have no input.

I'm also curious when a more concise note would be more protective. I've heard people speculate it can be, but haven't seen evidence more concise notes are protective. I had a mentor in fellowship discuss being sued for malpractice but was protected by having written comprehensive notes, and so malpractice insurance did not even settle the case and told the plaintiff to pound sand, and judge agreed.

 

[Sushirolls]

Sadly, admit is about as protective as you'll get... the rest is a role of the dice.

 

[BiscoDisco]

This is pretty much exactly what I'm looking for after I graduate. Do you mind sharing (or pm'ing) where you found this?

On a side note, anyone know of any similar gigs for upper level moonlighters?

 

[Mass Effect]

I had an attending in residency say that one of the main things that leave docs open to a lawsuit is overdocumentation. That said, in this setting, you have to clearly explain why you're not admitting as that's the primary thing that will likely get you in trouble. You can always explain erring on the side of caution by admitting. It's harder to defend not admitting someone with suicidal red flags up the wazoo who ends up committing suicide.

 

[wolfvgang22]

I had an attending in residency say that one of the main things that leave docs open to a lawsuit is overdocumentation.

I don't understand what the reasoning for that is, though. I mean, it would be a really bad idea if you "over document" by writing stuff like "I really hate this abusive alcoholic patient, so I'm going to prescribe Xanax 1mg QID in hopes I will never see him again." But if you never write or do anything that you aren't willing to defend to your peers, the state medical board, and a court room, why worry too much about "over documentation."

I'm sure a lawyer can always find something to nit pick, but most likely if you do a good job meeting or exceeding the standard of care and thoughtfully document it, you shouldn't need to worry as much. It feels sometimes like we are damned if we care and damned if we don't.

 

[WisNeuro]

I don't understand what the reasoning for that is, though. I mean, it would be a really bad idea if you "over document" by writing stuff like "I really hate this abusive alcoholic patient, so I'm going to prescribe Xanax 1mg QID in hopes I will never see him again." But if you never write or do anything that you aren't willing to defend to your peers, the state medical board, and a court room, why worry too much about "over documentation."

I'm sure a lawyer can always find something to nit pick, but most likely if you do a good job meeting or exceeding the standard of care and thoughtfully document it, you shouldn't need to worry as much. It feels sometimes like we are damned if we care and damned if we don't.

I am curious about this as well. I am a member of the MH clinical council at our hospital. Over the past several years, we've had a little over a handful of cases come up for disciplinary actions. A couple were for people just being untimely with notes (>1 month for inpatient units, which is absurd to me). But, the other handful were actually for medical decisions or prescribing habits that were somewhat atypical (though not necessarily wrong) and it usually came down to the provider not justifying in their notes why they made a decision/prescription that departed from normal standard of care. In most cases they could justify it to the council with good reason, they just didn't include it in their documentation. What kind of things in the overdocumentation realm would lead to increased liability?

 

[Mass Effect]

I don't understand what the reasoning for that is, though. I mean, it would be a really bad idea if you "over document" by writing stuff like "I really hate this abusive alcoholic patient, so I'm going to prescribe Xanax 1mg QID in hopes I will never see him again." But if you never write or do anything that you aren't willing to defend to your peers, the state medical board, and a court room, why worry too much about "over documentation."

I'm sure a lawyer can always find something to nit pick, but most likely if you do a good job meeting or exceeding the standard of care and thoughtfully document it, you shouldn't need to worry as much. It feels sometimes like we are damned if we care and damned if we don't.

The more you write, the more there is to scrutinize. Of course you need to explain your opinion and decision, but a risk assessment that's 10 paragraphs long raises way more red flags than one that's a paragraph, but includes all the pertinent information.

 

[wolfvgang22]

The more you write, the more there is to scrutinize. Of course you need to explain your opinion and decision, but a risk assessment that's 10 paragraphs long raises way more red flags than one that's a paragraph, but includes all the pertinent information.

The amount of detail required to cover "all the pertinent information" is nebulous and seems to vary wildly by whoever I'm talking to.

 

[calvnandhobbs68]

I had an attending in residency say that one of the main things that leave docs open to a lawsuit is overdocumentation. That said, in this setting, you have to clearly explain why you're not admitting as that's the primary thing that will likely get you in trouble. You can always explain erring on the side of caution by admitting. It's harder to defend not admitting someone with suicidal red flags up the wazoo who ends up committing suicide.

This is straight up not true. If you talk to any of the forensics guys they’ll tell you the only thing that saves you in court is documentation. It’s extremely hard to argue with concurrent documentation when it turns into a “he said she said” thing later as you explain what exactly went into your risk assessment. The docs that get screwed are the ones that just right “low risk of harm to self or others” with no reasoning.

They often talk about errors of fact vs errors of judgement. Very rare to have a successful lawsuit for an error of judgement (you just happened to make the wrong decision based on the facts you have at hand). There are mounds of evidence and expert papers testifying to the fact that we can’t predict short term suicide or homicide risk. Much more common to be successfully sued for an error of fact (you don’t document that you gathered all the relevant information at the time of your decision making).

I guess if you’re talking about including a lot of irrelevant information in your note than yeah nobody would recommend that...but why would you be doing that anyway.

 

[Merovinge]

This is straight up not true. If you talk to any of the forensics guys they’ll tell you the only thing that saves you in court is documentation. It’s extremely hard to argue with concurrent documentation when it turns into a “he said she said” thing later as you explain what exactly went into your risk assessment. The docs that get screwed are the ones that just right “low risk of harm to self or others” with no reasoning.

They often talk about errors of fact vs errors of judgement. Very rare to have a successful lawsuit for an error of judgement (you just happened to make the wrong decision based on the facts you have at hand). There are mounds of evidence and expert papers testifying to the fact that we can’t predict short term suicide or homicide risk. Much more common to be successfully sued for an error of fact (you don’t document that you gathered all the relevant information at the time of your decision making).

I guess if you’re talking about including a lot of irrelevant information in your note than yeah nobody would recommend that...but why would you be doing that anyway.

I also had some attendings in training focus on a less is more to protect from liability but the further out of training I get the more I think that was either misguided or an attempt to rationalize writing shorter notes. I think in specifically 100% psychotherapy notes, less is definitely more, but when we are deciding admission/discharge or why medications or tests were recommended (particularly off label, anything in CAP essentially), having a sentence or explanation of your discussion will almost invariably improve resiliency to future lawsuits.

Having said that, I read notes by surgeons or hospitalists for life/death decisions and they write almost nothing. Granted they have a much higher malpractice suit rate then we do but I imagine that's more related to the work then their documentation. I really wish this was something that was empirically studied.

 

[Sushirolls]

I document on the heavier side typically.
Already had moments where I was grateful I did.
I also would rather have piece of mind in future of knowing 'I documented as best I could at that time' to avoid the anxious thoughts of 'I wish I had documented XYZ...'

So until society removes the lawyer risks this is how I'll document. And it in turns has shaped the jobs I've worked out, the way I practice. I believe there wouldn't be Psychiatrist shortage if we didn't have to document for Billing or Lawyers, but simply clinical purposes.

 

[Stagg737]

I don't understand what the reasoning for that is, though. I mean, it would be a really bad idea if you "over document" by writing stuff like "I really hate this abusive alcoholic patient, so I'm going to prescribe Xanax 1mg QID in hopes I will never see him again." But if you never write or do anything that you aren't willing to defend to your peers, the state medical board, and a court room, why worry too much about "over documentation."

I'm sure a lawyer can always find something to nit pick, but most likely if you do a good job meeting or exceeding the standard of care and thoughtfully document it, you shouldn't need to worry as much. It feels sometimes like we are damned if we care and damned if we don't.

I've heard this quite a bit as well, and I actually have family members who work closely with healthcare-focused lawyers and there are times when less is more. From what I've been told, this is typically in the HPI or subjective portions of the note and not so much in the assessment and plan. A major issue can be when certain symptoms are mentioned or described in detail in the HPI but are not directly addressed in the AP portion. The more that is written in the HPI, the more "gotcha" moments you're creating for lawyers to twist your words. If you don't explain how you addressed those symptoms in the AP section, then you never did (what's not documented never happened). Idk how often that actually ends up resulting in a negative outcome for the physician in court, but that's what I've been told in regards to "overdocumentation" from people on the legal/insurance side of healthcare.

 

[wolfvgang22]

I've heard this quite a bit as well, and I actually have family members who work closely with healthcare-focused lawyers and there are times when less is more. From what I've been told, this is typically in the HPI or subjective portions of the note and not so much in the assessment and plan. A major issue can be when certain symptoms are mentioned or described in detail in the HPI but are not directly addressed in the AP portion. The more that is written in the HPI, the more "gotcha" moments you're creating for lawyers to twist your words. If you don't explain how you addressed those symptoms in the AP section, then you never did (what's not documented never happened). Idk how often that actually ends up resulting in a negative outcome for the physician in court, but that's what I've been told in regards to "overdocumentation" from people on the legal/insurance side of healthcare.

That makes some sense. Yesterday I had a patient who just got divorced and is facing bankruptcy and upset about finances. Patient has history of alcohol abuse, but in remission for months.
There isn't anything I can do about that social stuff, but he is already attending frequent psychotherapy and started taking an SSRI for a depressive episode, offered substance abuse programming (refused) and all that is documented in the AP portion and assessed for lethal means and intent (none, gave gun to brother). It occurs to me he might get really distressed with these social stressors and off himself one day, but not much else I can do about it. He knows how to access help 24/7. I suppose someone could play "gotcha" and ask why I didn't refer him to a financial counselor or something. There's always something.

 

[Mass Effect]

I guess if you’re talking about including a lot of irrelevant information in your note than yeah nobody would recommend that...but why would you be doing that anyway.

That is what I'm talking about. Of course you have to clearly document what went into your thinking, but we've all seen the 10-paragraph assessments written, most of which is irrelevant to the safety of the patient.

 

[Sushirolls]

That makes some sense. Yesterday I had a patient who just got divorced and is facing bankruptcy and upset about finances. Patient has history of alcohol abuse, but in remission for months.
There isn't anything I can do about that social stuff, but he is already attending frequent psychotherapy and started taking an SSRI for a depressive episode, offered substance abuse programming (refused) and all that is documented in the AP portion and assessed for lethal means and intent (none, gave gun to brother). It occurs to me he might get really distressed with these social stressors and off himself one day, but not much else I can do about it. He knows how to access help 24/7. I suppose someone could play "gotcha" and ask why I didn't refer him to a financial counselor or something. There's always something.

Or IOP, or PHP, attempt to get follow up moved closer with therapist. Or depending on timing with SSRI, offer more aggessive dose increase, or offer lithium adjunct as has been in remission from alcohol, or offer ECT if remission timeline is appropriate, or call to confirm that brother has the gun, etc. The list goes on and on for possible hind sight nit picking...

 

[clausewitz2]

Or IOP, or PHP, attempt to get follow up moved closer with therapist. Or depending on timing with SSRI, offer more aggessive dose increase, or offer lithium adjunct as has been in remission from alcohol, or offer ECT if remission timeline is appropriate, or call to confirm that brother has the gun, etc. The list goes on and on for possible hind sight nit picking...

This nitpicking is not going to go better for you if you write garbage documentation a la " denies SI denies HI engages in safety planning discharge to OP care". Then, instead of not considering enough options for addressing the patient's risk factors and ways of modifying them, it is very easy to make the case that you simply paid no attention to any of the details of the case and were just copying and pasting notes without thought.

Documenting decision-making rationale, provided the rationale is not so bizarre that it is clearly way outside of what a respectable minority of physician's would support, is never going to make you more liable and it is certainly not going to make you less sympathetic to a jury should it get to that. Do you think they're more likely to award damages against the thoughtful physician who clearly really thought about the case, or the careless physician who appeared to just be rushing the patient out the door as fast as humanly possible?

Plus with all the mandatory screenings and questionnaires in EDs these days, someone may have already collected a lot of the relevant information, and then it becomes "Doctor Y, is it your usual practice to ignore information provided by your patients in a crisis?" Around here the recent suits that have gone badly for defendants often involved major disconnects between nursing and physician documentation.

 

[Premed341]

This nitpicking is not going to go better for you if you write garbage documentation a la " denies SI denies HI engages in safety planning discharge to OP care". Then, instead of not considering enough options for addressing the patient's risk factors and ways of modifying them, it is very easy to make the case that you simply paid no attention to any of the details of the case and were just copying and pasting notes without thought.

Documenting decision-making rationale, provided the rationale is not so bizarre that it is clearly way outside of what a respectable minority of physician's would support, is never going to make you more liable and it is certainly not going to make you less sympathetic to a jury should it get to that. Do you think they're more likely to award damages against the thoughtful physician who clearly really thought about the case, or the careless physician who appeared to just be rushing the patient out the door as fast as humanly possible?

Plus with all the mandatory screenings and questionnaires in EDs these days, someone may have already collected a lot of the relevant information, and then it becomes "Doctor Y, is it your usual practice to ignore information provided by your patients in a crisis?" Around here the recent suits that have gone badly for defendants often involved major disconnects between nursing and physician documentation.

why is “denies si, hi” garbage if it’s true? Obviously if nursing indicates active si in their notes that’s bad but if no other notes contradict you you can write what you want, no?

 

[clausewitz2]

why is “denies si, hi” garbage if it’s true? Obviously if nursing indicates active si in their notes that’s bad but if no other notes contradict you you can write what you want, no?

If that's the entirety of the reasoning provided in your note you are not demonstrating that you actually evaluated the patient in a meaningful way. This is not a situation where you just take the patient's word for it 100% of the time.

 

[Mass Effect]

I feel like we're veering off into the weeds here. The question was about concise documentation. It's now gone into the territory of incomplete documentation, which I think we all agree is bad.

Concise -- brief but comprehensive.

There is nothing wrong with being able to sum up the risk factors and protective factors, along with the reasoning for your plan in one paragraph. If it includes all relevant information, you're protected. In truly complex cases, maybe 2 or 3 paragraphs. I've never read a risk assessment longer than that that was actually good or offered more protection. Usually, when you veer into the 5-paragraph category, you're resurrecting the HPI and blathering on about things that didn't impact your decision at all, but were just interesting to note.

 

[Mass Effect]

why is “denies si, hi” garbage if it’s true? Obviously if nursing indicates active si in their notes that’s bad but if no other notes contradict you you can write what you want, no?

You have to clarify. The patient may deny SI then kill themselves and meanwhile, he had admitted SI to the nurse and you never addressed it. In cases like that, it's best to document that patient denies SI to you, but admitted it to the nurse "and when asked about this..."

 

[milkncookies]

Talking to a company about it for some extra monies. Any drawbacks? The shifts are 4 hours, there is no prescribing. Its 160/hr. 45 min/patient.

They have shifts in a crisis stabilization unit that are 180/hr that does have prescribing.

A somewhat related question, are more concise notes more protective liability wise in settings like these? I'm at a state run facility currently and I write really comprehensive notes right now

Wondering if you ended up doing this gig. It sounds like something I’d be interested in if you wouldn’t mind PMing me the details