Patient File Ethics

[syzergy]

I’ve been rolling this issue around in my head and I wanted to get thoughts from SDN. So I’m doing an external placement at a VA right now. Within CPRS, we have access to all of patient’s medical/mental health notes within the VA, not just the notes from the clinic where I’m placed. Let’s say I have a patient who dropped out of PTSD treatment after a few sessions (no-call, no-show until we terminated treatment). What are your thoughts about occasionally looking up their CPRS file to see if they’re getting mental health treatment at a different clinic? Is this violating some sort of ethical code because they are no longer my patient, although they're still receiving VA services? Am I just satisfying my own curiosity by checking in on this patient because I’m worried about them? What about with a patient that successfully completed treatment?

Across the years, I’ve always wondered how my patients were doing after I’ve stopped seeing them – but with the VA you actually have the ability to check in.

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[erg923]

I’ve been rolling this issue around in my head and I wanted to get thoughts from SDN. So I’m doing an external placement at a VA right now. Within CPRS, we have access to all of patient’s medical/mental health notes within the VA, not just the notes from the clinic where I’m placed. Let’s say I have a patient who dropped out of PTSD treatment after a few sessions (no-call, no-show until we terminated treatment). What are your thoughts about occasionally looking up their CPRS file to see if they’re getting mental health treatment at a different clinic? Is this violating some sort of ethical code because they are no longer my patient, although they're still receiving VA services? Am I just satisfying my own curiosity by checking in on this patient because I’m worried about them? What about with a patient that successfully completed treatment?

Across the years, I’ve always wondered how my patients were doing after I’ve stopped seeing them – but with the VA you actually have the ability to check in.

HIPPA addresses this specifically. If you need to look at the chart to inform and/or document your care/treatment of the patient, its fine.

If its "curiosity," its not fine.

 

[syzergy]

HIPPA addresses this specifically. If you need to look at the chart to inform and/or document your care/treatment of the patient, its fine.

If its "curiosity," its not fine.

Ok, that's what I thought. I was leaning toward the nope, don't check unless I'm still involved in the treatment in some way. Thanks!

 

[Therapist4Chnge]

I've had this on occasion. In almost all of my evals I'll recommend F/U with a counselor/psychologist and/or specialist (sleep is the most common). If it's within 6mon of my eval I'll check the medical chart, but if it's past that I may ask the referring doc.

I know this is a very conservative approach, but I know I could defend my decisions if I ever came in front of a licensing board, etc.

 

[WisNeuro]

As others have said, depends on what for. In my practice, I will occasionally check back on patients to see about follow-up, but also to see if the diagnosis (where applicable) was accurate. As in, with a dementia, are we seeing any decline in functional status or what not. Also, we commonly recommend that these people come back to see us in a certain 12-24 month time frame. Easily defensible in my opinion for such cases. However, with therapy patients, a little harder to make the case of checking back in long after therapy is done and you are no longer involved.

 

[Ollie123]

I occasionally will review records from folks who terminated abruptly (typically by dropping off the face of the earth) for ~ 6 months. I think this is perfectly justifiable - wanting to manage caseload/patient flow due to the possibility of re-engagement and ensure they are not MIA due to health complications given I have many older/sicker folks.

Checking up on someone you saw 3 years ago to "see how they are doing" ....yeah, not really kosher. Can't imagine you ever actually having consequences from doing so given there are a million possible perfectly valid reasons you might want to look back at your own treatment notes (which to my knowledge - would be 100% kosher). I frequently refer to my notes from similar cases I've seen in the past when doing treatment planning. At least in our system - there is no way to do it without also pulling up current info. Still not something I'd make a habit.