Patient File Ethics

Started by syzergy
Get help with your application

Use all the free resources available to you from SDN: articles, guides, expert advising, forums discussions, and school research.

Browse articles Compare schools My application plan Read Interview Feedback
Practice for interviews Ask an Advisor
syzergy

syzergy

Full Member
10+ Year Member
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.
 
syzergy said:
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.
Click to expand...

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.
 
erg923 said:
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.
Click to expand...

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!
 
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.
 
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.
 
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.
 
You must log in or register to reply here.