Possible Ethical Violation--Writing Another Therapists' Notes

[PX1985]

Hi all,

I am a recent PhD graduate who has recently been given an appetizing freelance gig by a former mentor. This professor would like me to "scrub" her intake notes to include more detailed information about her intake assessments, as well as include supporting evidence for her diagnoses. The problem is that I have never been present for any of these sessions, nor am I certain about the accuracy of her diagnoses. There often isn't enough detail to warrant a specific diagnosis, so I have been using "Adjustment Disorder NOS" or "Generalized Anxiety Disorder."

Would it be illegal to continue assisting this psychologist by editing her notes? She intends to submit these notes to various insurance companies for reimbursement, and she is paying me a small stipend to do this after-hours. I'm wondering if anyone has had an experience like this before. She is flying out of town for a few weeks, so it has given me time to consider the ethicality/legality of this gig.

Any thoughts would be appreciated!

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[futureapppsy2]

This is super, super sketch, IMO, and just weird. How are you supposed to add detail about a client you've never seen, for an appointment that you weren't present for?

 

[foreverbull]

Hmm...this seems unethical.

Is it looking at the symptoms she assessed and then you put the symptoms together for a diagnosis? What "evidence" are you supposed to provide?

Not okay from a clinical/ethical standpoint. This only makes sense in the context of psychological assessments (psychometrists administering assessments and the psychologist interprets), and it goes the other way around--the more experienced person provides the diagnosis from the objective data.

 

[psych.meout]

Hmm...this seems unethical.

Is it looking at the symptoms she assessed and then you put the symptoms together for a diagnosis? What "evidence" are you supposed to provide?

Not okay from a clinical/ethical standpoint. This only makes sense in the context of psychological assessments (psychometrists administering assessments and the psychologist interprets), and it goes the other way around--the more experienced person provides the diagnosis from the objective data.

Yeah, this is very confusing.

If it's adding "details" and "evidence" that OP can't know to be true and it's for the purposes of submitting the notes for insurance reimbursement, wouldn't there be legal liability for insurance fraud?

 

[PX1985]

Hmm...this seems unethical.

Is it looking at the symptoms she assessed and then you put the symptoms together for a diagnosis? What "evidence" are you supposed to provide?

Not okay from a clinical/ethical standpoint. This only makes sense in the context of psychological assessments (psychometrists administering assessments and the psychologist interprets), and it goes the other way around--the more experienced person provides the diagnosis from the objective data.

To clarify, she already has notes that are loosely organized and more "impressionistic." She includes symptoms and and a formal diagnosis. My job is to organize the language and add more detail.

For example, one of her notes states:

"Patient attended inpatient setting for two weeks, reported depression and anxiety symptoms like low motivation, depressed mood, anhedonia, and worry about the future. Patient refused inpatient activities--was referred out for additional services."

My rephrasing of the note was:

"The patient was hospitalized at XYZ inpatient facility for two weeks, during which she reported symptoms of anxiety and depression. These symptoms included low motivation, depressed mood, and anhedonia, as well as a preoccupation with fears about her future. The patient refused to engage in inpatient activities and was subsequently referred out for additional services."

Not sure if this clarifies things. The tricky part is that some of her notes are very "bare-bones," so there isn't much detail to add.

 

[PX1985]

Yeah, this is very confusing.

If it's adding "details" and "evidence" that OP can't know to be true and it's for the purposes of submitting the notes for insurance reimbursement, wouldn't there be legal liability for insurance fraud?

Hey! Please see my other reply to see if it clarifies things a bit.

 

[ClinicalABA]

Would there be any indication in the final product (i.e., the one submitted to funder) of the fact that you edited and added to the note? Are you listed as a contributor, with your specific role detailed somewhere? In other words, is she claiming your work as her own? Is there info in there about the client that comes from you and not her? This is sketchy and weird. Writing a parsimonious yet comprehensive session note that meets funder requirements is a BASIC clinical skill. Submitting false info for insurance claims is fraud. Don't get involved with this nonsense.

 

[psych.meout]

To clarify, she already has notes that are loosely organized and more "impressionistic." She includes symptoms and and a formal diagnosis. My job is to organize the language and add more detail.

For example, one of her notes states:

"Patient attended inpatient setting for two weeks, reported depression and anxiety symptoms like low motivation, depressed mood, anhedonia, and worry about the future. Patient refused inpatient activities--was referred out for additional services."

My rephrasing of the note was:

"The patient was hospitalized at XYZ inpatient facility for two weeks, during which she reported symptoms of anxiety and depression. These symptoms included low motivation, depressed mood, and anhedonia, as well as a preoccupation with fears about her future. The patient refused to engage in inpatient activities and was subsequently referred out for additional services."

Not sure if this clarifies things. The tricky part is that some of her notes are very "bare-bones," so there isn't much detail to add.

Ok, that makes things clearer, but with this specific example I guess I'm not seeing how you're really adding any details other than the name of the facility. It looks mostly like copyediting and I'm not sure what added value there is in having you do most of this in the first place.

 

[summerbabe]

The tricky part is that some of her notes are very "bare-bones," so there isn't much detail to add.

If she’s having trouble getting reimbursed based on crappy documentation, that sounds like a ‘her’ problem that requires remediation, not the services of another professional to patch things over. I wouldn’t touch this regardless of legality.

If you’re really needing to generate side income, surely there are better options than this, no?

 

[WisNeuro]

If this is essentially acting as a scribe/transcriptionist, that is no problem. If the person is then wanting you conceptualize the case and then provide a diagnosis, that veers into worrisome territory.

To clarify, simply editing and organizing information that already exists, is no problem. Other specialties in healthcare do this regularly. However, if you are being asked to add information not in the notes, or to come up with a diagnosis, there is a problem.

 

[AcronymAllergy]

If this is essentially acting as a scribe/transcriptionist, that is no problem. If the person is then wanting you conceptualize the case and then provide a diagnosis, that veers into worrisome territory.

To clarify, simply editing and organizing information that already exists, is no problem. Other specialties in healthcare do this regularly. However, if you are being asked to add information not in the notes, or to come up with a diagnosis, there is a problem.

Agreed. If you're just re-organizing, clarifying, editing, etc., I would think that's fine. But if you're being asked to actually add information that's not in the notes, that's problematic, both for you and the treating psychologist.

 

[futureapppsy2]

Agreed. If you're just re-organizing, clarifying, editing, etc., I would think that's fine. But if you're being asked to actually add information that's not in the notes, that's problematic, both for you and the treating psychologist.

I'd agree with this as well.

 

[Ollie123]

I mean, the above example looks like copyediting. Which I can't imagine paying someone to do for progress notes (it should take what - max 5-10 minutes a note barring exceptional circumstances where risk is extremely high, etc). I guess that is probably OK with some obvious caveats about confidentiality and the like. Adding details about the case would be hugely problematic though.

I'm more just confused what practitioner would do this. Its one thing having a trainee generate a note for you both to co-sign when they were present during a session but not leading. Having one going back to revise progress notes for someone else is just.....exceedingly bizarre.

 

[erg923]

Hi all,

I am a recent PhD graduate who has recently been given an appetizing freelance gig by a former mentor. This professor would like me to "scrub" her intake notes to include more detailed information about her intake assessments, as well as include supporting evidence for her diagnoses. The problem is that I have never been present for any of these sessions, nor am I certain about the accuracy of her diagnoses.

Any thoughts would be appreciated!

Who on earth would this be anybody else's job/responsibility but hers? I would decline the offer based on that principle alone.

 

[WisNeuro]

I mean, the above example looks like copyediting. Which I can't imagine paying someone to do for progress notes (it should take what - 5-10 minutes a note barring exceptional circumstances where risk is extremely high, etc). I guess that is probably OK with some obvious caveats about confidentiality and the like. Adding details about the case would be hugely problematic though.

I'm more just confused what practitioner would do this. Its one thing having a trainee generate a note when they were present during a session, but going back to revise progress notes for someone else is just.....exceedingly bizarre.

Yeah, I wonder if this is just an extremely disorganized provider. Progress notes, definitely, you should just have templates and it should really only take 2-3 minutes to add session specific info. It looks like the OP is editing and organizing intakes, so it may be more of an intake report, 90791 type of situation. In which case, I would still prefer to do this myself. But, I don't really see any problem with having a "scribe" do this as long as they weren't being asked to also provide a diagnosis and treatment recommendations.

Who on earth would this be anybody else's job/responsibility but hers? I would decline the offer based on that principle alone.

I don't see a huge principle issue with having someone act as a scribe/transcriptionist. Maybe it saves this person a decent amount of time, whereby they could accrue more billable hours elsewhere. Many other specialties use scribes/transcriptionists, it's not an odd thing in and of itself.

 

[cara susanna]

There often isn't enough detail to warrant a specific diagnosis, so I have been using "Adjustment Disorder NOS" or "Generalized Anxiety Disorder."

This is the part of your post that would make me hesitate.

 

[WisNeuro]

This is the part of your post that would make me hesitate.

Yeah, that part is concerning. It's one thing if you're just transcribing what they have as a provisional diagnosis, but if the OP is taking notes and conceptualizing the diagnosis themselves, I'd be concerned.

 

[summerbabe]

This is the part of your post that would make me hesitate.

100%. Crappy syntax, poor grammar, convoluted sentence structure, & poor organization should probably still be enough get reimbursed. God knows that's probably the norm for many medical notes.

But it sounds like a lack of clinically relevant info is the actual problem and that's something that I would only help another licensed provider via verbal consultation and not direct edits of their notes.

 

[foreverbull]

Agree with others. The way you described it initially sounded like she expects you to insert your own conceptualization, which I find to be unethical.

The way you re-explained it made it sound like editing without inserting your own conceptualization.

If there’s even a hint of you changing her “impression” of a diagnosis, that is unethical.

 

[CheetahGirl]

Who on earth would this be anybody else's job/responsibility but hers? I would decline the offer based on that principle alone.

Agreed.

I would not proceed in this position. This person needs to learn to write notes per their aspirational goals. [period] Asking someone to add 'fluff' is plain weird and unethical.

 

[erg923]

Agreed.

I would not proceed in this position. This person needs to learn to write notes per their aspirational goals. [period] Asking someone to add 'fluff' is plain weird and unethical.

You don't make your problems someone else's problems. Editing/altering medical records after services and pretending that they were always that way, is fraudulent.

 

[borne_before]

Something is fishy - do they suck at tech?

 

[WisNeuro]

You don't make your problems someone else's problems. Editing/altering medical records after services and pretending that they were always that way, is fraudulent.

Need more nuance here, editing notes, particularly in an assessment/evaluation context is the rule, not the exception. Especially if they are taking notes and compiling a comprehensive report later on that includes those notes and relevant parts of the medical record. I don't anyone that is uploading their handwritten notes and calling it a day in this context. The key issue here being, is the OP doing any of the actual clinical work (conceptualizing, providing their own diagnosis). Doing the administrative part of the job for a provider is not unethical. Doing the clinical part could be an issue. Though, even here there is some leeway (e.g., trainee providing a draft). There is a lot of assuming going on here and some black and white thinking that goes above and beyond what the OP has provided in terms of the specifics of this situation.

 

[Ollie123]

Agree with wis that if this is just essentially acting as a scribe and/or copyeditor that's probably fine. I mean, I still don't "get it" but I don't think anything is inherently wrong with that.

It isn't clear if that is the case though. The OP indicates they were adding diagnoses based solely off a vague description of symptoms. That seems extremely not OK. I suppose I could still see it if the provider was intending to carefully review all edited notes before finalizing. What bothers me is how vague this seems to be. At a minimum I would expect very clear boundaries around what should and should not be changed in a scenario like this.

 

[ClinicalABA]

...The key issue here being, is the OP doing any of the actual clinical work (conceptualizing, providing their own diagnosis). Doing the administrative part of the job for a provider is not unethical. Doing the clinical part could be an issue. Though, even here there is some leeway (e.g., trainee providing a draft). There is a lot of assuming going on here and some black and white thinking that goes above and beyond what the OP has provided in terms of the specifics of this situation.

The OP said this:

"The problem is that I have never been present for any of these sessions, nor am I certain about the accuracy of her diagnoses. There often isn't enough detail to warrant a specific diagnosis, so I have been using "Adjustment Disorder NOS" or "Generalized Anxiety Disorder.""

This sounds like more than just editing. If it looks like, smells like, and tastes like ****, it's best to assume that it is ****. Once you get that stuff on you, it's hard to get rid of the stink. Also, outside of a training relationship, it seems odd for the senior clinician to be paying a junior one to make their notes better (maybe it's not, and I just haven't seen it). Where does the money come from to do this? Is she just throwing a bone to a new grad, or is the work of someone else being passed off as her own to increase her financial intake? Is there any indication on the not that a diagnosis is being added by someone other than her? If not, and the OP is not licensed, wouldn't that be "upcoding"?

 

[WisNeuro]

The OP said this:

"The problem is that I have never been present for any of these sessions, nor am I certain about the accuracy of her diagnoses. There often isn't enough detail to warrant a specific diagnosis, so I have been using "Adjustment Disorder NOS" or "Generalized Anxiety Disorder.""

This sounds like more than just editing. If it looks like, smells like, and tastes like ****, it's best to assume that it is ****. Once you get that stuff on you, it's hard to get rid of the stink. Also, outside of a training relationship, it seems odd for the senior clinician to be paying a junior one to make their notes better (maybe it's not, and I just haven't seen it).

I agree, in that instance, there is a potential problem. In their clarifying follow-up, it seemed to say they were just working and editing pre-existing notes. Definitely need some more specific info and some clarification to provide a judgment either way on ethical issues. I just wanted people to maintain some perspective, as some people seem to be jumping on a boat that says any note-taking editing is wrong, which is simply not true. It would not be the norm for psychology but is actually very prevalent elsewhere in healthcare.

If OP is uncomfortable sharing specifics from a privacy standpoint, I'd suggest the confidential consult option here on SDN, or even PMing someone.

 

[Shiori]

Totally off topic, but after watching Dr. Glaucomflecken, this is making me think of the ophthalmologist and his faith scribe Jonathan.

 

[msc545]

I would be concerned that this is not just unethical, but potentially illegal, in that it is being used to seek reimbursement from insurance companies. Are you being listed by name on any of this work and do you sign it, or is she essentially "hiding" you? If she is hiding you, I think there could be a LOT of trouble if any of the companies find out.

 

[George Lincoln]

This is super, super sketch, IMO, and just weird. How are you supposed to add detail about a client you've never seen, for an appointment that you weren't present for?

Good morning
One it’s unethical and secondly it’s a felony for insurance fraud. That’s the way I had to explain a similar situation I had when I saw a clergyman as a patient. First I told him what he was asking me to do was a lie, secondly I told him was unethical and as he continued to ask I told him thirdly it was a felony.
Read Churchill’s address about never giving up. It addresses ethical and moral behavior. Throughout my professional career I have been posed with dilemmas and you will always feel better about yourself when you know you’re doing the right thing.
People around you will recognize that behavior and will always defer to you and respect you because of it. Sometimes it’s not easy but the long view you always feel clean about yourself.
Good luck

 

[WisNeuro]

I'd still want more info before jumping to a premature conclusion of illegality. For example, is OP/trainee/scribe adding in info from the records, and stating such, when editing and writing notes? Or, are they adding things that do not exist elsewhere in the record to make a certain Dx fit? The former is standard of care, while the former is a definite problem.

OP, definitely consult with someone you can trust, who you can give more specific info to. I'm afraid you'll get a lot of assumptions and black and white thinking when it comes to internet advice, particularly when there is limited info.

 

[singasongofjoy]

Assuming you are in fact not adding any kind of additonal info or formulation / diagnostic impression but just copy-editing... it's still confusing. The only possibility I could fathom is they are giving you handwritten notes and don't know how to type effectively, use the EMR, or use voice dictation software.