Psych Eval Question

[loveoforganic]

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I was reading through one of the patient's admittance evaluation, and I came across two parts that seem to contradict each other pretty grossly and wanted to see if you all could tell me if I'm missing something.

Documented in one section of the eval is that the patient reports occasionally being told by a clown, specifically the clown from Stephen King's book/movie "It" to do bad things, and that sometimes she would listen to him and sometimes she'd ignore him. Later in the eval, it mentions that she has difficulty getting to sleep (hours laying in bed), and that she repeatedly hears her name called out to her while she tries to sleep.

It goes on to say how there is no evidence that the patient has any psychotic processing or delusions.

...

Do I have a misunderstanding of "psychotic processing" and "delusions"? I can understand how identifying the clown as being from a book/movie could possibly shift it toward a creation of the imagination, but the fact that it tells the patient to do things? Coupled with the fact that she hears some kind of voices? It seems hasty, to say the least, that there is "no evidence of psychotic processing or delusions."

Thanks in advance for your input.

Edit: I suppose it could possibly be referring to at the time of the eval? It doesn't specify.

 

[Regnvejr]

I would call that psychosis. Someone went on autopilot during the dictation of the mental status exam.

 

[PETRADOCS]

having command hallucinations and just plain auditory hallucinations but not delusions, psychosis is either hallucinations or delusions, delusions are not present in this case but hallucinations are which makes this person psychotic. delusions are fixed false belief not amendable to reason. poorly written case- not realistic

 

[hippiedoc13]

Hard to tell without the full context, but this sounds like either

(1) poorly written h&p as the above posters said,
or
(2) maybe the section where it says "no evidence of psychotic processing or delusions" was in the mental status exam??? ie documenting that this pt who claims to have psychotic symptoms does not, in fact, present as psychotic during the interview? I can imagine patients for whom I would explicitly document this type of mismatch between the symptoms they endorse and the thought processes they display.

More likely to be just a poorly written h&p though.

 

[Red Beard]

I recently read a radiology report that mentioned a non-enlarged prostate in a 60 something year old woman. Little stuff like that slips into dictation pretty frequently when you are dictating a lot.

 

[loveoforganic]

I recently read a radiology report that mentioned a non-enlarged prostate in a 60 something year old woman. Little stuff like that slips into dictation pretty frequently when you are dictating a lot.

Hippie - The two comments were mentioned nearly adjacent to one another, twice, in two different sections. I think one of them may have been under mental status.

Oh well, I think it's going to get cleared up in an upcoming meeting.

Out of curiosity, do those types of mistakes, assuming it's just a dictation error, tend to have a serious effect, or the potential for a serious effect? The patient also wasn't marked in the chart as a danger to self or others, but has a history of violence (assault conviction), cutting, suicidal ideation, and expressed in front of me on the day following admittance a desire to commit suicide.. :/

 

[OldPsychDoc]

Hippie - The two comments were mentioned nearly adjacent to one another, twice, in two different sections. I think one of them may have been under mental status.

Oh well, I think it's going to get cleared up in an upcoming meeting.

Out of curiosity, do those types of mistakes, assuming it's just a dictation error, tend to have a serious effect, or the potential for a serious effect? The patient also wasn't marked in the chart as a danger to self or others, but has a history of violence (assault conviction), cutting, suicidal ideation, and expressed in front of me on the day following admittance a desire to commit suicide.. :/

The main serious effect is the patient actually reading it, and getting his/her lawyer to make you look like an idiot in a civil commitment hearing.

Another adverse effect is having the error recur in future admission notes because the next doctor carries it forward in his/her dictation (or god-forbid, copy-pastes the damn thing in the EMR.)

I'm tending to agree with hippiedoc, though. What you've got in the eval are two pretty specific reports of "psychosis", one of which is a little over- dramatic and vivid, and draws on media imagery that many reasonable people might find disturbing, and the other could be described as a hypnogogic or hypnopompic phenomenon. The remainder of the interview might have displayed a linear, logical thought process and normal insight, leading to the conclusion that the patient was not psychotic.

The lack of documentation of the patient's past hx of violence to self and others is rather more egregious, given that past behavior is the best predictor of future risk in such folks... We'll be interested in hearing what the outcome of the meeting was.

 

[loveoforganic]

Just to be clear, the history of violence, self-harm, suicidal ideation, etc. was documented. The patient just wasn't declared as a danger to self or others.

I'm not in a position where I can bring it up, but the person over me gave me the impression she planned to, so I'll let you know the result assuming it does get brought up.

 

[whopper]

In addition to the above (poor history taking), the person could've presented differently. I have had psychotic patients momentarily hold it together.

It could also be a case of a malingerer. Just because the person claims to be psychotic, doesn't mean they truly are. I have written for example on people I suspected on malignering something to the effect of..."despite that the patient claims to have auditory hallucinations, I see no objective symptoms of psychosis other than the patient's complaints of auditory hallucinations. I do not see any of the several other symptoms that are associated with schizophrenia, bipolar or the other disorders where psychosis can present."

 

[loveoforganic]

She was transferred to another unit, into a separate group's affairs in which I have no connections, so sorry for the lack of update, but don't think it's going to happen.