Report Writing Dragon/Auto Correct Awesomeness

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So there are "dragonisms" for people who use Dragon software to transcribe, though since I don't currently use it, I simply have auto-correct awesomeness.

Today's…."Necrotizing Fascists" instead of Necrotizing Fasciitis.

LOL at "Necrotizing Fascists"...

Got an image of rotting zombies in SS uniforms doing the 'Heil Hitler' arm motion
 
Report in 45min…I wish!! A straight forward neuropsych is 3-4hr, but those aren't the kind of cases I get here. :laugh: I usually double that time once I do a full med chart review, check out any outside imaging/documents, etc.
 
That makes sense for a memory disorder eval.

With my TBI evals I usually do 1hr interview, 1-2hr chart review, 5hr-7hr testing (psychometrician), 2hr scoring, and 5-7hr report writing. Every once in awhile I can get by with 3-4hr of testing and a briefer report, but those aren't the types of cases that tend to come my way.
 
That makes sense for a memory disorder eval.

With my TBI evals I usually do 1hr interview, 1-2hr chart review, 5hr-7hr testing (psychometrician), 2hr scoring, and 5-7hr report writing. Every once in awhile I can get by with 3-4hr of testing and a briefer report, but those aren't the types of cases that tend to come my way.

I know that this is a very general question but in your experience (and to your knowledge) are there specific profiles in terms of neuropsychological deficits (and neurobehavioral symptoms) that are each more indicative of PTSD/mood disorders vs. indicative/attributable to mTBI (emphasis on the m)? Are these roughly detectable clinically (i.e., without specific neuropsych testing, simply relying on reported symptoms and observed signs)? I am not a neuropsychologist and the vast majority of folks I see in an OEF/OIF context have not had neuropsychological testing but present with diagnoses of PTSD/mood/etc. (psychiatrically) and mTBI. The main thing I look at is how remote (i.e., 2 weeks ago, 3 months ago, 3 years ago, 10 years ago?) was the original incident of head injury. Considering base rates and the research on the trajectory of recovery from mTBI (overwhelming majority experience resolution of symptoms/sequelae within 3-6months?), I consider any anxiety, impulsivity, anger/irritability, insomnia, (reported) concentration problems, etc. to be most likely attributable to the comorbid psychiatric condition(s) and not at all likely attributable to mTBI. Do you or any other neuropsychologists on the board have any suggestions for the generalist clinical psychologist clinician besides what I am doing (essentially, relying on 'base rates' and likely trajectory of recovery over time) to try to tease apart symptoms attributable to mTBI vs. co-morbid psychiatric disorders? Any input would be appreciated as this is such a commonly encountered situation in clinical practice in the VA.
 
5-7 hours of report writing?! How long are those reports?

As to profiles of mood disorders vs mTBI. After several months (that is being liberal, most people should recover in weeks), there are no legitimate measurable deficits in the vast majority of people, for either condition. Usually the attributable symptoms are from a variety of possible etiologies. Post-deployment adjustment, underlying mood disorder, low effort for a variety of reasons, or somaticizing presentation. Relying on self-report is not adequate at the moment. Symptoms of post-concussion are vague and non-specific. There is plenty of research showing that at any given time, healthy controls will endorse significant amounts of "PCS" (e.g., poor sleep, poor concentration, occasion headache, etc).

You could give the MMPI-IIRF to maybe tease apart some of the psychiatric stuff. Depression vs anxiety vs somatoform profile, or a combination. Psychoeducation is also important here. Too much bad science out there suggesting to people that if they have had a concussion or two they are damaged for life and will develop dementia at 40. Thanks Boston. Despite the psychoeducation, you'll get a lot of pushback from some people. Some people would rather be brain damaged than depressed or anxious.

Unfortunately, the VA has been both good and bad in how they treat mTBI. At an individual level, I have worked with great people who have tried to treat the underlying psych problems. But, at the institutional level, the VA system continues to perpetuate an implication that mTBI is a longstanding condition in a majority of people who have experienced a concussion. The iatrogenic effects are profound in some.
 
Thanks WisNeuro...I too wish that the VA policies/practices/culture could be more influenced by science, logic, and evidence rather than politics, emotion, and laziness (intellectual and motoric). I guess if we all try to exert influence the best we can within our person spheres of influence it can make a difference.
 
Agreed about the recovery time. Rohling, Larrabee, & Millis wrote a great article in 2012 that is well worth a read: The "Miserable Minority" following mild traumatic brain injury: who are they and do meta-analyses hide them?
 
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RE: Report wring time

I have my initial record review (before pt is interviewed), then I usually get more outside records once I know all of the docs involved, as my typical patient has been to a few other specialists (neurologist, neuro surg, physiatrist, etc) before getting to me. It'd be nice if they were all in our system, but I get cases from all over the place, so there are more records out there. As a result, a second review is done while writing.

As for report length, 6-8 pages...which includes a letter w. executive summary and 1.5-2.0 pages of detailed recommendations. I also include a summary chart of data (for the providers who prefer one). I have built a great referral base of providers because I am thorough in my assessments and provide the information that they want and in the format they want.

I do mostly Worker's Comp cases, take a handful of private insurances, see a few Medicare cases, and have a growing cash pay base. I negotiate my hours up front, and if the payor doesn't like them, I decline to take the case. I've seen 30-40% differences in rates for private insurances (and 50-60%+ less for budget/medicaid-like plans), so I dropped/declined to join any panel who tried to squeeze me. I'm about to drop off another panel bc of intrusive pre-auth requirements. I rarely have patients from them, so it is an easy decision.

There is far more demand out there, so I can be selective in who I see. I'd rather get paid a fair fee and do pro-Bono work on my terms, as opposed to trying to do volume that includes cases w 30-40% less in payment and not be able to afford taking pro-Bono cases.
 
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So there are "dragonisms" for people who use Dragon software to transcribe, though since I don't currently use it, I simply have auto-correct awesomeness.

Today's…."Necrotizing Fascists" instead of Necrotizing Fasciitis.

Caught in editing a few weeks ago- a Dragon dictated report indicated that the client was "climbing all over the cheerleaders in the testing room."

Client was a 20-month-old who was climbing on the CHAIRS. Working almost exclusively with kids under 3, there's a lot of fun stuff in my office. Alas, no cheerleaders (though they may be an effective stimulus for spontaneous initiation of joint attention- as it is the remote controlled cat doesn't always do the trick).
 
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