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The patient denies...

Discussion in 'Medical Students - MD' started by DragonWell, Feb 25, 2007.

  1. DragonWell

    Moderator Emeritus 10+ Year Member

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    "The patient denies..."

    I remember being surprised the first time I saw this phrase on a medical chart; it seemed to allude to a frank suspicion that everything the patient said either was, or very well could be, a lie. In spite of these adversarial connotations, emulating what I have read and heard, I now use this phrase in every case I present.

    This afternoon, reading Sapira, I found a stronger indictment against this phrase: she makes the point that to deny something implies it must be true, and for the doctor to state what the patient denies, implies that the doctor knows what is true and what is not. Also, if the patient has forgotten or doesn't know a piece of information, their negative response is not really a denial. Finally, patients might well get pissed when they see the phrase in their chart and take it as an implication that the doctor thinks they are lying.

    Any thoughts? Anybody use different phrasing than "the patient denies..."?
     
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  2. Law2Doc

    Law2Doc 5K+ Member
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    While psychologists use "denial" as a term that implies the truth, the word deny in other contexts (and the primary dictionary definition) simply means to declare something untrue. In law you can file documents denying assertions and that certainly doesn't mean they are really true. So this "stronger indictment" is just an argument based on bad semantics - this is at best a secondary usage of the word deny. That being said, patients have been known to lie about certain things, especially illegal activities, diet and habits.
     
  3. soonereng

    soonereng Double Trouble
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    I think that you are confusing denying something versus being in denial about something. For someone to deny something doesn't mean that the something is true.

    Now don't take this the wrong way, but if I were to ask you if your post was evidence of your innate stupidity, you would probably say no. You would deny that you are stupid. This doesn't mean that you truly are stupid.

    Similarly, one asks a patient: "Have you had a runny nose?" and when they say no, they are denying that they have had a runny nose; hence: "Patient denies rhinorrhea."

    Edit: Law2Doc beat me to the punch
     
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  4. Tired

    Tired Fading away
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    In addition to the above, it also serves as documentation that you actually asked the patient about the symptom or situation that they did not experience.

    Here's how it was explained to me:

    For example, the first time you get sued for Failure to Diagnose a SAH, and you document "The patient has not had a headache," their attorney will stand up and make a big point about how the patient actually DID have a headache, you just never asked about it. And from you documentation, it admittedly is not clear that you did. You may have simply assumed the patient had not been experiencing a headache.

    However, if you write, "The patient denies having a headache," you can successfully argue that, according to your documentation, you did in fact ask if the patient had a headache and they said no.
     
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  5. OP
    OP
    DragonWell

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    Why not just say "the patient notes no headache, drug use, alcohol use, etc" ?

    Doesn't this serve the same purpose of noting pertinent negatives and covering your a$$ legally without making it sound like the patient is lying? Maybe it is just semantics, but by influencing attitudes semantics can be important.

    Or am I just missing the point that "deny" serves a pointed purpose of reminding us that we should regard everything patients tell us with suspicion?
     
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  6. lord_jeebus

    lord_jeebus 和魂洋才
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    "Notes no" is not a direct action. Perhaps you didn't ask, or the patient was silent or unintelligible when you did.

    "Denies" is more specific. The patient specifically and directly stated that something wasn't present.
     
  7. Tired

    Tired Fading away
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    I don't think using "deny" serves the purpose you mention, I suspect it's mostly just that we learn to write notes by looking at other people's notes, and the phrasing is very common. At least that's why I continue to use "deny" without a second thought. Your phrasing makes intuitive sense to me too, however, and I can't see why anyone would object to it.
     
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  8. OncoCaP

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    Sounds like you are going to have a lot of fun with medical expressions and terminology. Deny is just the term that is used in that context. You could probably go back and study the history of that usage if you would like to. I get the impression that Tired gave you the reasoning (evidently legal in origin and then copied). It's also quicker/shorter to state 'patient denies' than 'patient said s/he did not have'. Maybe using 'note' is not as clear as deny (I don't think it is anyway). The term 'deny' is consistently used that way in medical records and it's probably not going to change anytime soon. There are all kinds of interesting legal expressions and terms that are somewhat (or a lot) different from what they mean in everyday usage.

    Here is a legal definition for 'bet'. (http://thelanguageguy.blogspot.com/2005/05/why-is-legal-language-impenetrable.html)

    "Bet" means the hazarding of anything of value upon the result of an event, undertaking, or contingency, but does not include a bona fide business risk.

    ... not exactly the way the average person on the street would say it (and if you gave the definition without the term few people would know that you are talking about 'bet') ....
     
  9. OP
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    DragonWell

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    Yeah, I guess I will continue to use "deny" since it's the standard, it just bothers me a bit because in my mind it is not a neutral term. I'm sure I will get over it...

    It would make more sense to me to reserve the term "denies" to connote information from a patient whose honesty you found questionable, and to use a more neutral term for patients whose information you had no reason to doubt. I guess I'll probably learn to suspect everyone sooner or later, though. :scared:

    Appreciate everybody's thoughts.
     
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  10. OncoCaP

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    Oh, I see what you mean. Deny contradicts something but doesn't establish (prove) a fact necessarily. For example, it doesn't establish that the patient does not have ______. It simply states that the patient said that they do not have one. This is more accurate because you are recording what the patient said rather than somehow proving that it is true. Maybe in 99% of the cases patients will tell you a fact when they state that they have no headache, but that 1% could burn you (patient didn't think it was important or did not want to bring it up, etc.). It's a cover your tail kind of thing I guess.
     
  11. akpete

    akpete Drinks, anyone?
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    I hate to say it, but you're thinking too hard. :)
     
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  12. OP
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    DragonWell

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    How does one contradict a yes or no question?

    In order to contradict in your example, wouldn't the physician have to say "You have a headache." to which the patient would respond, "No, I don't have a headache.", thus contradicting the physician's statement?
     
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  13. enanareina

    enanareina small but scrappy
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    I understand why the word "deny" might have a somewhat negative connotation. I continue to use it, however, for this reason: when I write "patient denies headache" or "patient denies using cocaine" I'm documenting a subjective finding, a question that I asked the patient. I may or may not believe them (which I think is your issue with the use of the word) but I'm reporting what they said. I don't see a real difference with "the patient notes no", but I think deny is a pretty accurate description.

    Besides, how many times does the social history say "patient denies illicit drugs" and then in the labs section the UDS is positive for cocaine, benzos, and thc? The best you can do is document what the patient said to you, whether you believe it or not, and then fill in the gaps with objective findings.

    Maybe I'm actually proving your point, since apparently I don't trust patients.
     
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  14. OncoCaP

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    Gah. You're too quick. I edited my post after I thought about it more. After thinking about it more, it looks like a way of protecting the physician against unusual situations (not always unusual) where the patient would say something that isn't true. Covering your tail is important too. No sense in sticking your neck out or to be overly trusting. This is also common in legal contracts. A legal contract spells out things even if the two parties trust each other completely. The language is there just in case something goes wrong; it doesn't mean we necessarily distrust everyone (but we don't always know who we can trust).
     
  15. OP
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    DragonWell

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    Yeah, very true. Maybe the adversarial connotation is right on the money. Damn lawyers (sorry law2doc)!
     
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  16. OncoCaP

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    Actually lawyers are your (well-paid) friends ... YOUR lawyers anyway. It's the "other guys/gals" lawyers that might not be :laugh: . Seriously though, most lawyers I have met are very honorable people. Jokes aside, many of them serve an important purpose and work hard to resolve difficult situations in an ethical and legal way. Having excellent attorneys can mean the difference between no trouble and hell.

    When you are dealing with the public, you don't control who you get. You deal with whoever is in front of you and that requires prudent care. You lock your doors, right? You don't leave your cash lying around in public places, correct? Does this mean you distrust everyone? No. It's the few that you cannot and should not trust that you are guarding your property against.
     
  17. Law2Doc

    Law2Doc 5K+ Member
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    While I'm sure it has some CYA purposes, I see no real problem with writing patient "states that he didn't..." as opposed to "denies", from a legal standpoint, if it makes you happier. As a prior poster indicated, that is a lot more wordy, but if it makes you happy, go for it. ("Notes" is not the same thing -- you need to make clear for the record that you were told definitively/unambiguously).
     
  18. AmoryBlaine

    AmoryBlaine the last tycoon
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    "Denies" is useful b/c many pts are not trustworthy in their story. This isn't a complaint or an insult, we all are. It is a really good idea to cover your arse with the word denies. That way when the consultant's ROS reveals that the pt did have a HA you can make the point that they didn't when you talked to them.

    It's so frustrating as a 3rd year to do an H/P, present the pt, and then have them change their story when they talk to the resident.

    FWIW someone was whining to me about how nasty it is that we use "Subjective," b/c it implies that everything the pt tells us is suspect. Sheesh.
     
  19. 8744

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    It alludes to it because patients do lie, all the time.

    "Patient denies illicit drug use" followed by a positive urine drug screen for cocaine metabolites.

    At Duke, they don't say "The patient complains of fever," they say, "The patient endorses fever."

    Political correctness gone horribly wrong.
     
  20. pillowhead

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    I have also had attendings and residents in internal medicine who told me not to use that term because of exactly what the OP says--it implies supsicion of your patients. If you're relying on "patient denies headache" instead of "patient has no headache" for you medicolegal defense, I don't think it's going to do much for you. The only rotation I used that word was psychiatry because with frankly psychotic patients, you cannot rely on their history and they deny stuff that's true all the time with the history changing from hour to hour. With non-psychotic patients, you've got to just put faith in what they say (even if you do think they're lying. chances are they know they're lying and they're not going to change their story significantly over one day.) of course, we've all had the experience where the story changes once the attending goes in the room, but that's life and the atttendings know stuff like that happens. just don't make stuff up--if s/he asks you something about the patient and you forgot to ask, just say so. so much better than getting caugt in a lie.

    oh, i've also heard that lawyers will tear people apart for using deny because it implies a poor patient-doctor relationship which we all know is one of the major indicators of whether or not a lawsuit will win against a physician.
     
  21. 8744

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    Gosh. This is a stupid thread and I am mortified that I have posted on it.
     
  22. Critical Mass

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    Same thing as "patient complains of." "Patient denies" is a short way of writing/saying that you asked, and he/she said no. It's really just a semantic way to quickly state that you're ass is covered.
     
  23. OncoCaP

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    PB denies hi IQ of "deny" thread. PB endorses mortal terror of posting on "deny" thread. :laugh: :laugh:
     
  24. asunshine

    asunshine can't sing but i got soul
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    How many times has a stoic elderly man "denied" chest pain? It happens all the time--a battered woman denying abuse, a kid denying SOB because they don't want to go through another test. It's not just the criminals or the liars that deny symptoms. Of course a good clinician would further question those patients, but if they say no, you have to document it as such and rely on other data for your diagnosis.
     

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