Tips to avoid stigmatizing language

[theadvocate]

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Hello, everyone. I was wondering what tips everyone had on replacing some of the more stigmatizing language that we can sometimes use in psychiatry. I'm in my ED rotation and the way we're trained to document our encounters relies heavily on negative language. For example, "patient is demanding, manipulative," or "history of multiple ED visits" preceding "malingering with secondary gain of shelter." Assuming it's clinically relevant to document that the patient is "manipulative," is there a better way to document that, such that it's more reflective of the patient's needs? In general, what are some more neutral ways that we can describe our patients, especially in the ED? Thank you.

 

[calvnandhobbs68]

Document as if your patient could read the entire note. Because they can. I'm not sure where this is that they're teaching you to document this way but you're gonna get burned in a bad way once a patient actually reads their note.

I mean you can document something like a frequent flyer who seems to be malingering pretty easily off the top of my head....
"EMR indicates multiple prior ED encounters/inpatient admissions for similar symptoms previously which tended to resolve quickly upon admission and did not seem dependent on therapeutic inpatient environment or medication management. Repeated inpatient admissions do not seem to be therapeutic at this point and unlikely to be best long term solution to maintain patient stability outpatient. Previous documentation recommending continued contact with social work to get connected with long term housing/employment/mental health support has not been followed up on. Will continue to encourage patient to utilize appropriate outpatient resources but does not meet criteria for inpatient admission at this time."

 

[Monocles]

The tricky part of language is that it changes very quickly, and normative nomenclature tend to change overtime. I think generally being around peers can be helpful in learning what's "kosher". For instance when I was a med student it used to be "non-compliant", now the preferred term is "non-adherent to med regimen" etc. "Homeless" has become "undomiciled" etc. I don't think anyone is documenting maliciously. We are all humans and it takes time to adjust and learn.

 

[Ironspy]

Document exactly what they are doing without labeling motive

Examples
Patient is manipulative: patient is reporting that they are acutely suicidal but asking for derm consult to evaluate 5 year old rash on arm

Demanding: pt requested warm lunch, declined available options of yogurt, crackers, cheese sandwich, ham sandwich, apple.

Secondary gain/manipulation : pt does not meet inpatient psych criteria but reporting that they do not want to return to shelter and do not have a place to stay. Now reporting that they will not be safe if they leave hospital

No compliant: pt does not take meds bc she hates the taste/hates the color/hates how they make her feel

 

[annoyedpsychiatrist]

Patient: "If you discharge me without a place to stay im going to kill myself"

Documentation: "Patient states that he will kill himself if he is discharged from the hospital without shelter. Of note, patient did present to the ER voluntarily, and had no shelter at that point. Despite this, he made no effort to harm himself in the immediate events leading up to his presentation for SI, and calmly sat down in the ER waiting room, waiting to be called. Given that his current SI is based solely upon his ability to obtain housing (and upon revaluation he further substantiates this), it appears unlikely that admitting the patient to an inpatient unit is going to offer the patient any acute stabilization, however we agreed to have a social worker in the ER speak with the patient and help get them connected to resources, and establish an outpatient psychiatry appointment, along with appropriate resources if suicidal thoughts were to substantially worsen"

Patient is manipulative translates to "Patient is fixated on one particular interest of obtaining shelter, as he frequently focuses on this during the interview rather than other subjects such as means suicidality, depressive sx, etc"

Patient is malingering translates to "Patients presentation today is similar to prior presentations in which the patient was discharged, despite having the same/similiar chief complaint multiple times, without acute issue"

 

[TheRightMedication]

With the word malingering, specifically, you had better be prepared to document enough to demonstrate that. Malingering is basically a crime, and patients can come after you for that accusation. At the VA I was told to basically never say malingering unless I'm so convicted I would and could defend the dx.

I see no reason to use the word "malingering" when you could just stick to the facts as you observe them and proceed with your assessment and plan as the above posters have outlined.

You can discharge high risk patients just fine without any speculation as to their internal motivation.

 

[Merovinge]

Document exactly what they are doing without labeling motive

Examples
Patient is manipulative: patient is reporting that they are acutely suicidal but asking for derm consult to evaluate 5 year old rash on arm

Demanding: pt requested warm lunch, declined available options of yogurt, crackers, cheese sandwich, ham sandwich, apple.

Secondary gain/manipulation : pt does not meet inpatient psych criteria but reporting that they do not want to return to shelter and do not have a place to stay. Now reporting that they will not be safe if they leave hospital

No compliant: pt does not take meds bc she hates the taste/hates the color/hates how they make her feel

These are great examples.

The big picture is document what is objectively happening with as little interpretation as possible, use quotes when appropriate (I would expect in these ED cases there would be a 1-5 times I would quote the patient on average). In assessment, you can draw upon what medical chart shows plus current presentation. Only time to discuss malingering is if you are quoting a patient who actually states they are malingering (this shockingly happens not that infrequently).

 

[Stagg737]

I work mainly in the ER and agree 1000% with Ironspy. It's okay to use "harsh" language in a note and it's sometimes necessary to convey what actually happened during those encounters, but you need to be able to justify in your documentation why you're saying that. There's nothing wrong with saying something like "history of multiple ER visits" if it's relevant to the situation and imo that doesn't have an automatic negative connotation like some other language like "patient is demanding and manipulative". If the patient really is demanding and manipulative, you can still write that but you need to be thorough with examples like Ironspy gave.

These are great examples.

The big picture is document what is objectively happening with as little interpretation as possible, use quotes when appropriate (I would expect in these ED cases there would be a 1-5 times I would quote the patient on average). In assessment, you can draw upon what medical chart shows plus current presentation. Only time to discuss malingering is if you are quoting a patient who actually states they are malingering (this shockingly happens not that infrequently).

Mostly agree, but after a certain number of encounters, I don't think you have to wait for a patient to explicitly state they're malingering to say they're malingering, as there are times when you wouldn't really have justification to discharge them from an ER otherwise. I do try and avoid make hard statements with malingering and try to phrase it as "concerns of malingering" or something along those lines if I can unless it's necessary.

The tricky part of language is that it changes very quickly, and normative nomenclature tend to change overtime. I think generally being around peers can be helpful in learning what's "kosher". For instance when I was a med student it used to be "non-compliant", now the preferred term is "non-adherent to med regimen" etc. "Homeless" has become "undomiciled" etc. I don't think anyone is documenting maliciously. We are all humans and it takes time to adjust and learn.

Yes, language is important, but I don't think it's reasonable to expect people to use terms just to be politically correct or "inoffensive" just because some patients want that, and I'd imagine a large number of my patients would probably be more offended/confused if I wrote "undomiciled" instead of just homeless. I do agree that some terms (like non-compliant) should be used more judiciously though. In the non-compliant example, I only write non-compliant without further explanation if the patient refuses to take meds that they're required (usually legally) to take as "non-adherent" is both more accurate in most cases and has less negative connotations than the concept of "compliance".

 

[G Sheb]

Eh.. I use 'secondary gain', 'chronic personality features'..etc all the time.
You should be able to provide an assessment of a patient's behavior and their motives. Not sure I agree with a bit of paranoia of being chased by a patient for this. The key thing is to make sure you have ample evidence to justify your assessment...' pt with 20+ visits to ER in the last 3 months in similar circumstances'..etc.
Do we really care if malingering patients are offended by this? The point is that you want to justify your reasoning if it comes to a court of law. And it would actually make sense to stack the documentation in your favor.
'manipulative' is not a word I would use, because frankly it's not accurate to start with.

 

[comp1]

There's a lot of great advice here. I greatly prefer patient quotes to paraphrasing whenever possible. If you can't quote, then do at least paraphrase instead of describing more generally what the interaction was. Concur with limiting the use of the term malingering. I generally limit that to inpatient admissions where I have time to have psychologists complete psychometric assessments and I can tie their results concretely to some sort of sought secondary gain. That said, you can and should always have it in your differential for every patient. We don't have lab results or imaging to refute or support whatever the patient is saying, we have to go by our own observations. I haven't written "non-compliant" since med school. It's very much out of fashion and definitely agree with the term non-adherent. I'm sure there will be a new one in 20 years. However, all of this has to be balanced with ultimately getting across the point of what happened and what is needed. We have to examine and reduce our own biases where possible. If a patient meets criteria for borderline personality disorder, that should be documented and the supporting evidence should be documented. We should not worry about labels in those cases. Similarly, if you have good supporting evidence for factitious disorder, lay it out. You can also get across the same points by using language in different, more subtle ways. For example, don't describe the patient "as demanding," that's kind of weirdly reductive. You're sort of describing a person as a list of demands. Instead, say that the patient demanded new housing or they would kill themselves. This gets the same point across without being reductive. It's also more accurate. I've never seen a psychiatrist use the adjective manipulative. That's a ED MD term. If you MUST, then use it as a verb and be extremely particular about how and what they are manipulating. But in general, just don't. There are better ways to explain it.

 

[Stagg737]

We have to examine and reduce our own biases where possible. If a patient meets criteria for borderline personality disorder, that should be documented and the supporting evidence should be documented. We should not worry about labels in those cases.

Eh, I'd disagree a bit here. We should examine and reduce our biases, but many other staff don't and that can interfere with diagnosis and treatment of other legitimate issues a patient may come in for. Unless a patient is telling me they have that diagnosis or there's documentation of it elsewhere, I'm not going to throw a PD into their problem list during an ER encounter. However, I do frequently document personality features/traits in my notes when they're present so I or others can reassess later and get a better understanding of what I was seeing. If it's features I'll say what I think is causing them to present this way (PTSD/other psych exacerbation, substances, major social stressor, etc) and will sometimes identify the specific trait if it's obvious. It's also a billable code (F54: Personality traits or coping skills affecting medical condition) if it is interfering with care, so full PD diagnosis isn't necessary from a billing perspective.

 

[comp1]

The above post was actually what I was talking about with the stigma that we as practitioners attach to personality disorders. I see a lot of practitioners who don't feel comfortable with diagnosing personality disorders in a single encounter. I disagree with this practice and am concerned it really does further the stigma of personality disorders in general. If you collect an appropriate history from a patient, or even better, have access to and deeply review extensive historical charting, you can diagnose a personality disorder no matter how many encounters you have had with the patient. The above poster's restriction, which isn't present or recommended anywhere in the DSM, does a disservice to patients in general because if we select out that group of disorders as things that require a higher bar to diagnose, then patients with personality disorders are ultimately going to be mislabeled with something that we have arbitrarily determined not to need that higher bar, such as bipolar disorder and then they'll be on the harmful medication merry-go-round. Maybe the poster won't do this, but at least one provider in the future isn't going to read through the lines of the personality traits in the assessment of their note. There's nothing special or magical about personality disorders. We even got rid of the whole axis system to more clearly demonstrate this. They're actually a heck of a lot more common than most (not all) primary mood, anxiety or psychotic disorders.

 

[calvnandhobbs68]

The above post was actually what I was talking about with the stigma that we as practitioners attach to personality disorders. I see a lot of practitioners who don't feel comfortable with diagnosing personality disorders in a single encounter. I disagree with this practice and am concerned it really does further the stigma of personality disorders in general. If you collect an appropriate history from a patient, or even better, have access to and deeply review extensive historical charting, you can diagnose a personality disorder no matter how many encounters you have had with the patient. The above poster's restriction, which isn't present or recommended anywhere in the DSM, does a disservice to patients in general because if we select out that group of disorders as things that require a higher bar to diagnose, then patients with personality disorders are ultimately going to be mislabeled with something that we have arbitrarily determined not to need that higher bar, such as bipolar disorder and then they'll be on the harmful medication merry-go-round. Maybe the poster won't do this, but at least one provider in the future isn't going to read through the lines of the personality traits in the assessment of their note. There's nothing special or magical about personality disorders. We even got rid of the whole axis system to more clearly demonstrate this. They're actually a heck of a lot more common than most (not all) primary mood, anxiety or psychotic disorders.

I'm actually concerned you're taking more of the nursing approach to "personality disorders" if you're diagnosing them "in a single encounter" and not understanding what they actually are if you're definitively diagnosing a bunch of people in the ER with a personality disorder of some kind.

Take a look at paragraph one in the DSM 5 personality disorder chapter:
"A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individuals culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment"

Also from DSM:
"Although a single interview with the individual is sometimes sufficient for making the diagnosis, it is often necessary to conduct more than one interview and to space these over time"

So yes, there is a higher bar to diagnose a personality disorder with some confidence rather than say MDD, which just requires a cluster of specific symptoms for 2 weeks.

 

[Shikima]

I like stigmatizing language. It's clear and concise. If your feelings are hurt from language as a professional, might be a warning sign for something bigger that needs to be addressed.

 

[randomdoc1]

Or you can document as if you are talking to the patient. Similar to what has already been said. I feel like in psychiatry, we learn a 3rd language after learning the medical jargon. It's an art to be able to communicate information delicately to a patient that also gets the point across in a way that they will feel motivated to continue to engage in treatment. This includes explaining borderline personality disorder and discussing things like benzos. So the patient is demanding benzos, but opening the discussion to what is the underlying root of all this and wouldn't it make much more sense to address the roots than throw pills at symptoms.

 

[Stagg737]

The above post was actually what I was talking about with the stigma that we as practitioners attach to personality disorders. I see a lot of practitioners who don't feel comfortable with diagnosing personality disorders in a single encounter. I disagree with this practice and am concerned it really does further the stigma of personality disorders in general. If you collect an appropriate history from a patient, or even better, have access to and deeply review extensive historical charting, you can diagnose a personality disorder no matter how many encounters you have had with the patient. The above poster's restriction, which isn't present or recommended anywhere in the DSM, does a disservice to patients in general because if we select out that group of disorders as things that require a higher bar to diagnose, then patients with personality disorders are ultimately going to be mislabeled with something that we have arbitrarily determined not to need that higher bar, such as bipolar disorder and then they'll be on the harmful medication merry-go-round. Maybe the poster won't do this, but at least one provider in the future isn't going to read through the lines of the personality traits in the assessment of their note. There's nothing special or magical about personality disorders. We even got rid of the whole axis system to more clearly demonstrate this. They're actually a heck of a lot more common than most (not all) primary mood, anxiety or psychotic disorders.

The biggest reason, imo, not to diagnose a personality disorder with a single ER encounter is because you have no idea what this patient's actual baseline or life is like. You can look at their behavior, but behavior over a couple of hours in an ER setting is not reflective of the person. You can take their word for it that they're answering everything honestly, but patients lie. Or have very poor insight. Or are just completely oblivious to their actual personality/situation. You can use screening tools, but they suck. The Zanarini and other screening tools for PD aren't worth using, even the Zanarini scale acknowledges it in the publications about it (requires hitting at least 7 criteria instead of just 5 because of poor specificity). Thinking you can diagnose a PD based on a single encounter with no collateral or ongoing observation is ignorant at best and dangerous at worst. Inpatient hospitalization is different, and I do think that you can glean more over the course of several days of monitoring and gathering collateral than in a 60 minute (or less) encounter.

I say this as someone whose primary area of interest (including fairly extensive ongoing research) is personality disorders and their nosological basis. If you know the research, PDs are some of the most poorly distinguished "disorders" we have, so much so that ICD-11 completely tossed them out as diagnoses and replaced them with a general "personality disorder" diagnosis with trait and domain specifiers. The DSM almost did the same thing in their most recent revision, and the next DSM will almost certainly scrap the current diagnostic model and replace it with the dimensional model; the AMPD actually has different criteria for BPD than the current dimensional model in which you can diagnose BPD 256 different ways, some of which look like completely different disorders., and completely scrapped some other PDs because the basis for their existence at all as unique diagnostic entities is poor (paranoid, schizoid, histrionic, and dependent were completely scrapped). I also say this as someone who spends a fair amount of time educating patients about what personality traits/disorders are and why they are important to address.

To the bolded, why would me saying "personality trait" instead of slapping on a disorder based on a blip in their existence cause someone else to diagnose them with something requiring "a lower bar"? I'm not diagnosing them with another disorder like bipolar or psychotic disorders unless I'm convinced they have them, so why would someone else diagnose that based on my note? Me changing my diagnosis from "borderline features/traits, r/o BPD" to BPD is not going to protect the patient from some other crappy provider throwing on an inappropriate diagnosis and I don't see how that's even relevant if they're not going to read the note. I can see them, not diagnose a hard PD, and still recommend their treatment address those traits and not just slam them with antipsychotics and mood stabilizers. If anything, you're doing them a disservice by labeling them with a longitudinal diagnosis based on a single, brief encounter which may impact how everyone else who reads their chart treats the patient.

My assessment is not about personal stigma, I diagnose patients with PDs or harmful traits when others are hesitant to all the time. My argument is about providing accurate and effective diagnosis and treatment for the setting you're practicing in, and the role of setting is something that too many physicians seem to poorly understand. An ER encounter without extensive collateral or documented history is not the appropriate place to diagnose PDs, or many other disorders for that matter, and doing so is akin to giving an ADHD diagnosis after a 20 minute eval. Be better than that.

/rant

 

[justalittlestar]

Hello, everyone. I was wondering what tips everyone had on replacing some of the more stigmatizing language that we can sometimes use in psychiatry. I'm in my ED rotation and the way we're trained to document our encounters relies heavily on negative language. For example, "patient is demanding, manipulative," or "history of multiple ED visits" preceding "malingering with secondary gain of shelter." Assuming it's clinically relevant to document that the patient is "manipulative," is there a better way to document that, such that it's more reflective of the patient's needs? In general, what are some more neutral ways that we can describe our patients, especially in the ED? Thank you.

I really like the advice of just documenting with more or less with words like @calvnandhobbs68 described.

Can't lie when you made this post I thought for sure you were going to speak about stimatizing language as it pertains to substance use because that seems to be the language I've seen that's most stigmatizing in the ED.

 

[splik]

I do a lot of teaching and consulting on different aspects of clinical documentation and also review lots of records in different contexts (forensic, chart reviews, second opinions etc) and my recommendation is to describe the behavior, statements, delusions etc, rather than abbreviate using short hand. Not just because that language may be pejorative, but also because it is often unhelpful to any future readers.

So rather than "patient is paranoid"it is better to put "patient reported he was being followed, stalked, microchipped"

Rather than patient is "manipulative" it is better to put "patient stated if discharge he would write in his suicide note how unhelpful I had been and that I would still be alive if I had admitted him" or "patient threatened to sue if not provided with a private room" etc. Using quotations from patient is golden, hard to object to, and livens up the notes.

I do not recommend using the term "malingering" unless you are 100% certain. Even as a forensic psychiatrist, I do not often use the term malingering. Instead, I might put something like "patient did not appear to be accurately reporting psychiatric symptoms given inconsistencies between subject reports and objective finding on MSE, inconsistent contradictory statements made, contradictory collateral, behavior when he did not think he was being observed, and record review noting a history of feigning psychiatric symptoms."

If you think the patient is faking it - feigning is better than malingering which implies you know why they are feigning (which you may or may not).

I think it is okay to report that they have a "history of multiple ED visits". The term "frequent flier" is not recommended, and "high utilizer of services" is also not recommended. Some people use the term "familiar face" but honestly, that seems a bit ridiculous to me. I would usually put "patient is well known to me and my team".

While in medicine we tend to use shorthand, sometimes it is much better to just document what the patient said or did rather than try to summarize it into a pithy and likely disparaging epithet. Much harder for the patient to be offended or argue with a dispassionate account of what transcribed in the clinical encounter. Finally, remember you cannot please everyone all of the time. We still need to be honest in our documentation, even if patients are unhappy about it.

 

[clausewitz2]

I do a lot of teaching and consulting on different aspects of clinical documentation and also review lots of records in different contexts (forensic, chart reviews, second opinions etc) and my recommendation is to describe the behavior, statements, delusions etc, rather than abbreviate using short hand. Not just because that language may be pejorative, but also because it is often unhelpful to any future readers.

So rather than "patient is paranoid"it is better to put "patient reported he was being followed, stalked, microchipped"

Rather than patient is "manipulative" it is better to put "patient stated if discharge he would write in his suicide note how unhelpful I had been and that I would still be alive if I had admitted him" or "patient threatened to sue if not provided with a private room" etc. Using quotations from patient is golden, hard to object to, and livens up the notes.

I do not recommend using the term "malingering" unless you are 100% certain. Even as a forensic psychiatrist, I do not often use the term malingering. Instead, I might put something like "patient did not appear to be accurately reporting psychiatric symptoms given inconsistencies between subject reports and objective finding on MSE, inconsistent contradictory statements made, contradictory collateral, behavior when he did not think he was being observed, and record review noting a history of feigning psychiatric symptoms."

If you think the patient is faking it - feigning is better than malingering which implies you know why they are feigning (which you may or may not).

I think it is okay to report that they have a "history of multiple ED visits". The term "frequent flier" is not recommended, and "high utilizer of services" is also not recommended. Some people use the term "familiar face" but honestly, that seems a bit ridiculous to me. I would usually put "patient is well known to me and my team".

While in medicine we tend to use shorthand, sometimes it is much better to just document what the patient said or did rather than try to summarize it into a pithy and likely disparaging epithet. Much harder for the patient to be offended or argue with a dispassionate account of what transcribed in the clinical encounter. Finally, remember you cannot please everyone all of the time. We still need to be honest in our documentation, even if patients are unhappy about it.

This so much, describe the observable behavior, save the shorthand for your assessment section. Don't tell me they're delusionally grandiose. Tell me 'Patient reports they are unable to afford a bus pass. They also report that they made $17 million posting their rap videos on YouTube. Patient does not attempt to reconcile these statements.'

 

[G Sheb]

This so much, describe the observable behavior, save the shorthand for your assessment section. Don't tell me they're delusionally grandiose. Tell me 'Patient reports they are unable to afford a bus pass. They also report that they made $17 million posting their rap videos on YouTube. Patient does not attempt to reconcile these statements.'

Right, but you should write 'paranoid' and 'grandiose' delusions in the assessment section. If we can't put a label on what we consider pathological, then it's a big problem. I hope we don't get there.
One of the biggest pet peeves of mine is doing this in the HPI. This is where you describe what the patient is reporting.
The MSE is what you're observing.
If I'm cosigning note, I write 'paranoid' or whatever, and I explain what are the paranoid behaviors/thoughts.

I don't use 'malingering' either, not because it will make someone upset though, but one should always give the patient the benefit of the doubt. If something happens and it seems like you didn't believe a word of what the patient says, it is not a good look.
'secondary gain' assumes a more subconscious process. Throwing it at the end of the differential is a *wink wink* for whoever is reading the chart, even if it's not 100% accurate (a lot of the time it's fully conscious).

This is different from outpatient providers, but fear of offending patients reading their charts in the ER is frankly one of the least of my concerns. Most of the patients are not there because they want to, and a few times you'd have to call security to get the malingerers out, LOL.

 

[psychmd03]

Eh.. I use 'secondary gain', 'chronic personality features'..etc all the time.
You should be able to provide an assessment of a patient's behavior and their motives. Not sure I agree with a bit of paranoia of being chased by a patient for this. The key thing is to make sure you have ample evidence to justify your assessment...' pt with 20+ visits to ER in the last 3 months in similar circumstances'..etc.
Do we really care if malingering patients are offended by this? The point is that you want to justify your reasoning if it comes to a court of law. And it would actually make sense to stack the documentation in your favor.
'manipulative' is not a word I would use, because frankly it's not accurate to start with.

Right, but you should write 'paranoid' and 'grandiose' delusions in the assessment section. If we can't put a label on what we consider pathological, then it's a big problem. I hope we don't get there.
One of the biggest pet peeves of mine is doing this in the HPI. This is where you describe what the patient is reporting.
The MSE is what you're observing.
If I'm cosigning note, I write 'paranoid' or whatever, and I explain what are the paranoid behaviors/thoughts.

I don't use 'malingering' either, not because it will make someone upset though, but one should always give the patient the benefit of the doubt. If something happens and it seems like you didn't believe a word of what the patient says, it is not a good look.
'secondary gain' assumes a more subconscious process. Throwing it at the end of the differential is a *wink wink* for whoever is reading the chart, even if it's not 100% accurate (a lot of the time it's fully conscious).

This is different from outpatient providers, but fear of offending patients reading their charts in the ER is frankly one of the least of my concerns. Most of the patients are not there because they want to, and a few times you'd have to call security to get the malingerers out, LOL.

Agreed alot with the points that it is going way too far to start avoiding using paranoid and grandiose. That just doesn't make sense those are not derogatory or punitive. Those are accurate descriptors. Also if a patient is malingering personally I do not mind if they were to read my note and see that I said that. I will document malingering "said I will kill myself if I do not get xanax" Then it is quite justified and defined. But I am not going to be spending my time thinking hmmmm what would my patient think if they read this, I am thinking I am going to use clinically descriptive documentation that will support my plan and decisions so that I can get my patients the IP coverage from insurance and cover my ass for liability. I am not going to document 5 extra sentences to assuage someone from being hurt by their own clinical presentation. Also you can choose to block patients from seeing your notes on the MyCharts.

 

[docksan]

The above post was actually what I was talking about with the stigma that we as practitioners attach to personality disorders. I see a lot of practitioners who don't feel comfortable with diagnosing personality disorders in a single encounter. I disagree with this practice and am concerned it really does further the stigma of personality disorders in general. If you collect an appropriate history from a patient, or even better, have access to and deeply review extensive historical charting, you can diagnose a personality disorder no matter how many encounters you have had with the patient. The above poster's restriction, which isn't present or recommended anywhere in the DSM, does a disservice to patients in general because if we select out that group of disorders as things that require a higher bar to diagnose, then patients with personality disorders are ultimately going to be mislabeled with something that we have arbitrarily determined not to need that higher bar, such as bipolar disorder and then they'll be on the harmful medication merry-go-round. Maybe the poster won't do this, but at least one provider in the future isn't going to read through the lines of the personality traits in the assessment of their note. There's nothing special or magical about personality disorders. We even got rid of the whole axis system to more clearly demonstrate this. They're actually a heck of a lot more common than most (not all) primary mood, anxiety or psychotic disorders.

I wholeheartedly disagree with your approach and don't think at all that you can diagnose a personality disorder just by reading someone else's notes.

I use chart data to know the situation and past history, but my personal interactions, testing how the patient thinks and responds, all assist better with diagnosing personalities than pretending I've known the patient my whole life because someone documented "patient manipulative and has a 9/9 Zanarini and stuff".

 

[hamstergang]

Also you can choose to block patients from seeing your notes on the MyCharts.

But doing so would either take the patient's consent or some indication of significant risk of harm to them reading the note. Making patients uncomfortable with the language we use does not reach that threshold and would not qualify as a legal reason to block the note.

 

[G Sheb]

But doing so would either take the patient's consent or some indication of significant risk of harm to them reading the note. Making patients uncomfortable with the language we use does not reach that threshold and would not qualify as a legal reason to block the note.

Not really.
If you feel the care of the patient will be compromised by automatically sharing notes, you ARE justified in blocking access.
You are actually not 'taking away their consent'. They can still request the records from medical records; they just can't have access to it in real time.
In one of the hospital systems I work at (top 25), sharing notes is automatically blocked for inpatient care and CL. You have to allow it for this to happen.

I imagine many will be 'offended' by 'delusions'. It's actually really ridiculous to stop calling delusions 'delusions' because it's stigmatizing. Like, what do you write in the MSE? There is just no better clinical term that captures what is happening. By this logic, we will have one language for health care providers, and another for patients. I think this is hypocritical and don't think it is helpful for patient care.

 

[calvnandhobbs68]

Not really.
If you feel the care of the patient will be compromised by automatically sharing notes, you ARE justified in blocking access.
You are actually not 'taking away their consent'. They can still request the records from medical records; they just can't have access to it in real time.
In one of the hospital systems I work at (top 25), sharing notes is automatically blocked for inpatient care and CL. You have to allow it for this to happen.

I imagine many will be 'offended' by 'delusions'. It's actually really ridiculous to stop calling delusions 'delusions' because it's stigmatizing. Like, what do you write in the MSE? There is just no better clinical term that captures what is happening. By this logic, we will have one language for health care providers, and another for patients. I think this is hypocritical and don't think it is helpful for patient care.

You're correct in that the regulations don't require information to be PUSHED to the patient (ie alerting them they have a new note and can read it right away the way a lot of EMRs defaulted to), they just require the patient to be able to PULL that information very easily (need to be able to access it within 24hrs of request if I remember correctly). This doesn't equate to BLOCKING access though, you cannot block the access to pull records without significant specific justification, see here:

https://www.healthit.gov/sites/default/files/2022-07/InformationBlockingExceptions.pdf

 

[G Sheb]

You're correct in that the regulations don't require information to be PUSHED to the patient (ie alerting them they have a new note and can read it right away the way a lot of EMRs defaulted to), they just require the patient to be able to PULL that information very easily (need to be able to access it within 24hrs of request if I remember correctly). This doesn't equate to BLOCKING access though, you cannot block the access to pull records without significant specific justification, see here:

https://www.healthit.gov/sites/default/files/2022-07/InformationBlockingExceptions.pdf

Right, but frankly there's a lot of jargon in that document. It's very open to interpretation and someone needs to call up a lawyer. Whether we call this 'blocking' or not I guess depends on how you define the term in a specific context.

I can tell you how these 'rules' are interpreted institutionally.
See for example, Columbia:

https://www.hipaa.cuimc.columbia.edu/file/1396/download?token=Dam_3wDu

The policy actually is NOT to automatically release notes for patients in the psychiatry department.
They also give a case example of when you are justified for not releasing the note.
i.e someone who came with a history of violence (or HI, or anything that can be interpreted as harm).
This probably will apply to a huge chunk of patients in the ER.

 

[calvnandhobbs68]

Right, but frankly there's a lot of jargon in that document. It's very open to interpretation and someone needs to call up a lawyer. Whether we call this 'blocking' or not I guess depends on how you define the term in a specific context.

I can tell you how these 'rules' are interpreted institutionally.
See for example, Columbia:

https://www.hipaa.cuimc.columbia.edu/file/1396/download?token=Dam_3wDu

The policy actually is NOT to automatically release notes for patients in the psychiatry department.
They also give a case example of when you are justified for not releasing the note.
i.e someone who came with a history of violence (or HI, or anything that can be interpreted as harm).
This probably will apply to a huge chunk of patients in the ER.

Correct, that's what I said to begin with. The notes still have to be released if the patients request them. Again, it's the difference between pushing the information to the patient vs the patient pulling information. Lack of push does not equal ability to block in most cases.

See Slide 38 "What if a patient or proxy asks for notes or results are not automatically released to Connect?"-> "These requests must be honored. Direct the patient to Health Information Management (HIM) using the contact info below, or refer them to the Medical Record Request Form on Connect."

 

[Merovinge]

Correct, that's what I said to begin with. The notes still have to be released if the patients request them. Again, it's the difference between pushing the information to the patient vs the patient pulling information. Lack of push does not equal ability to block in most cases.

See Slide 38 "What if a patient or proxy asks for notes or results are not automatically released to Connect?"-> "These requests must be honored. Direct the patient to Health Information Management (HIM) using the contact info below, or refer them to the Medical Record Request Form on Connect."

It says on that slide "assuming no substantial risk of patient harm". I think the question is if there is substantial risk of patient harm what happens then? I don't see a follow-up for that in the slides.

 

[calvnandhobbs68]

It says on that slide "assuming no substantial risk of patient harm". I think the question is if there is substantial risk of patient harm what happens then? I don't see a follow-up for that in the slides.

You can block the note release in that case. "Substantial risk of patient harm" is unlikely to include not releasing notes because you called a patient "malingering" in them or something.

 

[comp1]

You could make the argument that a patient with a substantial risk of harm has that potential harm significantly increased by releasing a chart with the term malingering all over it... My bet is that a judge is going to side with the doctor's expert opinion on this matter.

 

[calvnandhobbs68]

You could make the argument that a patient with a substantial risk of harm has that potential harm significantly increased by releasing a chart with the term malingering all over it... My bet is that a judge is going to side with the doctor's expert opinion on this matter.

You do realize that you're literally saying that the patient doesn't have a substantial risk of harm to themselves if you're stating that they're "malingering" right?

I mean maybe you could argue if a person has a history of actual violence there's an increased risk of harm to YOU for saying they're malingering. There's no "judge" either for this, it likely would be a complaint to HHS for information blocking.

 

[comp1]

I can see where the confusion would arise, but people can be malingering about things other than harm to others, but then have a risk to others (eg me, my staff, the building) when they read information supporting a malingering diagnosis. In terms of self harm, this is trickier, but it's not horribly uncommon for a patient to not actually want to die, but instead to perform a risky physical act as a demonstration if/when they don't feel their self report is being accepted as completely accurate such as when reading their chart. We can never be sure that something like this will happen, but we can often be sure that releasing such records would increase the risk. The poster above is right about this going to HHS. I just looked up their guidelines on information blocking. At most, they can "disincentivize" the healthcare provider if they decline to release the records inappropriately. There are as of yet no current rules about what would be an inappropriate decision about risk to self or others that the healthcare provider made, or who exactly, if anyone, would overrule the original healthcare provider. (Believe me, they'll still be able to find you liable if you released the records knowing said records could pose an increased risk of harm and that harm occurred). They don't even know yet what disincentivization would involve if HHS did ultimately disagree with the provider. Maybe Medicare funding pulled? There are states that have much clearer processes. California, for example, requires a mental health provider to release the records to another licensed mental health provider of the patient's choosing if the original provider felt they would be a harm to someone to directly release it to the patient. This seems like a reasonable balance as it would then shift the burden onto this new provider in terms of safety if they elected to disclose the information the original provider felt may be harmful.

 

[G Sheb]

I think this discussion is a bit superfluous.
Would you really worry all the time about patients reading their charts if they don't get real time access to their notes automatically? Because that's STILL the standard policy at many institutions.
They would have go to through the process to request access to the chart, and you can technically 'block' them if you believe there's a risk to harm themselves or others. I imagine you'd have reasonable belief of such for anyone with history of harm to self and others or even threatening behavior, especially when there's compromising information in the chart, including calling them a 'malingerer'. It's ultimately how you think they would interpret what you write.

This is really a non-issue in the ER.
Like, worry first how not to get punched by said malingerer while you are talking to them.

 

[Stagg737]

Not really.
If you feel the care of the patient will be compromised by automatically sharing notes, you ARE justified in blocking access.
You are actually not 'taking away their consent'. They can still request the records from medical records; they just can't have access to it in real time.
In one of the hospital systems I work at (top 25), sharing notes is automatically blocked for inpatient care and CL. You have to allow it for this to happen.

I imagine many will be 'offended' by 'delusions'. It's actually really ridiculous to stop calling delusions 'delusions' because it's stigmatizing. Like, what do you write in the MSE? There is just no better clinical term that captures what is happening. By this logic, we will have one language for health care providers, and another for patients. I think this is hypocritical and don't think it is helpful for patient care.

I feel like there should be a standard regarding inpatient mental health and accessing records while still in the hospital. I've had patients access their notes while they were still admitted and it ended up prolonging their admission for various reasons, including patients requiring care suddenly demanding to leave and then having to be placed on an involuntary hold.

 

[calvnandhobbs68]

I feel like there should be a standard regarding inpatient mental health and accessing records while still in the hospital. I've had patients access their notes while they were still admitted and it ended up prolonging their for various reasons, including patients requiring care suddenly demanding to leave and then having to be placed on an involuntary hold.

Oh sure absolutely, this applies to all fields. Theres tons of stories about people finding out devastating diagnoses from their radiology report that gets pushed to their app automatically while they're still in the hospital even before their team has had a chance to review it or people going wild over the fact that EPIC is flagging their sodium of 134 as "out of range".

I'm absolutely not in support of open notes, I think it's pretty ridiculous they're as open as they are right now.

 

[psychmd03]

You can block the note release in that case. "Substantial risk of patient harm" is unlikely to include not releasing notes because you called a patient "malingering" in them or something.

This is literally built into the EMR I use at one hospital I click it every single note and say could cause to patient or others. Patients do not get access they have to go through a normal request. I’ve had a few families that were reading the notes of all providers during the stay except mine. I have no issue blocking immediate access for each note every day

 

[Candidate2017]

So rather than "patient is paranoid"it is better to put "patient reported he was being followed, stalked, microchipped"

Some seemingly paranoid patients are actually telling the truth. I've had some patients tracked by Apple air tags by their ex, followed by federal agents, etc. I've also run across manic patients whose stories about their many accomplishments and wealth, etc. are 100% true (e.g., "I invented... after finishing my pro athlete career.., then became the CEO of... and blew millions on Picassos... etc).

 

[hamstergang]

This is literally built into the EMR I use at one hospital I click it every single note and say could cause to patient or others. Patients do not get access they have to go through a normal request. I’ve had a few families that were reading the notes of all providers during the stay except mine. I have no issue blocking immediate access for each note every day

You do you, but I feel your practice is in violation of the ruling. Firstly, the harm must be "Danger to life or physical safety of the patient or another person" or "Substantial harm to such other person" as per Frequently Asked Questions | HealthIT.gov
It's very unlikely that you are writing things in all or even most of your notes rising to this level.

Secondly, the blocking must be no broader than necessary. That is, even if there is something harmful in your note, that doesn't allow you to block your entire note. You should only be blocking the harmful part (I do this by writing 2 notes on the encounter when necessary).

 

[G Sheb]

You do you, but I feel your practice is in violation of the ruling. Firstly, the harm must be "Danger to life or physical safety of the patient or another person" or "Substantial harm to such other person" as per Frequently Asked Questions | HealthIT.gov
It's very unlikely that you are writing things in all or even most of your notes rising to this level.

Secondly, the blocking must be no broader than necessary. That is, even if there is something harmful in your note, that doesn't allow you to block your entire note. You should only be blocking the harmful part (I do this by writing 2 notes on the encounter when necessary).

I think you're misinterpreting a couple of things here.

See:

Keep in mind, physicians are not required to proactively make data available to patients who have not requested it. But, once a patient requests their EHI, a delay in the release or availability of EHI, may be considered an interference under the information blocking regulation.

New Information Blocking Rules

Physicians are now required to share electronic patient records and other information. Learn more today.

www.facs.org

The Cures Act is essentially tied to patient requesting the information. It is not synonymous with open notes i.e notes being immediately available for patients once they are signed.

Making the note unavailable for immediate reading does not constitute 'blocking' (as the word is defined).
It also seems that the only onus on the physician is if they act unreasonably to block the information.

There's a lot of legal mumbo jumbo here, and you need a lawyer to parse through these things. But you are not required to make notes available for patients without their explicit request to see the notes. So I don't think clicking the button 'don't share the note' violates anything since sharing in the first place is you being proactive.


----

IMO, I agree with others that while a lot of this was well intentioned and empowers patients, it was hastily implemented without much thought. Fact is, part of the 'beast' is that we cannot be entirely forthcoming with patients in psychiatry on what's going on. I cannot tell a patient 'your MSE is that you are disorganized, have poor insight and your thought content has delusions'.
In 90% of the cases it is a non-issue. If you have a patient who is requesting to see their notes every other day, then you deal with it however you need to deal with it.

 

[hamstergang]

I think you're misinterpreting a couple of things here.

See:

Keep in mind, physicians are not required to proactively make data available to patients who have not requested it. But, once a patient requests their EHI, a delay in the release or availability of EHI, may be considered an interference under the information blocking regulation.

New Information Blocking Rules

Physicians are now required to share electronic patient records and other information. Learn more today.

www.facs.org

The Cures Act is essentially tied to patient requesting the information. It is not synonymous with open notes i.e notes being immediately available for patients once they are signed.

Making the note unavailable for immediate reading does not constitute 'blocking' (as the word is defined).
It also seems that the only onus on the physician is if they act unreasonably to block the information.

There's a lot of legal mumbo jumbo here, and you need a lawyer to parse through these things. But you are not required to make notes available for patients without their explicit request to see the notes. So I don't think clicking the button 'don't share the note' violates anything since sharing in the first place is you being proactive.

While I'm not a lawyer, I was with some on my hospital's committee to figure out how we were going to implement procedures in compliance with this. I spent plenty of time reading and arguing the legal intricacies involved.

While you are correct that the law does not require pushing notes to patients automatically, I was not making that mistake. The other poster stated that he would click a button to block the note and cite patient harm as the reason. By invoking one of the specified exceptions, the hospital is clearly referencing this law.

Also, there's no way that if you block a note from being pushed to a patient and cite patient harm as the reason, and then the patient asks medical records for that note, that they will give it to them. Medical records people would have to reach out to you to see if it's still harmful. At my hospital, if I felt it was safe I'd have to explicitly unblock the note so it's not still labeled as harmful. So labeling a note as too harmful to send to the patient would result in delays should they request the note.

 

[clausewitz2]

This is literally built into the EMR I use at one hospital I click it every single note and say could cause to patient or others. Patients do not get access they have to go through a normal request. I’ve had a few families that were reading the notes of all providers during the stay except mine. I have no issue blocking immediate access for each note every day

The Cures ACT gave hospital systems a longer deadline for implementing rapid patient access to electronic medical records. You may not retain this ability to block things across the board.

 

[psychmd03]

The Cures ACT gave hospital systems a longer deadline for implementing rapid patient access to electronic medical records. You may not retain this ability to block things across the board.

Actually all psychiatric notes were blocked automatically while everyone else had to make three clicks to do it. Then Jan this year psych lost the automatic block and also had to make 3 clicks to block. So unless they plan on a further step back it doesn’t seem that way

 

[clausewitz2]

Actually all psychiatric notes were blocked automatically while everyone else had to make three clicks to do it. Then Jan this year psych lost the automatic block and also had to make 3 clicks to block. So unless they plan on a further step back it doesn’t seem that way

The CURES Act specifies that blocking release of a patient's own notes to them due to concern for harm requires significant danger to the life or physical safety of the patient or another person. This is the standard. Are you really able to justify that if you just click to block for every note?

 

[WisNeuro]

The CURES Act specifies that blocking release of a patient's own notes to them due to concern for harm requires significant danger to the life or physical safety of the patient or another person. This is the standard. Are you really able to justify that if you just click to block for every note?

In the rare case anything went to a legal setting, I doubt it very much. Best defense would be to just feign laziness or ignorance, which may actually be the truth here.

 

[G Sheb]

The CURES Act specifies that blocking release of a patient's own notes to them due to concern for harm requires significant danger to the life or physical safety of the patient or another person. This is the standard. Are you really able to justify that if you just click to block for every note?

This is misleading again.

'blocking' exists only after a patient's explicit request to see the note. The Cures act does not mandate 'open notes' i/e making notes available in real time.
If you chose not to automatically share notes, that is not 'blocking'.
This is essentially what psychmd03 is doing, he is not automatically sharing notes with patients. That is not violating the Cures act and it is the standard procedure at many hospitals.

 

[clausewitz2]

This is misleading again.

'blocking' exists only after a patient's explicit request to see the note. The Cures act does not mandate 'open notes' i/e making notes available in real time.
If you chose not to automatically share notes, that is not 'blocking'.
This is essentially what psychmd03 is doing, he is not automatically sharing notes with patients. That is not violating the Cures act and it is the standard procedure at many hospitals.

Nope, it improves a positive obligation on all healthcare providers to give patients access to all health information in their medical records (all note types and more) without delay. Blocking is doing anything that "is likely to interfere with the access, exchange, or use of electronic health information." If you put it in the medical record and it is their health information, they are supposed to be able to access it more or less tout suite. It doesn't mean you have to push everything to the patient but if they want to see it you cannot throw up any obstacles unless you are covered by the explicitly delineated exceptions.

I would strongly suggest reading the provisions of this act again.

 

[G Sheb]

Nope, it improves a positive obligation on all healthcare providers to give patients access to all health information in their medical records (all note types and more) without delay. Blocking is doing anything that "is likely to interfere with the access, exchange, or use of electronic health information." If you put it in the medical record and it is their health information, they are supposed to be able to access it more or less tout suite. It doesn't mean you have to push everything to the patient but if they want to see it you cannot throw up any obstacles unless you are covered by the explicitly delineated exceptions.

I would strongly suggest reading the provisions of this act again.

You're wrong.
This only applies after a patient makes a request to see the notes.
I'm done with this. Please do your research.

 

[clausewitz2]

I was literally quoting from the text of the act.

Y'all reading this thread can read it, and healthit.gov's resources about it, and the AMA's lengthy guide to the Cures Act, and come to your own conclusions.

 

[G Sheb]

I was literally quoting from the text of the act.

Y'all reading this thread can read it, and healthit.gov's resources about it, and the AMA's lengthy guide to the Cures Act, and come to your own conclusions.

But you're not a lawyer.
There are tons of intricacies involved in how this is implemented in the real world.
If Montefiore and Columbia do not immediately share notes with their patients in the psychiatry department, are you saying they are violating the CURES act?
My guess is that they consulted with top notch lawyers and know what they are doing.

 

[clausewitz2]

Can't resist, from the healthit.gov FAQs:

"
It would likely be considered an interference for purposes of information blocking if a health care provider established an organizational policy that, for example, imposed delays on the release of lab results for any period of time in order to allow an ordering clinician to review the results or in order to personally inform the patient of the results before a patient can electronically access such results (see also 85 FR 25842 specifying that such a practice does not qualify for the “Preventing Harm” Exception).

To further illustrate, it also would likely be considered an interference:

• where a delay in providing access, exchange, or use occurs after a patient logs in to a patient portal to access EHI that a health care provider has (including, for example, lab results) and such EHI is not available—for any period of time—through the portal.
• where a delay occurs in providing a patient’s EHI via an API to an app that the patient has authorized to receive their EHI."

What I am saying is that if you are declining to share notes with patients, the law lays out 8 exceptions, only a few of which are relevant to us as doctors. By clicking to not share them, you are asserting that they fall under these exceptions. I would not be surprised if some tedious mandatory training that was required sometime last year officially informed you of the standard (although obviously everyone just plows through these as quickly as possible). then, if it turns out later you can't justify doing it, it's not on the institution.