Ugh Notes...

[penandpaper]

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So I have a pt who has both narcissistic and aspd traits, depression super responsive to maoi. So pt has been gaming clinic x20 yrs, saying anytime an employee fired him/her, a short term disability letter was immediately provided for "treatment resistant depression."

I said go ahead and apply but my letter will reflect my own assessment of how well you were doing. Pt then said he/she would write a letter on his/her own behalf and have me sign"to save time"...I declined such an offer...

Recently left me a msg saying not sure if applying for short-term disability or not, already got certification for a job, but wants all my progress notes and a "registered" letter identifying him/her as my pt so he/she can get "a misplaced social security card back." Im on the fence . Wondering if pt can write a letter using my letterhead while manipulating my notes or some other bs? Can I just give a summary of my notes and send directly to SS?

I find it odd that a person would allegedly lose their social security card and need a psychiatrist to write them a letter identifying him/her as a pt and outlining their diagnosis in order to get their card back after the psychiatrist refused to sign a disability letter he/she wanted to write for him or herself. Am I being cynical?

This person has done other questionable things, i.e. claim pharmacy lost controlled substances in mail multiple times (though tracking confirmed delivery), asking for a disability bus pass while owning and operating a car, living outside the zip code area that this clinic is intended to serve, and so on...

 

[shan564]

I've had to replace a lost social security card before, and it's actually a surprisingly straightforward and efficient process.

 

[penandpaper]

What about for someone who offered to write their own disability letter for you to sign and then allegedly lost their soc sec card after you declined to do so? Something makes me uncomfortable given that history. Plus, there are fingerprints the county has on record for pt- ie other ways of being identified...

I've had to replace a lost social security card before, and it's actually a surprisingly straightforward and efficient process.

 

[vistaril]

So I have a pt who has both narcissistic and aspd traits, depression super responsive to maoi. So pt has been gaming clinic x20 yrs, saying anytime an employee fired him/her, a short term disability letter was immediately provided for "treatment resistant depression."

I said go ahead and apply but my letter will reflect my own assessment of how well you were doing. Pt then said he/she would write a letter on his/her own behalf and have me sign"to save time"...I declined such an offer...

Recently left me a msg saying not sure if applying for short-term disability or not, already got certification for a job, but wants all my progress notes and a "registered" letter identifying him/her as my pt so he/she can get "a misplaced social security card back." Im on the fence . Wondering if pt can write a letter using my letterhead while manipulating my notes or some other bs? Can I just give a summary of my notes and send directly to SS?

I find it odd that a person would allegedly lose their social security card and need a psychiatrist to write them a letter identifying him/her as a pt and outlining their diagnosis in order to get their card back after the psychiatrist refused to sign a disability letter he/she wanted to write for him or herself. Am I being cynical?

This person has done other questionable things, i.e. claim pharmacy lost controlled substances in mail multiple times (though tracking confirmed delivery), asking for a disability bus pass while owning and operating a car, living outside the zip code area that this clinic is intended to serve, and so on...

ummm....why not just fire the patient? you clearly believe the pt is FOS on a number of fronts....

 

[penandpaper]

Im in a county clinic as a resident. No one fires these folks. In fact the years of this pt being appeased is why I'm facing this problem today...

What about for someone who offered to write their own disability letter for you to sign and then allegedly lost their soc sec card after you declined to do so? Something makes me uncomfortable given that history. Plus, there are fingerprints the county has on record for pt- ie other ways of being identified...

 

[whopper]

As a clinician, you have the right to tell a patient that too many questionable things have occurred.

I wouldn't tell the patient I think they're lying. In fact in doing so, you could be successfully sued. I'm not making this up, in the AAPL forensic psychiatry board review course, Resnick recommends you never make character judgments against a person or write something to the effect of malingering unless your data is rock-solid, e.g. there's psychological testing strongly pointing to that.

What I do in situations like this, and remember, I'm a Suboxone provider who's seen a lot of BS, I tell patients something to the effect of...
"I cannot tell if you are telling me the truth or not. I will not be able to tell because I cannot hire a detective to watch you all the time, but professional guidelines demand that I treat this case as if you are likely not telling me the truth. "

Or in the case of a suspected malinger...
"I cannot tell if this patient is malingering with 100% certainty but given that he shows no signs of mental illness, is drug-seeking for Xanax and a place to sleep for the night, his presentation is consistent with someone who is likely not mentally ill and for that reason I will discharge him from the E.R."

I've gotten replacement SS cards before. I've checked the guidelines. Unless there's anything new, there is nothing that needs the utilization of a physician. This smells of something questionable.

As for progress notes, he is entitlted to receive them since patients have the right to their records (but not psychotherapy notes). But you only have to give him the notes, not something that manipulated the data in your notes.

 

[hamstergang]

Im in a county clinic as a resident. No one fires these folks. In fact the years of this pt being appeased is why I'm facing this problem today...

Are you getting support from your attending?

I have a patient at the VA I don't trust much that is asking me to fill out questionable paperwork that already has the conclusion he wants filled in, and my attending supports me saying no.

 

[Ceke2002]

Tread very carefully, and only give them what they're legally entitled to (or, as you said, see if you can send the notes directly to the Dept in question and by pass the patient completely). I'd make them go through whatever proper channels they have to go through to get the notes as well, because their story sounds like FOS ramped up to Cholera. In my experience on patient orientated boards, when a patient suddenly wants their notes for what sound like BS reasons they are trying to find 'proof' that their Pdoc has been incompetent with a view to launching a complaint. Usually there seems to be a large amount of entitlement and transference involved (you wouldn't give me XYZ, so now I'm going to punish you for it).

 

[penandpaper]

So there are loads of prior notes citing both narcissistic and aspd traits with this case (including my notes). the pt called back today stating he/she is "entitled to the notes" and has "no particular intention, but has had experiences with psychopharmacologists cutting and pasting notes in the past..."

As you said, pt is looking for incompetence and with a lot of transference since I told pt that I didn't think BASED ON MY NOTES AND PRIOR NOTES, that a short-term disability application would be very viable....There was nothing in my work with pt to indicate disability (in fact, pt was managing a large facility up until getting fired due to believing bosses were overworking pt). Finally, pt stated, "Well, actually the letter I want you to write for social security requires you to indicate you are my doctor, what my diagnosis is and it doesn't need to be certified, just leave it for me at the front desk." Um, no... I do think I should contact risk management on this given potential to manipulate letterhead.

My attending basically said just appease pt by applying for short term disability, which pt probably won't get...The issue is, I told pt he/she probably won't get it based on my assessment, and so he/she is upping the ante. The interesting thing is, pt had actually left a previous voice message saying he/she would write his/her own letter for me to sign! I deleted it, but I even had proof of less-than-scrupulous intentions (probably not admissible in court)...

 

[Ceke2002]

I should just clarify that my response was from a patient's point of view. I'm not a medical professional, but I enjoy the privilege of being allowed to frequent these forums, because I find the discussions interesting (plus, as my avatar suggests, I also enjoy the opportunity for learning). I have seen fellow patients behave in the manner I previously described though - 'my Doctor won't do X for me, I'm going to get my notes and prove they're incompetent so I can make a complaint, because I'm just that petty and self absorbed' - which is why what you've been saying has set off alarm bells for me.

Sorry you're being put through this.

So there are loads of prior notes citing both narcissistic and aspd traits with this case (including my notes). the pt called back today stating he/she is "entitled to the notes" and has "no particular intention, but has had experiences with psychopharmacologists cutting and pasting notes in the past..."

As you said, pt is looking for incompetence and with a lot of transference since I told pt that I didn't think BASED ON MY NOTES AND PRIOR NOTES, that a short-term disability application would be very viable....There was nothing in my work with pt to indicate disability (in fact, pt was managing a large facility up until getting fired due to believing bosses were overworking pt). Finally, pt stated, "Well, actually the letter I want you to write for social security requires you to indicate you are my doctor, what my diagnosis is and it doesn't need to be certified, just leave it for me at the front desk." Um, no... I do think I should contact risk management on this given potential to manipulate letterhead.

My attending basically said just appease pt by applying for short term disability, which pt probably won't get...The issue is, I told pt he/she probably won't get it based on my assessment, and so he/she is upping the ante. The interesting thing is, pt had actually left a previous voice message saying he/she would write his/her own letter for me to sign! I deleted it, but I even had proof of less-than-scrupulous intentions (probably not admissible in court)...

 

[splik]

this patient is right, he is entitled to the notes, but you should NOT give them to him. He needs to contact medical records and put a request in to access his notes.

 

[notdeadyet]

this patient is right, he is entitled to the notes, but you should NOT give them to him. He needs to contact medical records and put a request in to access his notes.

He doesn't have the right to them carte blanch.

It may vary by state, but you have the right to withhold and redact given sufficient reason. If there are sections of the chart in which release would be damaging to the patient and the like, you can withhold portions. For instance I had a note that contained collateral that was important for diagnosis and treatment but whose release would have jeopardized the relationship with the only remaining caregiver for the patient, so I withheld this portion.

But in general, splik is right. And the first couple times you review your notes in bulk in preparation for the release to the patient, you really learn something. There is an art in which you can often convey exactly what you think without being so explicit as to damage the patient or your relationship with him later. It's good learning.

 

[penandpaper]

I appreciate everyone's input...I never questioned the right to notes and had heard about witholding exceptions (for example, pt has reported "violent fantasies of retaliation" against people that reported wronged pt, in prior notes). I'm curious to know how to navigate pt intentions, esp given the history of dishonesty. The "letter to social security on letter that I will pick up" allegedly to replace card with, also reeks of something. We should be able to fire pts before they "up the ante"...Pt is going to claim "copy n paste" but luckily varying attg sat in on our 3-4 f/u sessions

this patient is right, he is entitled to the notes, but you should NOT give them to him. He needs to contact medical records and put a request in to access his notes.