What do you tell patients who ask you not to put something in the chart?

[Trismegistus4]

Today I saw, in follow-up, a woman with trichotillomania. This was the 3rd or 4th time I've seen her; she'd previously seen another psychiatrist at another location in our organization for a year or two but transferred for convenience's sake. On initial eval, she told me she engages in hair-pulling about once a week. She wears a wig and has no eyebrows.

One of the things she asked of me today was not to put trichotillomania down as a diagnosis. She said this was because she still knows some nurses in the ER (she used to be one, before becoming "disabled") and is worried that if she ever goes to the ER or has any other reason for anyone in the organization to look in her chart, they will see it and start gossiping about her, saying "remember Jane who used to work here, who wore a wig? She pulls all her hair out!" She said the previous psychiatrist stopped putting down "trichotillomania" and used "obsessive compulsive disorder" instead at her request.

Another related phenomenon I'm sure we've all experienced, which to me feels slightly different, is when a patient asks you not to document something they've told you in the narrative of the note. E.g., "oh, can you please not put down that my stepfather molested me, because my daughter comes with me to my oncology appointments and I wouldn't want her to look over at the doctors' screen and see that."

I have to admit, this kind of thing makes me yearn for the days of paternalism, when we could just say "I'm the doctor" and do it anyway. I mean, this woman is wearing a wig and has no eyebrows. She has trichotillomania. It belongs in the chart. What does everyone do in these situations?

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[wolfvgang22]

I take it case by case. The two cases you mentioned seem to have pretty good reasons to protect privacy and they have some insight. I think the key is to facilitate the recovery process while being as honest as possible.

 

[hamstergang]

I agree it's case by case. If details don't need to be included I'll stay vague. But some things need to be written down, and if a patient doesn't like it then they have to seek care elsewhere.

With the trauma, you can stay vague and just say that the patient discussed a trauma from the past. The specifics don't need to be in the chart.

However, I would not be able to put a diagnosis other than trich in that case. Your notes have to be evaluating the symptoms of the diagnosis. You need to justify the diagnosis.

 

[Crayola227]

I was taught a totally different school of thought on this in med school.

One, not sure why you put "disabled" the way you did. There's probably a more appropriate way to address that particular issue.

Trichotillomania, if I'm not incorrect, is considered in the umbrella of anxiety disorders, specifically obsessive compulsive?

Those problem lists are jacked up, there's a real issue with how they're done and what they add to meaningful documentation. It's been argued that the problem lists in EHRs, as opposed to within a given note, up until recently weren't even a thing in classic documentation. Not that documentation isn't something that has changed or improved with time. Just that I argue that it hasn't been an essential aspect for many years, and it might not be that essential now in some ways.

The goal of documentation is ALWAYS patient care first and foremost. There's a medicolegal aspect, sure.

If you or this other psychiatrist die, and someone else has to pick up the patient's care going off notes alone, if the problem list does not say trichotillomania, and they must go off the rest of the notes, how difficult would it be with basic chart review for them to see this?

This comes up ALL the time - psych notes are held in more confidentiality than other types of notes, so if you go to the ED, they have to break the glass or whatever. HOWEVER, these potentially problematic lists are a way that psych info, that may have NO bearing on the rest of someone's care, act as a "leak." Don't get me wrong - care of the whole patient, if you've got psych meds on a patient's med list, there should be some dx to go with that for other providers.

Screw paternalism. Therapeutic alliance, patient autonomy, right to privacy. We seem to think these notes are only for us. They're not. They need to be written like an attorney will read it, a jury will read it, YOUR PATIENT will read it, your dead patient's family will read it, your colleagues will read it, and after you die, the next person who assumes care and can't call you.

That doesn't mean you aren't honest, and that you don't document what needs to be said, and things people are going to find difficult to see said about themselves. However, I was taught for all notes, especially psych notes, you actually do your best not to document more than what is necessary, as difficult to judge as that might be.

I was taught to respect all patient requests to leave information out of the chart, where that would be ethical to do so. I've seen this negotiated between provider and patient. It's a big deal for the therapeutic alliance. It's part of the oath about keeping the secrets entrusted to us - it's OK for us to have conversations "off the record." The record was never meant to take away from what is told us in confidence. The record facilitates communication for care of the patient (sadly part of which is billing, malpractice, legal aspects), but it doesn't take the place of it, and where possible we should seek to minimize how much it gets in the way of it.

If a patient has a sexual assault that they don't wish the details in the chart, and they won't talk to me about it otherwise, or what will I document - I tell them the focus of the visit is to discuss how the trauma affected them, and that I will ask questions or document what allows me do risk management for harms that affect treatment for the patient, such as STD testing. I bring up where I am a mandatory reporter. Besides that, I don't really need to put more in the chart about the patient's private experience. I kinda feel it's inappropriate for me to document that which the patient wouldn't have told me otherwise, unless there's a clear medical or legal reason to do so.

To me, your post reads like a countertransference issue, or some other personal feelings, maybe frustration, and certainly bring up paternalism in this fashion right there tells me there may be a power dynamic going on somewhere.

 

[Crayola227]

as for what you call this, it gets into the sections where you put a diagnosis, versus what is on the active problem list. You can list diagnoses, assess, and bill, and it doesn't have to go on the active problems list.

One will argue this is an active problem, and I'm frankly too tired to explain why ongoing chronic diagnoses like CHF or depression don't go on the active problems list, nor do resolved ones like broken toe.

 

[Crayola227]

given how notes are written and billed, I've absolutely seen individual notes be rather specific, but the chart overview sections be a bit more vague, and I don't think that's inappropriate at all.

I would just see a psychiatrist that wasn't more rigid than necessary in documentation and understand the discretion that does indeed ethically exist in where you list certain things.

 

[Sushirolls]

Being vague on the abuse history documentation is okay, details of that is best for outpatient or better yet therapy notes, unless for a mandatory reporter population than better document in detail.

Patient makes the request to not document, or gives a preamble pre-conditioned request to divulge if not documented - don't bite. State you can't make any promises, and remind of the HIPPA fail safes inherent in the health care system. In summary you document it. Insurance contracts and CMS are riddled with fraud language. Documenting a diagnosis that isn't the diagnosis is tantamount to fraud. Having any documented cases of dishonesty with insurance, charting, etc can be career ending. In psychiatry which has civil inpatient/outpatient commitments, this could be easily brought up by patient's counsel and now your ability to be an expert testimony is gone. Don't fudge the diagnoses because you were asked.

A medical person who is concerned about others seeing/reading and gossiping will essentially have a fantastic HIPPA violation case if their fears materialized. They also have the ability for EMRs like Epic to request to see the chart audit of who all clicked on their chart. As some hinted at above there is some flexibility in where you document, so could avoid putting it in the problem list area and keep only in the actual chart note, reducing its ability to carry thru for all future encounters.

If pt expresses fear of child reading it on the screen, then encourage patient to contain the child (i.e. be a parent), encourage patient to discuss with provider if unable to contain child to keep screens more hidden, or don't bring the child to the medical appointment. These are things the patient has in their control.

The manner of problem lists and how the larger EMRs carry them thru and the divisions of psych / addiction notes from the rest of the general medical chart are a failing of the EMR and health system. This system failure does not warrant you to fail in maintaining your documentation integrity.

Having moments in one's career where people pick over a note for whatever reason, patient request, quality assurance, billing utilization review, etc. are fantastic ways to reinforce the need to document, document well and not fudge things. This patient may have a disability review in the future, and when the reviewers get all the medical records, they note where's the trichotilomania? Disability denied? Patient comes after you after the fact for such poor documentation.

 

[OldPsychDoc]

..
If pt expresses fear of child reading it on the screen, then encourage patient to contain the child (i.e. be a parent), encourage patient to discuss with provider if unable to contain child to keep screens more hidden, or don't bring the child to the medical appointment. These are things the patient has in their control.
.

I presumed this was an adult daughter assisting with transport & communication for the appointment. Rather different dynamic than you are implying in terms of "containment".

 

[hallowmann]

Personally I'd stay vague with the abuse history and I'd list the trichotillomania in the note, but not on the "Problem List" of the chart/patient summary. The truth is that if someone goes into your psych note to find the trichotillomania, that's a bigger issue in terms of HIPAA than anything else. That said, you don't have to make it easy for anyone caring for the patient to see it on their problem list every time they open the chart.

For all the statements of the legality of documentation and billing, I think this is an issue of doing what's best for the patient and for long-term care. Your note is what's important, and its also the thing that will be billed upon. It should have the accurate diagnosis and treatment. I don't particularly care for the problem lists unless its a chronic condition. Being vague is something that seasoned docs do in medical records as it is for the sake of brevity, so I don't see what the big deal is with being vague about the trauma for the sake of the patient.

 

[HIPAAHasOneP]

Patients ought to be able to decide who can access their medical records. It's a shame that hospitals (thanks to HIPAA and the HITECH Act) have taken that right away from patients. Regardless of how patients feel about it, hospitals now decide for us that everyone in the system gets access. I had to change to a dermatologist outside of a hospital system in order to keep my urogynecology records from ending up at the dermatologist, and everyone else I saw in that hospital system. The dermatologist doesn't even need or care about those records. These big hospital systems are sharing everything just for the hell of it. It's ridiculous...not to mention unethical. With the exception of duty to report, patients ought to be able to decide who gets access to their medical records. If hospitals respected the patient's right to privacy and allowed her to restrict the record to her psychiatrist, then she wouldn't have to worry about what diagnosis was documented.

I miss the olden days when we could talk to our physicians in confidence and not have to wonder if the information would end up in an HIE, if the physician is using an EMR that is selling our data, all the data mining going on, and who all gets access to it. Now, every time I open my mouth I have to wonder where the information going to end up. I guarantee you more and more people are withholding information from their physicians because of the way our medical information is being handled today. I was talking to co-workers at the hospital where I work, and every person present said they withhold information because of EMRs.

 

[thepoopologist]

"Namaste"

 

[calvnandhobbs68]

Another related phenomenon I'm sure we've all experienced, which to me feels slightly different, is when a patient asks you not to document something they've told you in the narrative of the note. E.g., "oh, can you please not put down that my stepfather molested me, because my daughter comes with me to my oncology appointments and I wouldn't want her to look over at the doctors' screen and see that."

Why would your detailed psychiatric note be showing up on screen during a patient visit during the oncology appointment would be a better question...hopefully the oncologist knows better than to open psych notes in front of family members. Although in this case it's relatively easy to just put something about complex trauma due to a family member in the notes and leave out the details.

 

[michaelrack]

I have to admit, this kind of thing makes me yearn for the days of paternalism, when we could just say "I'm the doctor" and do it anyway. /QUOTE]

Now you can say, " I am a doctor licensed in the state of X and a Medicare provider, and also a participating member in your insurance plan". "I have certain obligations to the state, to the federal governmment, and to your insurance plan, sorry"