Writing "Malingering" in the chart

[cbrons]

Thoughts on this from the medical malpractice insights newsletter?
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"Malingering" or a spinal epidural abscess?

Facts: Immediately after "bucking hay bales," a 34 yo male experiences pain in his neck radiating to his L shoulder. A week later he is worse and presents to the ED with 7/10 pain that is worse with movement and associated with intermittent numbness in his L upper arm and weakness adducting his L shoulder. He reports chills and headache 3 days prior but is afebrile. He denies bladder/bowel symptoms. He is documented to be a "recovering drug addict" (last IVDU > 1 year ago) with a "possible hx of Hep C." The L side of his neck is tender w/ spasm & decreased ROM. Sensation is WNL. Able to walk to DI for C-spine films, which are negative.

He is diagnosed with a cervical strain, discharged with an rx for 30 Norco and told to f/u in 5 days. He returns to the ED 36 hours later by ambulance w/ increased weakness, 10/10 pain, paresthesias, trouble walking and says "I can't move or feel anything." Bowel/bladder function not documented. There is no reference to prior ED visit. A chem 7 is normal; no CBC or ESR is done. The physician documents "Refuses to move, resists movement, complete sensory loss over his entire body" and "presentation is consistent w/ malingering and conversion disorder w/ DSB." Given Narcan w/o effect, said to be "stable" and discharged w/ a dx of "conversion disorder and substance abuse."Nursing note says "MD notified... and states that patient is still to be discharged." [emphasis mine/CP] Required security and 2 person assist for discharge by wheelchair due to inability to walk.

Family takes patient directly to another hospital where he is admitted for a cervical epidural abscess. Chart notes there record IVDU in past week, incontinence of urine earlier same day, hyper-reflexia, clonus, weakness & sensory abnormalities. Immediate surgery is unsuccessful at preventing quadriplegia. The case is referred for expert review.

Plaintiff: You wrote me off as a drug seeker and called me a malingerer. You didn't do a neuro exam. I had problems peeing and you didn't even ask about it. I couldn't walk and you said I was faking it. The nurse didn't think you should send me home, yet you did. If you would have treated me like a human being and not jumped to conclusions I'd be able to walk today.

Defense: You lied about your recent drug use. Your care was reasonable on the first visit. Even if we found the abscess on the second ED visit, it was already too late to prevent permanent disability.

Result: Despite expert review that found negligence on the second visit (and perhaps the first), no case was filed. "Patient factors" and questions about causation both played a role, i.e. if the care on the first ED visit was reasonable, it was nevertheless too late to prevent paralysis at the time of the negligent second visit.

Takeaway: Don't EVER use the words "malingering" or "conversion disorder" in a medical record (unless you are a board certified psychiatrist.) If you write "cervical strain" and you're wrong, that's one thing. If you write "malingering" and you're wrong, you're an arrogant fool on your way to becoming a defendant. Document facts. Do a neuro exam. Explain your medical decision making. [Editor's Note: I hate to keep reporting these cases but they're occurring far too often. Just keep SEA in mind with neck and back pain patients and you'll be fine./CP]

Source: https://madmimi.com/p/5f4487

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[deleted307836]

Malingering and conversion disorder are two very different things, no? While it may seem appropriate at first glance for conversion disorder to be included in the differential, was there a clear attempt at some secondary gain in this case? I don't see it. I've seen malingering used appropriately in charts but only in cases where everything else has clearly been ruled out and there is clear desire for some secondary gain.

 

[RustedFox]

I wrote malingering in a chart just two weeks ago.
I wrote: "Review of records reveals a longstanding history of malingering and abuse of hospital staff, directed at gaining opioids".

 

[Vandalia]

"Just the facts, ma'am."

Risk/reward. If you use "malingering", you had better make absolutely, positively sure that you are completely correct. Not just correct based on the available evidence. Juries absolutely hate that sort of thing if it turns out the patient actually has an injury/illness - even if it is unrelated to the reported symptoms - that is a guaranteed max judgement. As states put restrictions on malpractice, attorneys look for ways to get around them and the caps on damages. Depending on the state, a demonstrably false statement about a patient in the medical record that causes injury to a patient can be classified as libel. A couple of lawyers in different places have tried this, but have usually lost because the statement was an opinion - "drug user" - and/or there was no evidence of actual damage to the patient.

If the patient who you diagnose as "malingering" has a completely undiagnosed/unexpected condition, and another clinician relies on the report of malingering to refuse/delay treatment for that condition, then you open up the possibility of a libel suit. Again, it depends on the state. In some cases, the medical record is considered a privileged communication, in others not, in others it depends if it is relied upon by another person. Since this is not a professional tort, it also would depend on the exact language of your malpractice policy if your defense and any damages are covered. So this is a nasty combination of unsettled law, the possibility of unlimited damages (see Gawker and Hulk Hogan), and the possibility of the defense not being covered by malpractice.

Now, I would say the odds are pretty good that you would be on solid ground on both getting such a suit dismissed, and getting it covered by your malpractice carrier. But, I am not going to risk that when I can say exactly the same thing by reporting objective facts.

 

[bravotwozero]

Writing malingering on the chart seems to have no palpable benefit and increases liability - why take the risk?


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[WilcoWorld]

I will write a chart that details facts, such that anyone reading it can see the malingering from a mile away. I'll also include choice quotes that will help any reader to easily conclude that the person was being a complete a$$hat in the ED.

But I generally avoid the term "malingering". It doesn't really add anything to the chart that isn't already gained by the impression "1 - Neck pain 2 - Paresthesias without focal neurologic abnormality 3 - History of narcotic overdose" and perhaps a bit in my MDM explaining that the patient's symptoms do not fit any known organic pathology.

 

[WilcoWorld]

To put a financial point on it, which diagnosis bills better - malingering or a symptom-based diagnosis such as neck pain, paresthesia, etc?

 

[gman33]

charting is for billing and legal protection. a distant third is a historical record which may be useful to another provider.

I don't document anything that puts my view of a patient in a negative light.

 

[e30ftw]

Wow that chart looks horrible.

Spinal epidural abscess can be tricky but I'd bet 95% of BCEP would've MRI'd that guy. Or CT then MRI depending or resources.

I don't think I've ever written, "Patient is malingering" in a chart, for the above reasons.

The most I'll write is something like:

"Patient has hx of chronic back pain, has seen multiple providers for this and has been on pain management. Patient states he is not currently taking narcotics. Review of database shows > 5 opiate Rx filled from > 5 separate providers in past 90 days. DW pt conservative treatment options of chronic back pain, wrote Rx for mobic and referred pt to additional PCP. Pt then became angry and eloped without notifying staff."

 

[Rendar5]

I've written conversion d/o one time only after negative imaging and a board-certified neurologist saw the patient in the ED and diagnosed it themselves. I've written malingering only after a well-established hx of such and presentation w/the exact same sx's as previous. I've written drug abuse/narcotic seeking behavior only after documenting that I offered alternative tx that was refused or something extremely obvious. Just the other day I had someone that I thought was faking paralysis after an MVC (as did the trauma surgeon) because they could maintain their legs in certain positions that wouldn't make sense w/ paralysis. However just because we thought they were faking it, we still did full imaging and found a. C2 fracture (despite no neck pain complaint lol). So if you suspect something, don't write it down in the chart. Work it up, only write down in the chart after you proved there's nothing more severe because otherwise you may look like a fool and a complete judgmental dingus (my chart in that last case wrote that put maintained legs in certain positions so that while put was complaining of hemiplegia, it appeared to be more hemiparesis on exam).

I've had some similar cases to the 1st one presented in this case. Despite believing the patient to be total drug seeing and malingering, I would still MRI the pt or do some other test to prove there was nothing to it. THEN I would admit them for pain control. Then I would call them drug-seeking if they returned for the same complaint after. Alleged neuro deficit = MRI 1st, malingering after

 

[goodoldalky]

I have done this before, but usually it is best to describe the behavior and this is what I usually do.

"Patient here for the 126th time in the last 12 months, requesting "xanax, soma, and dilaudid" for my "back pain that started when I was hit by a car 48 years ago." When the nurse approached to administer ibuprofen, they came out of the room saying, "F*** you, I ain't taking that ****, as they then kicked over a chair and threw a trashcan across the room."

 

[namethatsmell]

Agree with above: there's nothing to be gained by using those words in the chart. Unless you're a plaintiffs attorney. Use quotes and write objective findings and an emotionless impression.

One place I used to work had a separate part of the EMR to flag pts internally as possible seekers, abusers, etc. You could write whatever you want for your colleagues to see for future visits and it wasn't part of the pt's chart. It was the best thing ever.


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[deleted245139]

Writing malingering on the chart seems to have no palpable benefit and increases liability - why take the risk?


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Agree. If a person is aggitated, aggravated, rude, qgressive, etc, I document it all, along with a witness attestation. I document it plainly but I always have a primary dx that's unrelated along w a statement about their malcontent. I just don't see a benefit any other way, esp a our current legal climate

 

[gutonc]

There is nothing, ever, to be gained by being judgmental in a chart note.

Easy enough to pass on your thoughts about the situation to other docs who will read your chart, without giving the lawyers who might also read you chart some rope to hang you with.

 

[BAM!]

To put a financial point on it, which diagnosis bills better - malingering or a symptom-based diagnosis such as neck pain, paresthesia, etc?

Usually doesn't matter when you're talking about the malingering population...

 

[TrumpetDoc]

If I ever use malingering, and I sometimes do, I make a point to dictate my reasoning and why exactly it is not XYZ. And I never say it to someone based on clinical eval.
IMO, to say this safely needs a workup that's negative.
Even when I do I usually make the impression as symptoms an malingering is in the last line or so if the MDM as likely or something of that nature.

 

[southerndoc]

If a patient needs to be discharged by police/security carrying him/her out, the physician should SERIOUSLY consider what is going on as his/her career is in jeopardy if he/she misses something.

 

[winkleweizen]

I wrote malingering in a chart just two weeks ago.
I wrote: "Review of records reveals a longstanding history of malingering and abuse of hospital staff, directed at gaining opioids".

I write at risk for opiate abuse in these charts. Not sure it's any better

 

[Old_Mil]

I wrote malingering in a chart just two weeks ago.
I wrote: "Review of records reveals a longstanding history of malingering and abuse of hospital staff, directed at gaining opioids".

I tend not to write that even in such cases. I go with the objective "Mr. Y/Ms. X is a patient well known to this emergency department. She has presented to this department 35 times in the past year. 25 of these visits were for back pain. Today she again presents with a chief complaint of back pain similar in character and intensity to her prior presentations."

...and go from there. Although it takes a little more time to go through the emr to count the number of prior visits and determine the cause of the chief complaint I find that "you've visited the ER every other week for a year" screams malingering louder than the word without the side effect of subjectivity.

 

[WildcatS11]

If a patient needs to be discharged by police/security carrying him/her out, the physician should SERIOUSLY consider what is going on as his/her career is in jeopardy if he/she misses something.

I agree, in many settings. I'm at an urban academic center, and we see a large amount of indigent population. We have to get security involved 5-10x per day, probably. I have yet to feel nervous about it.

 

[WilcoWorld]

I agree, in many settings. I'm at an urban academic center, and we see a large amount of indigent population. We have to get security involved 5-10x per day, probably. I have yet to feel nervous about it.

Do you mean to say security escorts a patient off of the premises 5-10/day?

 

[WildcatS11]

Do you mean to say security escorts a patient off of the premises 5-10/day?

Yeah, give or take, depending on the day. We also have a group of 10 or so patients that come in every single day without fail, and we know which ones will need security. They're not all like the case described above, by any means.

 

[RustedFox]

I tend not to write that even in such cases. I go with the objective "Mr. Y/Ms. X is a patient well known to this emergency department. She has presented to this department 35 times in the past year. 25 of these visits were for back pain. Today she again presents with a chief complaint of back pain similar in character and intensity to her prior presentations."

...and go from there. Although it takes a little more time to go through the emr to count the number of prior visits and determine the cause of the chief complaint I find that "you've visited the ER every other week for a year" screams malingering louder than the word without the side effect of subjectivity.

Yeah, you're right. This is the only case in which I've ever written it - and I looked thru his visit history to see psych making that diagnosis after episodes with pseudoseizures and other asshatery.

Worst part: Guy gets to me and is all in his military hero gear, T-shirt that says "101st Whatever Division" and Wounded Warrior patches and other regalia. Gives me that whole "I'm a combat vet, thank you so much for taking care of me canIhavesomeDilaudid?" schpiel.

What a zero.

 

[southerndoc]

I agree, in many settings. I'm at an urban academic center, and we see a large amount of indigent population. We have to get security involved 5-10x per day, probably. I have yet to feel nervous about it.

Are they presenting with a neurologic complaint when they have to be toted out? I'm not talking about the drug seeker that security has to walk out the door. I'm talking about someone who is refusing or unable to walk and must be toted out the door.

 

[WildcatS11]

Are they presenting with a neurologic complaint when they have to be toted out? I'm not talking about the drug seeker that security has to walk out the door. I'm talking about someone who is refusing or unable to walk and must be toted out the door.

No, I just responded to your thought that physicians should be cautious using security. I agree we should be cautious, but Sometimes it's necessary. I wasn't talking specifically about a neurological complaint, or the patient from the original anecdote.

 

[GeneralVeers]

I probably write "Malingering" on a chart 3-4 times per year. I only use it on patients who have multiple visits to multiple hospitals for a complaint that has been FULLY worked up AND they requested narcotics/admission.

I have no problem using security to escort out someone with diagnosis of malingering or drug seeking behavior.