By Jeff Ribordy, MD, MPH, FAAP, Regional Medical Director

Back in 2018 we published a mildly humorous blog post highlighting medical bloopers that we have encountered as we peruse the chart notes we receive. Of course back then, EHRs were so new that most providers were still getting used to working with them. Nowadays, everyone is such an expert we rarely see charting mistakes…..

Just kidding!

Here is our long awaited sequel with upgraded oopsies – just like the EHRs we all use.

As we share these I want to mention as in the previous post – this is not to point fingers but with the understanding we all have made similar mistakes.

From the “Not Sure That’s How That Works” Department…

–…he sleeps flat with 8 pillows <…>

–She lifts boxes which way 5200 pounds all day long while working in a warehouse.

–General: Pt is awake, alert and oriented. No acute distress. Husband present. PT is ambulating in a wheelchair.

–Born as full term at 51 weeks, no major complication reported during delivery.

–Allergies: CARBOHYDRATE

–He was twin B (5 lb 11) needed chest compression for 3 days. Not intubated.

–Is a 56-year-old male – Alcohol: Currently does not drink; but did drink a sixpack of beer per day for 78 years.

–Sister states that patient carries a diagnosis of schizophrenia but patient refused to take medication. Main symptoms of her schizophrenia was shyness and not talking to others.

–Patient states she believes she has MS. She states she did some online research and wants to be tested for MS. When asked what sx she is currently having in regards to MS, Pt asked, “Can I have a phone to look up the symptoms of MS.”

–Ms. M… had a sudden loss of both eyes that occurred in December 2018.

Might Need Another Treatment Plan…

–If the injection helps, then consider radio frequency abrasion.

–He was diluted with x-rays and sent home.

–Prognosis for controlling incontinence: Hyperlipidemia

–Discussed – Unfortunately kidney has failed to have any benefit from an L4 transforaminal epidural steroid injection.

–PLAN – Hyperlipidemia, unspecified, TraMADol HCI 50 MG tablet, 1 every 4-6 hours as needed, 30 days, 0 refills.

–Methamphetamine abuse  F15.10 – The patient appears interested in taking this habit.

Kid’s Doctors Say the Darnedest Things…

–3yo daughter Callie, works as a cashier

–SOCIAL HISTORY: The patient is in the fourth grade, denies use of alcohol and tobacco.

–10 year old female here with a chief complaint of eating.

–Please let mom know Xray from last week shows moderate poop.

Captain, the Universal Translator is malfunctioning…

–Ongoing tobacco use: Advised to quit yet another gallops left left knee surgery on their printer milligrams daily.

–Reminder of value of glucose level w/level of pain & why.

–Plan: Patient with hypoplastic left heart status post Norwood procedure N salmonella shunt mother with excellent Binder for following medical home we’ll need to clarify dosages of medications.

From The MD who was an undergrad Philosophy Major…

–The symptoms occur.

And more good advice for everyone:

–She married a drug dealer which she advises not to ever marry a drug dealer.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“If it wasn’t documented, it didn’t happen.”
     -Aphorism passed on to all health care providers in their training

One of the promises of Electronic Health Records was that it would make medical information more legible, and complete.

While computer text is undoubtedly more legible than most handwritten clinical notes, it does not solve the issue of incompleteness, and may make it worse. A long progress note can be created using templates and short-cuts, but sometimes a clinician fails to record the core information of the history of present illness and the part of the physical exam relevant to that complaint. When this happens, anyone reviewing the record would come to the conclusion that the quality of care in that visit was poor and unacceptable.

For example, a patient comes to the office complaining of back pain. The progress note includes a depression/anxiety screen, smoking history, alcohol history, review of current medications, and the medical assistant’s note of the chief complaint of back pain, for the past week since moving a heavy couch. The clinician documents no further history, and the physical exam notes that the heart sounds are normal, the lungs are clear and the patient is in no acute distress. There is no recorded back or neurological exam. The assessment is back pain, and an MRI is ordered.

This electronic medical record generated note not only gives the Partnership HealthPlan of California (PHC) medical directors no details by which to judge the medical necessity of the MRI request, it reflects either poor quality care by the clinician, or poor documentation by the clinician, and possibly both.

The consequence of this: a denial of the MRI request, the need for a repeat visit to do the relevant history and physical exam, and a delay in getting appropriate care for the member.

This issue is definitely not universal. In the process of conducting utilization management reviews and investigations of potential quality of care issues, we also encounter very complete and appropriate documentation that reflects a logical collection of historical information, a thoughtful physical exam and a delineation of the differential diagnosis considered.

Sadly, we encounter many progress notes that incompletely address the reason for the patient’s visit. When we bring this to the attention to the Medical Director of the organization, they are often unaware of the issue. This is perhaps even more concerning, that health care organizations don’t closely monitor the quality of medical records and clinical decision making.

One of the best resources to offer a clinician with poor documentation practices is the UC San Diego PACE Medical Record Keeping course. Having your clinicians periodically audit each other’s charts is another way to promote attentiveness to the quality of medical recordkeeping and clinical decision making. Having a standard set of review criteria is important; Family Practice Management has an article on this topic.

Physician Assistants are required by the Medical Board to have a percentage of charts reviewed by their supervising clinician, a good opportunity to identify poor documentation practices. Although physician review of a sample of Nurse Practitioner Charts is not required by the State of California, it is also a best practice to do this on at least an annual basis, as part of a yearly performance evaluation.

One final note: excellent documentation practices help prevent medical liability lawsuits and licensure actions by California Medical Board/Nursing Board. It is better to have a system to improve documentation and decision making before such actions force the issue.

For a collection of de-identified humorous examples of actual medical records PHC has reviewed, see Dr. Jeff Ribordy’s blog.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Redemption comes to those who wait.  Forgiveness is the key.”

Tom Petty’s 1999 ballad Lonesome Sundown (part of Echo, his tenth album with The Heartbreakers) was written after completing inpatient rehabilitation, recovering from a 3-year period of heroin use. The line about redemption and forgiveness is a reflection of his need to be forgiven so he could again create new songs and genuinely share his art.

Some Partnership HealthPlan of California (PHC) members have experienced hard periods in their lives when their actions cause distress to those around them. In the health care setting, this may lead them to repeatedly missing medical appointments or have verbal outbursts with medical office staff. Sometimes, their behavior leads to disenrollment from a practice.

These patients may sometimes turn their lives around, and be ready to re-engage productively in relationships with medical providers and offices. They are often ready to seek redemption and forgiveness from the medical office that disenrolled them.
At the June PHC Physician Advisory Committee meeting, several physicians related how their practices handle these situations. Here are some highlights:

• Patients should write a letter (potentially with assistance from an advocate), requesting re-enrollment, acknowledging the reasons for their disenrollment, explaining how their life has changed and expressing a commitment to act differently.
• The office/health center should have a process for reviewing such requests, ideally involving both clinical and administrative leaders.
• Many practices require the patient to wait for at least a full year after the disenrollment to consider a request for reinstatement.
• If the request is denied, the former patient is given a written response, indicating if and when they may apply again for reinstatement.
• If the request is accepted, the patient has an orientation session outlining expectations of behavior, up-front. For PHC members, PHC needs to be notified, as well.

Tragically, Tom Petty ultimately died of an opioid-benzodiazepine overdose in October 2017, related to his attempts to treat severe pain from hip osteoarthritis, for which he was hesitant to have surgery. In the 18 years between his recovery from heroin addiction and his death, he produced 8 albums and 2 film documentaries—a pretty good redemption.

If your office doesn’t have a process for considering re-enrollment requests, please consider developing one to allow former patients who have turned their lives around to have a second (or third, or fourth) chance.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

Early data suggests that deaths due to suicide and overdose have increased since the beginning of the COVID-19 mitigation measures in the United States. Social isolation, financial insecurity, and unemployment increases the number of deaths from suicide, overdose, and illness. The factors leading to suicide disproportionately impacting communities of color. Individuals who have a history of Adverse Childhood Experiences (ACEs) are particularly at risk.

Primary care clinicians have the opportunity to screen, intervene and prevent these events. There is no way to know if someone is in trouble unless they are asked. When risk for suicide is identified, there are tools and resources that reduce the probability of suicide attempts.

One best practice is to routinely screen for depression using the PHQ-2 and PHQ-9 questions, adding some additional questions about depression risk for any patient screening positive for depression (PHQ-9 score of 10 or greater).

The National Institute on Mental Health (NIMH) developed the Ask Suicide-Screening Questions (ASQ), four questions in 20 seconds to identify people at risk of suicide. In a NIMH study, a “yes” response to one or more questions identified 97% of youth aged 10 to 21 at risk of suicide:

1. In the past few weeks, have you wished you were dead?
2. In the past few weeks, have you felt that you or your family would be better off if you were dead?
3. In the past week, have you been having thoughts about killing yourself?
4. Have you ever tried to kill yourself?

What’s next?

If an individual responds “yes” to one or more of the four Ask Suicide-Screening Questions, they are at “imminent risk” or “potential risk” of suicide.

The next step to better understand risk-level, if any of the four questions above are answered “yes”, ask “are you having thoughts of killing yourself right now?” and if the individual says “yes,” then they are at imminent risk of suicide and need an urgent mental health evaluation to ensure immediate safety. If the individual answers “no,” then a potential risk is identified and they require a brief suicide safety assessment to determine next steps.

The Zero Suicide Model is an evidence-based practice outlining how to apply this model in a clinical setting. Practices include:

• Make a safety plan the patient can follow if thoughts of suicide appear, including calling help lines such as the National Suicide Prevention Lifeline                        (1-800-273-255).
• Discuss restricting access to things they might use to hurt themselves – especially firearms (firearms in the house are a major risk factor for completed suicide).
• Create a follow-up monitoring plan to ensure the patient receives ongoing help and support.

All three of these activities are appropriate for those who answered “yes” to any of the four ASQ questions above.

Overdose and Suicide: An overdose or self-harm event in the emergency department indicates an extreme high risk. An opioid overdose indicated an 18-fold greater risk of suicide and over 100-fold greater risk of overdose in the next year, compared to the general population. A visit for suicidal ideation led to a 30-fold increase in the risk of suicide in the next year.

ACEs and Suicide: Individuals with four or more Adverse Childhood Events (ACEs) are 37.5 times as likely to attempt suicide, when compared to individuals with no ACEs. For more information on addressing ACEs in your clinical practice, visit www.ACEsAware.org.

Screening individuals for risk of suicide saves lives! Health care professionals can help people get needed care, support and resources. We recommend a refresher training for our clinical staff on this topic, in this time of increased risk of suicide.