Separating the subjective from the objective

Posted by on Jan 21, 2014 in Best Practices, Blog, Legal Nurse Consulting, LNC, Medical Conditions/Terminology Blog Series

When Legal Nurse Consultants analyze medical records, we had better be able to compare and contrast subjective and objective documentation. In other words, we earn our keep by determining what constitutes a subjective complaint versus an objective finding. Sounds simple right? Not so fast! While these terms are used all through medical documentation, they can be confusing. Here are some of the reasons why: Non-medical people often mix the terms Medical records themselves can be confusing Attorneys and claims representatives often don’t understand the condition or clinical picture from a medical perspective Information that falls under each of the objective or subjective categories are often misunderstood, misquoted, or confused. To make matters even worse, there are medical terms that actually can fall under BOTH categories. A case in point Here is an actual Physical Exam taken from one of our company’s case files: Physical exam: Abrasion to left knee, right 5th finger, thumb and chin. Lips also noted to be swollen. Elevated BP. Swelling noted to right hand, limited ROM, decreased strength, tenderness to touch. Glasgow coma score 15/15. Neurovascular intact. So, is the physical exam findings objective or subjective? First let’s review the definitions. <spaSubjective = Information that is reported by the patient, BUT cannot be verified or perceived by the examiner. The examiner should document SUBJECTIVE COMPLAINTS. The term subjective findings (or subjective symptoms) is wrong. Examples – feeling hot, pain, numbness, tingling or nausea. Objective = Measureable abnormality or finding that is perceived by the examiner. The examiner would document OBJECTIVE FINDINGS. More obvious objective findings would be lab or diagnostic testing. Here’s a map of the same Physical Exam that deciphers the objective and subjective elements: Abrasion (objective)to left knee, right 5th finger, thumb and chin. Lips also noted to be swollen (objective) and painful (subjective).Elevated BP (objective.Swelling (objective) noted to right hand, limited ROM (likely both),decreased strength (likely both),tenderness to touch (subjective).Glasgow coma score 15/15 (objective) Neurovascular intact (objective). Depending on what side of the case they’re on, attorneys and adjusters can end to focus on what seems to help their case. But a good evaluation depends on clear understanding and accurate interpretation of the objective AND subjective data. The entire clinical picture – along with associated diagnostics, radiological studies and lab tests all – should be considered. This is where it can get tricky You have to really understand your clinical information…all of it. It is at this point that legal nurse consultants often get called to help out on a file. While a medical record may have all kinds of subjective complaints, the absence of objective data that could account for the complaints should raise a red flag – irrespective of what...

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How are you at telling a story?

Posted by on Jan 9, 2014 in Blog, Kari Williamson, Legal Nurse Consultant, Social Media

I often tell the nurses on our staff, “You have to tell the story with your legal nurse consulting comments.”   I explain that the chronology or medical timeline will mostly tell itself. But it’s the analysis of the medical facts that tells the real story.  It’s expressing the subtleties and nuances buried in the facts that tend to make the difference in the value of an analysis. It is these small, yet important tidbits that really bring into focus the story of the case.  And, it’s the story telling that helps the reader connect with the truth of the case.  This is what helps your analysis sink in and almost come to life. But most importantly it assists your reader in fully understanding the facts about a medical malpractice or liability insurance claim. A story-telling confession I have been stuck in a blog writing rut for months!!  So, I discussed the problem with a biz colleague.  I whined and groused about how I had nothing to write about.  He just looked at me and said, “Just tell the stories.” I thought about it and then replied, “What stories?!”    “The stories within your cases,” he said confidently – and, I might add, a bit smugly. I thought… he was right.  He was telling me exactly what I tell my nurses every day!  I tell them to write about the stories behind our cases. Just tell the story! Hold on to your keyboard!! OK, starting with New Years 2014, MKC will tell stories.  We will post stories for you about rotator cuffs, curious slip and falls, mysterious intervening events, prolonged labor, questionable ED care, missed tumors and the removal of the wrong organs…just to name a few. And through these MKC case stories, you’ll get great information and, we hope, better insights into medical reviews, medical management, legal nurse consulting and all the associated benefits!  You’ll get lots of useable knowledge, great take- aways and helpful tips…such as: Informative tips on how to better understand medical issues What is this “mechanism of injury” thing? And, WHY is it so important? How to best decipher a quirky trauma timeline. How attorneys, insurance claim and risk management personnel can get the most from legal nurse consultants and other experts. What’s in a ‘WORD’? What’s the difference between a CT scan and a MRI? So, stay tuned!  Let us know if you have a story you would be interested in reading about.  And, Happy New Year! Kari Williamson, BS, RN, LNCC, CCM BSN, is the founder and president of MKC Medical Management.  Contact Kari at 865-551-6800 and...

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