Separating the subjective from the objective

Posted by on Apr 18, 2017 in Blog

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 just a few 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 range of motion, 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 of subjective and objective. Subjective Definition: Information that is reported by the patient, BUT can’t 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 Definition: Measurable abnormality or finding that is perceived by the examiner. The examiner would document OBJECTIVE FINDINGS. Examples:  Lab or diagnostic testing; fracture visible on xray; bruising; swelling;redness. So let’s take another look at that physical exam. Here’s a map, pulling out 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 range of movement (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 typically focus on what seems to help their case. But a good evaluation depends on a 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. And this is where it gets 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...

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Gym Revelations

Posted by on Apr 11, 2017 in Blog

The importance of isolating muscle groups – and case records For years, I’ve been going to the gym. I’ve run through the same workout week in and week out. I thought I was doing a great job, honing in on specific muscle groups and staying fit. So, when a personal trainer suggested I do those triceps exercises that I’ve always done with three-pound weights, not 10-pound ones, I was a little skeptical. Why? I’ll never work those muscles with just three pounds of weight, I thought. And then I did it. After the third set of 20 reps, my triceps were screaming. It turns out, I’d been doing it wrong all of the time. And, let’s just say, I’ve been taking my personal trainer’s advice ever since that day. He knows the equipment. He’s read up on the latest research. And he knows the importance of isolating those muscle groups for the most efficient and effective workout. What does this have to do with legal nurse consulting? A lot. We know the equipment. Our LNCs bring decades of experience as registered nurses. We know our way around complex medical records, including the digital kind, and complicated diagnoses. We’re always on the lookout for red flags when evaluating, for instance, a motor vehicle accident injury. We know ways to avoid getting tripped up by the pages and pages of medical records that come with just about every case. And, whether it’s lead poisoning or workplace back injury, we know the tough questions to ask – and what records are critical to figuring out exactly what happened. We know the latest research. Opioids should no longer be the go-to pain killer for certain injuries. ICUs may be overused. Let’s talk the biomechanics of minor automobile accidents. As a lawyer or insurance adjuster, you are well versed in the constantly evolving rules and regulations of your industry. And we know medicine, an always developing field that brings about new revelations just about every day. We know the importance of isolating the details. The devil, as they say, is always in the details. I’m getting a better workout because my personal trainer is teaching me how to isolate certain muscle groups. At work, we’re helping our clients “isolate” the details in every case. To the layperson, they might seem like minutiae – tiny technicalities in a medical record that seem to have little to do with the case overall. But, as experts in the field, we know that every little detail counts. In a lead poisoning case, for instance, what were the parents’ occupations? In a slip and fall, when exactly did the patient seek treatment? If you can’t master the details –...

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Getting to the ‘tooth’ in dental claims

Posted by on Apr 4, 2017 in Blog

Reviewing dental claims is a regular part of our job at MKC Medical Management. But the work isn’t as clear cut as it might seem when you’re dealing with a cracked tooth or gum lacerations. They often take a lot of sleuthing. Let’s look at one case we reviewed. A man was reportedly struck on the left side of the chest. The claimant reported that he fell and injured his left knee and chest. Buried in the same records, however, was a costly dental restoration plan. Based on the facts, I wondered how the claimant could justify such a thing. So, I started with the emergency department records. Checking the facts I reviewed everything and cross referenced the alleged event facts and ALL of the objective data, including the lab tests and diagnostic results. I looked at pieces of information tucked in the emergency room nurse’s triage notes, what the EMS documented, the treating physician’s exam and the discharge orders. In other words, I looked at everything. I really focused on the subjective complaints and reported information  In fact, I reviewed everything three times! And, guess what?! NO oral trauma was documented. There was NO subjective complaint regarding oral, dental, teeth, gum pain or trauma. In fact, the claimant self-reported NO head trauma. Furthermore, there was an entry documenting “no oral trauma.” None of the hallmarks of oral trauma were there:  No blood, no laceration, no missing or cracked teeth. NO oral pain. Instead, the exam stated, “Oral mucosa, pink and moist.” Wait, no oral trauma? So, I am thinking, why did the carrier send this file? I kept digging. Because nothing is really obvious, is it? I discovered that the records reported that the claimant received chiropractic care about three days after the incident date. But there was no mention of facial or oral trauma in the chiropractic notes. Considering the account of the event and that the description of all of the other injuries was very detailed, it was odd. Then, more review … this time the dental records. The injured man was seen by the dentist the day of the alleged incident. More mystery, as there was no documented problems. I concluded that he must have been seen before the accident as well. Next, I pulled out the dental billing statement. There was NO billed return visit until four weeks after the alleged accident. Alert, alert! I then went back to the handwritten dental documentation. The corresponding notes clearly documented NEW findings involving MULTIPLE teeth:  A fractured bridge, damaged  crown, cracked/loose teeth and a FRESH laceration around the gum with an associated a tooth fracture. These findings were significant and a HUGE RED FLAG! A person...

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