Reducing and preventing physician medication order entry errors
Physician medication orders entered for the wrong patient is a constant battle for hospitals. At MKC Medical Management, as we investigate our client’s claims and cases, we see it all of the time.
Many factors can lead to medication errors. In fact, the Institute for Safe Medication Practices has identified 10 key elements with the greatest influence on medication use and notes that weaknesses in these areas can lead to medication errors.
- patient information
- drug information
- adequate communication
- drug packaging, labeling and nomenclature
- medication storage, stock, standardization and distribution
- drug device acquisition, use and monitoring
- environmental factors
- staff education and competency
- patient education
- quality processes and risk management
Medication administration is a complex and multistep process that involves prescribing, transcribing, dispensing and administering drugs, as well as, monitoring patient response. An error can happen at any step, but we see many errors happening in the beginning – at the prescribing stage.
Researchers tackle issue
With the introduction of electronic medical records, there have been numerous studies focused on ways to reduce and prevent order entry errors.
Researchers at Montefiore Hospital in New York, for instance, wanted to find a way to detect wrong-patient orders in their electronic medical records system. They devised a tool to track errors, such as prescribing medications for the wrong patient, and to suggest ways to reduce potentially life-threatening mistakes.
The study lasted from December 2010 to June 2011. It found that two different interventions could decrease the number of wrong-patient orders that were later retracted.
Phase 1 of Montefiore’s research: Physician Interviews
Interviews with 233 physicians over a four-month period showed that 76 percent of the original orders had been for the wrong patients. They were near misses that could have turned into actual medical errors involving orders for imaging or lab tests or medications.
Their findings of the study translated to wrong-patient electronic orders being entered by one in six clinicians for one in every 37 patients admitted to the hospital, an average of 14 such orders per day. This did not include or reveal how many orders for the wrong patients went through and were carried out.
Phase 2 of Montefiore’s research: Verify Patient Identifiers
In the randomized controlled trial, 4,000 providers were assigned to groups, which were prompted to verify patient identifiers before entering orders, re-entering patient identifiers – or neither.
The results were encouraging compared to the control group. ID verification reduced the odds of retract-and-reorder events by 16 percent; ID reentry decreased them by 41 percent.
It took clinicians only half a second on average to verify a patient’s ID, versus 6.6 seconds for reentering identifiers. The latter could add up to a fair amount of time over many orders, but it did not explain why only half of the wrong-patient orders were prevented even with ID reentry.
The research is encouraging and provides tested information that will help other hospitals develop similar software programs that would prompt reentering of patient information and not allow the physician to override the prompts.
Ingenuity, creativity required
In fact, one of the nation’s leading hospitals, Johns Hopkins Hospital in Baltimore, has begun requiring clinicians to re-enter patient identifiers before submitting orders. Hopefully, soon others will follow as hospitals continually work to address medication issues with ingenuity and creativity.
When compared with the old pen-and-paper charts, electronic medical records are believed to prevent far more mistakes than they cause. They also are forcing hospitals to develop new and innovative ways to reduce errors in ordering.
As a nurse, I am very aware of the challenges of the electronic medical chart. It is my belief that adding patient photos to the medical chart is (almost) a surefire way to guarantee you have the right patient.
Leave it to a nurse to solve one of the on-going battles hospitals face.
Here are studies, reports and stories that caught our eye in the last month.
No “standard” claim: Isn’t one rear-end crash like every other rear-end crash? No, says an article in Property Casualty 360 that’s part of a six-part series about adjuster ethics. “Each claim is unique, the people involved are individuals, and each claim needs to be adjusted on its merits,” the article says. “When we try to do away with individualism in each loss, we either over-pay or under-pay, hence the claim is no longer ‘fair and equitable.’”
Bodily injury claims: Claimants must prove both liability and damages to be entitled for compensation in bodily injury claims. But, says an article in Claims magazine, liability is often overlooked. “A good rule of thumb for all adjusters is to never underestimate the importance of liability as a critical element of the claims investigation,” the article says. “Beyond the potential accuracy improvement in indemnity payments, there is a dramatic rise in subrogation potential.”
Cars could someday alert drivers to their own medical emergencies: Sudden cardiac events for drivers behind the wheel can turn into tragedies for not only the driver, but his passengers and others on the road. Toyota, along with a team of researchers at the University of Michigan, are exploring technology that could monitor a driver and predict if they are going to have a heart attack or other adverse cardiac event while driving, according to an article in Insurance Journal.
The role of social media in personal injury claims: Defense attorneys are adding a new weapon in their arsenal as they fight personal injury claims: A plantiff’s social media accounts. “Many plaintiffs make things very easy for the defense, simply by posting things on social media that undermine their claims,” says an article in Forbes. “For example, a simple post about mowing the lawn could be used as evidence to refute a personal injury claim about a back injury.”
Can robots review personal injury claims? The answer, at Zurich Insurance, is yes. The company is using artificial intelligence to decide personal injury claims. “We recently introduced AI claims handling … and saved 40,000 work hours, while speeding up the claim processing time to five seconds,” chairman Tom de Swaan told Reuters as reported in Claims Journal. The robots began doing the work in March to review paperwork, including medical reports.
What’s the best practice? Both
When reviewing medical records, it may seem redundant and not at all cost effective to pay for both a physician’s peer review and a legal nurse consultant’s examination of the same claim or case.
They both, however, offer unique perspectives. And, when you combine the two, the result affords you a more complete timeline of both the events that have happened and the medical future for the patient.
The Physician Peer Review
A physician peer review or medical review of a case can give you a pinpointed, detailed reporting of what has happened to date. It provides intricate details about specific pieces associated with the medical event and how those pieces fit directly together.
More myopic in construction than an LNC report, the medical review yields very precise answers and insight into a medical event and the subsequent treatment strategies. Simply put, it’s a very accurate snapshot in time of the patient and the event.
The LNC Report
Also a major standard in the industry, an LNC takes the medical review and expands it. MKC nurses create a detailed medical record summary with ongoing embedded commentary, helping the reader understand both the material and its impact on the case. Contact us if you would like to see a sample report.
An LNC report provides information about peripheral factors relevant to the case as well. It also considers long-term patient care and interaction, pre-accident medical information, specific information about the mechanism of injury and ongoing details pertinent to the injury and case. This broader approach often uncovers inconsistencies that may otherwise go undetected.
An LNC’s granular level of review is equally important to the case as the focused review of the physician. As one claims examiner once explained, “We know we will never have a silver bullet on these cases, but what is more valuable is that with the nurse review the details of the record evolves into a shotgun effect, thus exposing equally important details that are often missed.”
Using a Whole Person Approach
The patient involved may have a single event or episode, but the effects and ramifications of that single event can weigh heavily on the future treatment of that injured party.
By using both reports, you gain a more complete picture of the claim, the specific injuries and the prognosis.
Without using both reports, you could very well end up making future patient decisions with one eye closed.
Impacts of putting off medical care after injury
Legal nurse consultants frequently find that a claimant has delayed treatment. Sometimes the delay may be only days, but many times the delay extends into weeks or months after the injury.
Delayed treatment makes it difficult to establish what injuries, if any, are causally related to the incident. With any gap in treatment, we cannot reliably know a claimant’s clinical presentation immediately after an injury, which is key to assessing the legitimacy of an insurance claim.
The medical perspective
Without a complete understanding of the claimant immediately after the injury, there is no way to unequivocally relate subjective complaints reported well after an injury. What’s more, when analyzing the claim, the rule of thumb is this: Compare subjective complaints to objective findings. Delays make this more difficult.
If the claimant is not evaluated within a reasonable timeframe after the incident, any bruising, contusions or lacerations, which may have occurred at the time of injury, would likely have resolved, leaving it impossible to assess for signs of direct trauma.
The bottom line
As legal nurse consultants, we are asked to review medical records and render an opinion if the alleged injuries are consistent with the mechanism of injury. So another critical question is this: What the delay may indicate about the injury and treatment.
An argument could be made that if someone is really injured they would NOT delay seeking treatment for an extended period of time. Any delay also allows for ADDITIONAL injuries, which could potentially draw into question the legitimacy of the original injury itself.
While we may not be able to directly relate subjective complaints reported weeks or months after the injury, what we can do is provide the claims handler with information about why the delay or absence of medical care makes it very difficult to relate the complaints to the incident.
Debra West, RN, BSN,CCM, LNC is a legal nurse consultant with MKC Medical Management. Contact Debra at firstname.lastname@example.org or 865-551-6800.
For anyone trying to understand a medical record or condition — including patients — it helps to take a look at definitions and how they’re applied.
When chiropractors and physical therapists appear in those records, we often see confusion from clients. How are the professions different? How are they the same? Can they address the same injuries or complaints?
We expect those questions to keep coming as both the number of physical therapists and chiropractors grow, in part, to serve a growing aging population. According to the Bureau of Labor Statistics, the number of chiropractor jobs will grow by 17 percent through 2024. For physical therapists, it’s a whopping 34 percent. By comparison, average job growth during the same period is forecasted at 7 percent.
Let’s take a look at the definitions of each profession first.
Here’s how the American Chiropractic Association defines chiropractic: “Chiropractic is a healthcare profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health. Chiropractic care is used most often to treat neuromusculoskeletal complaints.”
Chiropractic therapies mainly consist of pain management through adjustment and manual manipulation. Those therapies could include:
- soft tissue mobilization
- joint adjustment
- electrical stimulation
- and acupuncture.
And here’s how the American Physical Therapy Association defines physical therapy: “Physical therapists are healthcare professionals who maintain, restore and improve movement, activity and health, enabling individuals of all ages to have optimal functioning and quality of life, while ensuring patient safety and applying evidence to provide efficient and effective care.”
Physical therapists have a much broader base within their systems. Physical therapy isn’t just for pain relief. It’s also critical for rehabilitation focused on restoring functions and preventing disabilities after disease, injury or the loss of a body part.
These practitioners use several techniques to achieve this goal. They include:
- exercise to strengthen muscles
- encouraging improved range of motion
- and retraining individuals to perform activities required for day-to-day living.
Promoting healing – in different ways
While both professions promote healing, it’s important to remember the differences.
The chiropractor focuses on manipulation on the musculoskeletal and spinal system. The physical therapist focuses on maintaining, restoring and improving movement of musculoskeletal and neuromuscular systems through strengthening programs.
Most confusion about the difference between chiropractic and physical therapy is a result of how these two very different professions overlap in their treatment of the spine.
Keep this in mind: While a chiropractor remains the King of Spinal Manipulation, the physical therapist is the King of Physical Rehabilitation through exercise, activity modification and muscle strengthening.
Barriers to access
Another significant difference relates to access. Chiropractors are accessible to the general public. Often, a medical referral is required for physical therapy. That referral also might include limits ordered by the physician to the amount of care rendered.
There is some good news for patients on this front. Some states now give patients direct access to physical therapists, boosting patient access.
So, while a goal of both professions – to promote healing – is the same, the treatments can be very different. To fully understand a medical record, it’s critical to understand why the patient went to one – or both – and what relief either may have provided.
Here are studies, reports and stories that caught our eye in the last month.
Auto technology and insurance claims: Technology and consumer expectations are among the issues driving the evolution of auto insurance as we know it, according to an article in Property Casualty 360. The article explores “seven key areas that are ripe for further discussion, research and analysis.”
Storefront crashes: “Storefront crashes,” which involve a vehicle running into a commercial, public or retail building, cost insurers millions of dollars a year, according to an article in Claims magazine. In fact, in 2015 and 2016, the Storefront Safety Council is aware of more than $100 million in claims paid. “The trend is increasing as more cases go to trial and plaintiffs find it easier to show that a location was poorly protected against a foreseeable and preventable risk,” says the article, which also details new safety standards and trends to watch.
Top liability loses: Allianz Global Corporate & Specialty’s Global Claims Review 2017 recently ranked the top modern corporate liability exposures. The report finds that defective product or work; collisions and crashes; and human error were the leading causes of liability losses.
Drowsy driving: At least 21 percent of fatal crashes involve exhausted drivers, according to an article in Claims Journal. But activities to keep drivers alert, including radio adjustments and opening a window, come with their own risks. The article explores the issues, signs of drowsy drivers and ways to ensure drivers get enough sleep before they hit the road.
More data needed: According to a report from the National Safety Council, 2016 may have been the deadliest year on the nation’s roads since 2007. Last year, 40,000 people may have died because of a motor vehicle crash. Another 4.6 million were seriously injured. But, the council’s report says that “little is known about key driver behavior factors in these crashes because critical data is under-reported.” The report makes recommendations for law enforcement and those in the traffic safety field.
Why what’s missing is sometimes the most important detail
There is no safe blood lead level in children, according to the Centers for Disease Control and Prevention. But, more than 500,000 U.S. children have elevated levels, which can cause lifelong developmental delays.
One of our clients, an insurance company, pulled in MKC Medical Management to review the alleged lead poisoning case of a toddler. The child was healthy as an infant, but he developed significant speech and other developmental delays. Doctors eventually diagnosed the child with pervasive developmental disorder (PDD), which is on the autism spectrum.
What we found, according to the medical records, was that the child had lived in a building with toxic levels of lead. Tests also revealed that he had elevated blood lead levels.
But, those findings don’t necessarily mean that lead poisoning was behind the child’s diagnosis and delays. In any case under review, correlation doesn’t always mean causation.
Here are the facts of the case:
Overview: The claimant is a three-year-old child who, the plaintiff attorney alleges, has developmental and behavioral issues because of lead exposure in the home. MKC’s legal nurse consultants worked on the defense team for the insurance carrier.
What the records say about the child’s lead levels
At one year of age, the child’s blood level was 5 mcg/dL, which is considered elevated. Five months later, it was up to 5.3 mcg/dL. Six months later, it was up to 6.9 mcg/dL. The blood lead level was later reported to have spiked to 16 mcg/dL before dropping to 11 mcg/dL, but no lab reports for these final two tests were submitted for review.
What the records say about the child’s home
When the child was age two, city officials sent a letter to the property owners of the building the child was living in to notify them that there were “toxic levels of lead in or on the dwelling.” A lead abatement plan was required. It’s unknown how long the child had lived in the home and whether he had lived anywhere else. After the abatement order was issued, the family was relocated.
Missing lab reports were just one of this case’s red flags. Here are some other warning signs:
- The child lived with five siblings, ages 2 to 12, but no test results were submitted to indicate that any of the other children had elevated levels of lead in their blood.
- According to an assessment with the family, there is a family history of genetic issues, sickle cell trait and seizure disorders, but the relationship to the individuals with these medical issues and more specific diagnoses were not identified. If the child has a genetic history for autism, for instance, then this could be the cause or at least contribute to his developmental delays – not lead poisoning. More information about the family’s genetic history is needed to understand the origin of the child’s issues.
- The child’s parents failed to follow through on several of the doctors’ orders, including timely follow up with appointments, medication recommendations and possible failure to monitor lead levels. The medical records aren’t clear, but if the parents missed appointments to check lead levels, that detail could be critical for the defense.
- When the child is diagnosed with autism at age 2, the pediatrician does not ask for a repeat lead level blood test to determine if lead poisoning is a contributing factor to the child’s developmental issues. Did the pediatrician not believe that lead was the cause of the child’s delays? Why didn’t doctors recommend the family relocate?
- Anytime the medical records are incomplete, it’s suspicious. In this case, both lab results and genetic testing were completed, but the results were not submitted for review. Is the information being withheld because it might provide documentation for the defense to argue that the elevated lead level wasn’t the cause of the delays?
- At age 3, the child was diagnosed with pervasive development disorder, part of the autism spectrum. The condition’s learning and developmental delays can be similar to lead poisoning. What’s more, the disorder occurs during infancy, but, like the claimant’s diagnosis, is typically is not identified until age 3. For the defense, this could be a critical point in case.
After reviewing the case records, we recommended the client seek expertise and obtain missing medical information to better analyze the case. Those recommendations included:
- Working with a toxicologist, who specializes in lead poisoning, to identify at what level a child typically becomes symptomatic for lead poisoning. The child also was exposed to secondhand smoke, another source of lead exposure. A toxicologist also could help determine if that could be one reason for the elevated lead level.
- Seeking advice from a genetic specialist with expertise in genetic issues, including the sickle cell trait and autism, and the developmental disabilities they can cause. Determining other factors that could contribute to the child’s elevated lead levels, including whether any other children in the home have high lead blood levels; whether the child comes into contact with an adult whose job or hobby involves exposure to lead; and does the family use products or natural remedies that could be high in lead.
- Obtaining all records of genetic testing, lab results and any other information not submitted for the initial review.
At the outset, the case might seem clear cut: “Toxic” levels of lead in the home and elevated blood lead levels in a child, who, over time, develops intellectual and behavioral delays.
But, with a family history of genetic issues, lack of concern about lead from doctors and missing documentation, it’s impossible to determine the exact cause of the child’s issues. The plaintiff’s attorney might argue that the issues are directly related to lead exposure, but until all the medical records are reviewed by experts, clear causation can remain elusive. It is also possible that a clear causative factor cannot be determined and that in this particular case the child’s issues are caused by more than one factor.
Lead poisoning, especially in children, has made headlines in recent years, for good reason. The condition, found in more than 500,000 U.S. children, can lead to lifelong delays, including damage to the brain and nervous system; slowed growth and development; learning and behavior problems; and hearing and speech issues.
The most recent blast of headlines began with the crisis in Flint, Mich. There, after the city started drawing drinking water from the Flint River in 2014, the number of children under six years with high levels of lead in their blood almost doubled. Those rates returned to normal levels after Flint went back to its original drinking water source – Detroit’s water system. Several officials face charges in the case.
But, those headlines have only continued as further research has uncovered high levels of lead poisoning among children across the country. One examination by Reuters, the news agency, discovered nearly 3,000 U.S. communities with high rates of lead poisoning among their youngest residents.
More claims, cases
This renewed concern means some of our clients are seeing more claims related to lead poisoning, a condition the Centers for Disease Control and Prevention calls the “most preventable environmental disease among young children.”
But, to truly understand the medical records and history in those case files and get to the bottom of the cause, you’ll need to explore more than just the patient’s health information.
Everything from whether the child ever lived outside the country to what products their family uses to the child’s own genetic history are critical for a fully informed review of a lead poisoning case or claim.
Aware for decades
The public and officials have been aware of the dangers of lead for decades. In the 1950s, the first cities started passing laws about lead-based paint. The federal government didn’t take action until the 1970s.
In 1978, legislators banned the residential use of lead-based paint. When coupled with the phase down of the use of lead in gasoline, researchers documented a big drop in the average blood lead levels in the United States.
These days, the most common sources of lead aren’t from house paint or gasoline, but regular exposure to things such as toys, nutritional supplements, water in lead pipes, residue from a parent’s occupation and dishware, among other items.
According to the American Academy of Pediatrics, the annual cost of childhood lead exposure in the United States is $50 billion. Lead toxicity is blamed for the loss of 23 million IQ points among children and is attributed to 20 percent of cases of ADHD.
Today’s goal: Prevention
Today, the focus is on stopping lead exposure before it happens. According to the CDC, there is no safe blood lead level in children.
“Even low levels of lead in blood have been shown to affect IQ, ability to pay attention and academic achievement,” according to the federal agency. “And effects of lead exposure cannot be corrected.”
Federal agencies and states across the United States have enacted their own lead laws to reduce lead poisoning rates. Here are some basic facts to know about lead poisoning, how it’s diagnosed and who is at risk, according to the CDC:
- A simple blood test, which is covered by Medicaid and most private health insurance, can measure lead levels in a child. For those enrolled in Medicaid, all children are required to receive screening tests at age 12 months and 24 months. Any child between 24 and 72 months with no record of a previous test should receive one, according to the Centers for Medicare and Medicaid Services.
- All children should be screened for lead poisoning, but those ages six months to six years, who live in or regularly visit “deteriorated old buildings,” are the highest priority group.
- Children with unexplained seizures, neurological symptoms, abdominal pain and other symptoms, which could indicate lead poisoning, should be tested. So should children with developmental delays, slow growth, hyperactivity, hearing loss, anemia and behavioral disorders.
- A lead level of 5 micrograms per deciliter in a child indicates a “blood lead level of concern,” according to the CDC, and requires medical management.
- Medical treatment is recommended when the level is greater than or equal to 45 micrograms per deciliter of lead in the blood.
The American Academy of Pediatrics recommends pediatricians assess lead exposure risks at well-child visits until a child is six. Tests, however, are recommended only if the assessment indicates there is risk that a child could have been exposed.
The academy’s lead exposure risk assessment seeks answers to the following questions:
- Does the child regularly visit or live in a house built before 1978 with peeling or chipped paint?
- Has the child or family lived outside the United States?
- Does the child have a sibling or family member being followed for lead poisoning?
- Does the child frequently put things in his mouth such as toys, jewelry or keys?
- Does the child eat nonfood items because of a disorder such as pica?
- Does the child frequently come into contact with an adult whose job or hobby involves exposure to lead?
- Does the child live near an active lead smelter, battery recycling plant or other industry likely to release lead? Or, does the child live near a heavily traveled road where soil and dust could possibly be contaminated with lead?
Full medical review required
While the results of a blood test for lead may be simple to read, for attorneys and insurance adjusters, lead poisoning cases aren’t always clear cut. Many factors – not just the old building where they attend daycare or regularly visit their grandmother – must be investigated.
If you’re looking over a lead poisoning claim, here is the medical information that’s essential to build any case:
- Complete medical records, including infant and child growth percentiles with height, weight and head circumference measurements; labs; and documentation of well-child check ups.
- All testing and lab results for the individual.
- A full medical history of family members, including their genetics, that could identify any underlying medical, developmental or cognitive issues that could account for or contribute to the allegations of lead poisoning.
- Research into the individual’s geographic area, especially the town and building in question, to uncover any other claims or possible environmental factors such as lead in the water.
More than medical records needed
Attorneys and adjusters also must look beyond the medical records. Here are other questions you should ask about the claimant:
- What are the parents’ occupations? Could a child be picking up lead from residue left on their parents’ clothes and shoes, tracked in from their workplaces? The National Institute for Occupational Safety and Health lists nearly two dozen jobs that could lead to lead exposure.
- Does the family use Mexican folk remedies, which may contain lead, such as greta, azoque and azarcon? The CDC lists other folk medicines that may contain lead.
- Is drinking water contaminated with lead?
- How old is the claimant? Babies and toddlers are at the highest risk because they play on the floor, picking up contaminants on their hands and skin and putting anything in their mouth.
- Does the child chew on toys, which possibly contain lead paint? Since 2008, the Consumer Product Safety Commission has recalled about 50 toys because of lead.
- Are foods stored in containers high in lead such as leaded crystal, pottery or pewter?
- Is the claimant exposed to household dust which contains lead from lead paint chips or contaminated soil brought in from the outside?
- How is the child doing in school? Are there behavioral and cognitive test results to review?
- Has a developmental behavioral pediatrician, toxicology specialist and genetic specialist been consulted? Some genetic disorders can cause cognitive and neurological disorders that, at first glance, may appear to be lead poisoning. These experts could provide critical information into the child’s well being.
- Do other family members, especially children, have elevated levels of lead? If not, genetics may be the culprit.
After all, genetics, for instance, not lead exposure could cause learning delays that might be attributed to lead poisoning. A favorite old toy, passed down from a grandparent, could be full of lead. Or, grandma’s remedy for colic could be behind the high lead levels.
In other words, a clear understanding of the clinical, genetic, cognitive and environmental presentation – and not just the medical history – is critical when analyzing an alleged case of lead poisoning. Attorneys and adjusters who don’t have the full picture could miss the details that might just make or break a case.
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.
- 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.”
- 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 absence of objective data that could account for the complaints should raise a red flag – irrespective of what side of the case you are on.
Much of what LNCs do is analyze all the medical data fairly and report on it. People like me take that data and explain it clearly and concisely. This explanation often becomes a story that tells the reader what happened.
Harnessing technical know-how
Here are a few tips to help you deal with the subjective versus objective issue:
- Look closely at all the data with a balanced view. Are you being objective about the case or file – or subjective?
- Compare and contrast the information. Are there lots of subjective complaints with few objective findings? How does this honestly affect your case?
- Consider whether the findings change or shift in any way through the medical record.
- Determine whether the subjective complaints have been thoroughly evaluated by clinical and diagnostic studies.
- Try to follow the course of subjective AND objective data through an accurate timeline. Is it possible? Or is something missing?
Finally, take the time to learn what is really subjective versus a measurable and verifiable finding. Even if you don’t fully understand the clinical picture, a common sense approach to reviewing the data is always helpful.
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 – and get to the bottom of what is really important in a case – you’ll be missing critical elements to the case or claim that you’re investigating.
Working with an expert always brings about new revelations. It might happen at the gym. And it definitely will come when you work with one of our LNCs.
Questions? Contact us.