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.
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.
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 with so much dental damage – and pain – would likely not wait four weeks to seek evaluation or treatment.
And, while some of this might be a mixed bag of acute and non-acute findings, those findings clearly did not fit the alleged mechanism of injury and the claimant’s report that he suffered no facial and head trauma at the time of the accident.
I recommended that BEFORE payment consideration be made, the carrier should request additional documentation that supported the initial mechanism of injury and lack of oral injury. I also recommended asking the treating dentist to explain the current findings in light of a four-week treatment gap.
We often review claims with dental injuries. These can be tricky. The information documented in a dental record is often presented very differently than a medical record.
There may not be the familiar “dictated” note. The daily visit notes are often handwritten abbreviations and acronyms known only to dentists and hygienists.
Sure, there are other components of the dental record, including medical and dental histories, diagnostics and X-rays, personal information and electronic records, among others. But this information is often not submitted with a liability claim.
Getting to the truth takes ingenuity, a willingness to dig and a practical understanding of trauma care.
Here are studies, reports and stories that caught our eye in the last month.
Workers’ comp safety net: Panelists and audience members at the recent Workers’ Compensation Research Institute conference say the workers’ compensation industry must play a role in a broader safety net as “job security, employer-funded pensions and health insurance is weakened,” according to an article in the Insurance Journal. Participants also want professionals and policymakers to clearly define what responsibilities they have for those falling outside the workers’ compensation system, including aging workers with chronic illnesses, undocumented immigrant laborers and those working in the gig economy, the article says.
Blood pressure and dementia: Middle-aged people who have a sudden drop in their blood pressure could be at risk of developing dementia and other cognitive decline when they get older, according to new research from Johns Hopkins Bloomberg School of Public Health. An article in Medical News Today about the research says that “temporary, rapid drops” in blood pressure may cause “serious damage” because they “stop the necessary blood flow from reaching the brain.”
Impact of arthritis on healthcare costs: New research from the Medical University of South Carolina offers the “first time the relationship between arthritis or joint pain limitations and medical expenses has been examined in a large U.S. cohort,” according to an article in MedPage Today. Researchers found, according to the article, that “activity limitations may explain the difference in medical expenditures between patients with arthritis or joint pain and those who don’t.”
Curbing drug use at the ER: A simple conversation about cutting back on drug use during an emergency room visit could be the “basis for a long-lasting drop in a person’s use of illegal drugs or misuse of prescription medicines,” according to new research from the University of Michigan. According to a press release, the “findings, from a carefully designed randomized controlled trial involving 780 people at a Flint, Mich., ER who indicated recent drug use on a health survey, suggest that ER visits might serve as effective ‘teachable moments’ for drug use.”
Palliative care boosts quality of life: Patients who received palliative care during a bone marrow transplant report better quality of life, according research at Massachusetts General Hospital, but more study is required to determine the long-term outcomes and costs, reports the National Institutes of Health.
Study finds that truckers’ poor health could spike crash risk
Truckers with three or more medical conditions carry two to four times the risk of being in a crash when compared to healthier drivers, according to a new study from the University of Utah School of Medicine.
Researchers say the study indicates that truckers might not just be a danger to themselves – but to other drivers on the road, according to a press release about the study. The results were published in the Journal of Occupational and Environmental Health.
“What these data are telling us is that with decreasing health comes increased crash risk, including crashes that truck drivers could prevent,” says the study’s lead author Matthew Thiese, an assistant professor at the Rocky Mountain Center for Occupational and Environmental Health, in the press release.
Researchers looked at medical records from nearly 50,000 commercial truck drivers. Nearly 35 percent showed signs of at least one of many serious medical conditions such as heart disease and diabetes that are connected to poor driving. Then, researchers compared a driver’s medical and crash history.
According to the study, there were 29 injury-causing accidents among all truck drivers per 100 million miles traveled. For those with three or more illnesses, it spiked to 93 injury-causing accidents per 100 million miles traveled. Accidents increased regardless of a driver’s age or experience.
Current guidelines require that truckers stop driving only if they have a major health concern, not a variety of less serious illnesses. Researchers said they need to continue to study the issue to determine the best practices to keep both truck drivers and the public safe on the road.
“If we can better understand the interplay between driver health and crash risk, then we can better address safety concerns,” said the study’s senior author Dr. Kurt Hegmann, director of the Rocky Mountain Center, in the press release.
Here on the MKC Medical Management blog, we’ve said it before. When evaluating vehicle accident claims, it’s critical to consider pre-existing conditions that could have caused the crash and could impact the level of injuries – not only to the drivers, but to other people involved.
A thorough reading of emergency room and other health records is critical to suss out all of the relevant information and how that information impacts the claim whatever the payer source. That should always include pre-existing conditions.
Need help? Contact our experienced staff of legal nurse consultants.
Here are studies, reports and stories that caught our eye in the last month.
Changes for casualty insurance market: An article in Property Casualty 360 ticks off the 10 trends that are expected to shape the market this year. They include increased employer and workers’ compensation complexities, more underwriting scrutiny and a push for higher casualty rates, among others.
Patients skeptical of healthcare information technologies: Concerns about cybersecurity are among the reasons why more than half of consumers are leery of the benefits of healthcare information technologies such as patient portals and electronic health records, according to an article in FierceHealthcare. What’s more, 70 percent of Americans don’t trust health technology, up from only 10 percent three years ago.
Sepsis readmissions: Sepsis is a leading cause of unplanned hospital readmissions. And, once there, patients’ hospital stays are longer and more expensive when compared to those with heart failure, pneumonia and other illnesses, according to a study in JAMA. Researchers make recommendations for ways to reduce readmissions and cut costs.
Technology helping with diagnosis: An article in MIT Technology Review explores the new technologies, including smartphones and machine learning, that uncover vocal patterns that could help doctors diagnose everything from post-traumatic stress disorder to heart disease.
Opioid alternatives: As healthcare professionals and entrepreneurs look to curb the use and abuse of opioids, new technologies on the market seek to offer alternatives to opioids for chronic pain. An article on CNBC.com covers this growing class of FDA-approved devices.
For more great information and topics, check out our blog on MKC Medical Management.
How technology is helping doctors spend more time with patients, less time with paperwork
The next time you’re at the doctor’s office, it might not be just you and your doctor involved in the conversation.
A medical scribe also could be listening in thanks to new technology that uses Google Glass, the headgear that looks like a pair of glasses, but is connected to the Internet.
It’s touted as a timesaver for doctors, who spend as much as 35 percent of their day on recordkeeping. Proponents also say it’s a better way for doctors to build relationships with their patients because they can look them in the eye instead of down at computer screens or a clipboard to check and update records.
With the software, made by Augmedix, doctors put on a pair of Google Glasses, which have a camera and microphone built in, and are able to interact with their patient’s medical records with simply their voice. During the visit, a medical scribe watches and listens in.
The scribe, trained to work with a particular practice, can answer the doctor’s questions about a patient’s history, for instance, and, once the exam is over, help ensure the records for that day’s visit are complete.
For doctors, the technology allows for hands-free recordkeeping as they direct medical record updates with simply their voice. Doctors must approve any records before it becomes part of a patient’s permanent record.
The service also complies with HIPAA requirements. According to an article for Stanford University’s medical school, patients sign off that they want to use the service before they meet with the doctor. Nearly 100 percent of patients agree, said Pelu Tran, the company co-founder who was a Stanford medical student when he launched the company.
Scribes for Augmedix work from offices in San Francisco and India in sealed-off rooms and must leave pens, paper, smartphones and other belongings outside, according to an article in the Washington Post.
The company is growing by leaps and bounds with big customers – Dignity Health, Sutter Health, and TriHealth, among them – and big investments. So far, funding has totaled more than $60 million, according to an article in Medscape.
At the Consumer Technology Association 2017 Digital Health Summit in January, Augmedix cofounder and CEO Ian Shakil called Google Glass the “stethoscope of this century,” according to the Medscape article.
And it’s expected to help fuel the medical scribe industry. By 2020, a report in JAMA estimates that doctors will employ about 100,000 scribes or one scribe for about every nine doctors. There were about 20,000 medical scribes in 2014.
As the technology and acceptance grows, it could be a boon for patients and doctors. Patients get more focused, one-on-one time with their doctors.
But, for doctors, overwhelmed with recordkeeping requirements, it could make an even bigger difference. A recent study in the Annals of Internal Medicine found that for every one hour spent with patients, doctors spend another three to four hours on computer and clerical work, leading to burnout.
With technology like Google Glass and Augmedix, they could be spending more time with their patients – and much less time on the paperwork.
Celebrating 2016, ready for what 2017 brings
Last year was a busy year for MKC Medical Management.
In 2016, we saw a 15 percent increase in business, thanks to multiple newaccounts coming on board and increased referrals from our existing client base.
Along with more clients, our roster of employees also is expanding. We now have 10 legal nurse consultants working for us either as full or part-time contractors.
Some have been with us for six years, when we started actively working to grow MKC’s presence. Our newest hire came on board four months ago. All are experienced registered nurses who, together, bring decades of experience in medicine. In fact, after so many years hiring such capable LNCs, I recently shared some tips in Attorney at Law Magazine.
And we take our job seriously. Being an MKC LNC is a demanding job with a steep learning curve. We require excellence and continuing education. We meet virtually a couple of times each month to analyze and discuss reports.
We’re not surprised by last year’s growth. As medical tests, health records and treatments become more complex, attorneys and claims adjusters are turning to us more often to help them ferret out the most important details of their cases and claims. Emergency room records, especially, are critical to building a solid case, but are growing in complexity and difficult for a layperson to fully understand.
In fact, 2017, already, is shaping up to be big.
Business is up nearly 30 percent over the same time last year as we work to increase referrals and gain visibility across the industry. In the past several months, you may have seen our articles in prominent publications such as Property Casualty 360. Our article, “10 red flags that could signal fraud for vehicle accidents,” was the fifth most popular article on Property Casualty 360’s website in January.
We look forward to all of the possibilities and continued opportunities in store for MKC Medical Management in 2017. And we are eager to help our clients – new and existing – get to the bottom of the claims and cases on their desks.
Let us know how we can help you.
Continuity of care and information are critical when reviewing a medical record. It all begins with the initial injury, but the continuum of information, evaluations and treatments travels through the entire medical record.
And, what first started out as a nice straight line quickly becomes a bowl full of spaghetti with plenty of nuanced twists and turns. It takes an expert’s eye and first-hand experience to follow these long, slippery strands.
Here are six tips to avoid getting tangled up yourself:
Look at each medical provider closely and on its own merit. Does the information at the beginning of the record hold true at the end of the record? This is particularly important for emergency department records. For example, did both the ER triage nurse and the physician get the same information?
Check for consistency: When a claimant or patient is seen by another provider, does the information about the injury, event or diagnosis remain constant and consistent or does it morph into something else? If information does not line up, then that should be a red flag for the attorney or adjuster that something – a crucial fact or piece of data – may be missing or even misrepresented.
Pay attention to shift changes: If you are reviewing an inpatient stay record, look closely at the change of shift documentation. Nurses report to other nurses when there is a shift change. Is the information documented by the receiving nurse the SAME as what had been noted earlier by the departing nurse? If not, that’s another red flag.
Track the ordering physician: When reviewing a diagnostic report, look at the reported diagnosis and ordering physician. Is this information consistent with other documentation? Sometimes you can determine that a new physician has been brought in on the case as that physician is the “ordering physician.” This is especially true for outpatient diagnostic studies. Remember: Consistency and continuity are key.
Examine what the injured party is reporting or describing to each provider. Is it consistent or does it change or grow? The information should be fairly consistent and make sense in the context of the alleged event and throughout ongoing treatment documents.
Follow the trauma timeline through the record. Look at timing and treatment, along with the associated responses. Did something new or different appear long after the initial injury? If so, is it a secondary complication or truly a horse of a different color?
This process can be daunting, especially for a non-medical person. That’s where Legal Nurse Consultants can help.
We are used to following that slippery string of spaghetti. From receiving a report from a medical colleague to documenting the reason for a test, a nurse typically does it all. LNCs take this invaluable work experience and overlay it onto insurance and legal files. We follow the pieces and make sense of that tangled mess.
Sometimes insurers must spend a little more to get best outcome
No matter what type of insurance line is involved, medical care will often be the largest part of the claim. The associated care and treatment will be the primary driver of damages.
So how do you get a handle on the medical aspects of a claim and the associated charges so that an optimal outcome is achieved?
Here are some tips:
Be proactive: Don’t wait. Work the claim aggressively. Open medical cases take on a life of their own and can quickly spiral out of control. Review all material as soon as you get it. A single diagnosis code can be a big tip.
Use all internal and external resources: Pull out the stops and USE resources – internal and external. Medical review software can help. Medical professionals are just an email away. At MKC Medical Management, we often get questions by phone and email on basic things.
Don’t be penny–wise and pound foolish: Sure, medical reviews through experts or software can sometimes be expensive, but, in the long run, they will pay off. Take advantage of the resources. For smaller claims, more basic reviews are always a great place to start.
Look at the fundamentals of the case: Really focus on the foundation of the mechanics of the injury. Ask for initial vehicle AND bodily impact points and verify initial complaints against the medical visit, records and police report, if available.
Set the reserve early: Early assessment and analysis is key to setting the initial reserve. Do frequent re-assessments against new medical records. If you’re not sure what the records indicate, consult an outside medical provider for additional insight and prognostications.
Don’t jump the gun on settlements: Depending on the diagnoses, it may not be advisable. Conditions such as burns and head trauma often improve with time. In fact, for many conditions, maximum medical improvement, the point when a patient’s condition is stabilized, is not until two years after an injury.
Evaluate, review and consider ALL co-morbidities: Diabetes, hypertension, osteopenia, peripheral vascular disease and many psychiatric conditions can have an influence on the injury sustained. If you don’t know the impact, ask a medical professional.
Look at the medical case as a whole: Don’t just review the narrative or bills on their own. Review the documentation side by side. Are critical pieces of information missing?
Seek an outside film review: This may sound expensive, but, when possible, have a physician review the actual films, especially if you don’t have the written diagnostic report.
Anticipate higher emergency department care: The cost for all emergency department care is going up and becoming more costly every year. Review ALL emergency department documentation carefully. Seek help with an expert in deciphering the records.
Upfront, thorough medical reviews can be costly and time consuming. But, in the end, they can result in the best outcomes for both patient and insurer.