Imagine reading a story where each chapter was written by different authors, and as you read through the pages you discover that each new chapter seems to provide a recap of the relevant history needed to understand the upcoming events. But as each chapter opens with the same background, some of the minor details appear to be different and begin to confuse the reader as to what history they should be using to inform their opinion of upcoming events. This is what happens when you have multiple authors contributing to a story without the proper coordination.
In behavioral health treatment, particularly inpatient and residential settings, it is so easy for a team of providers with the best intentions to innocently provide conflicting information to the story that we know as a patient’s chart.
Chapter 1: The patient arrives for detox
Consider Chapter 1, when a patient first arrives at the facility for detox. The medical staff begins a Nursing assessments that includes taking vitals, a review of past medical services, and asks the patient to paint a picture of their complete substance use history.
At this time when the patient arrives for detox there are so many variables that can lead to what will amount to either an incomplete or inaccurate account of pertinent historical information. Patients are often under the influence of drugs or alcohol at this time, or have undergone a typically “one last day” before checking in for detox.
Whatever the reasons, starting detox can often result in the patient either knowingly or unknowingly providing a false medical or substance abuse history.
Chapter 2: The clinical assessment
It could be up to 24 or 48 hours later when the patient receives a complete clinical evaluation. Clinical evaluations often overlap some of the medical and substance use history questions from the initial detox screening.
This time, the patient is no longer under the influence of drugs or alcohol, and it is not common for the answers to those questions to change. They may have previously understated a certain part of their history, or in sobriety are much less forthcoming than they were under the influence. The point here is that between medical assessments and clinical evaluations, answers to patient history often undergo some change.
Chapter 3: Providing medication
Medical history is an important part of prescribing medications, and we need to consider the possibility that a key part of medical history was provided during the clinical evaluation instead of the medical assessment.
If those involved in prescribing medications look at only one or the other of the evaluations to educate themselves on patient history, the possibility for a poor decision looms, due to lack of coordination.
Chapter 4: Treatment during the stay
As the episode of care continues, the different services providers begin to make treatment decisions based on the information in the patient’s chart. The nurses make their determinations, and the clinical staff theirs. But each is likely to base those decisions on the sections of the chart they know the best, which may contain different information.
Even for a mental health provider not making a medication decision, the absence of a hospital emergency visit for example, would be a piece of their trauma history missing from treatment considerations.
You may also enjoy the article: Trauma Informed Care Is More Than Trauma Focused Treatment
Chapter 5: Group treatment planning
If there are discrepancies between the mental health “story” and the medical “story,” it makes group decisions harder. If a group of providers is trying to decide about whether to discharge a patient, one side may make the decision to not discharge, and then the other team may have to continue treatment not knowing why. On the other hand, one group may decide to discontinue treatment and send a patient home that has not yet received all services that should have been provided to ensure that the patient is ready to function in society and is not at high risk for recidivism.
Epilogue: Common overlap questions
Some of the discrepancies that result from overlapping questions are predictable, and identifying them is the first step toward reconciling your patient charts into a single story. Here is my list of common question types that produce discrepancies between the medical and mental health sides of inpatient treatment programs.
- Substance Use History
- Prior Hospitalizations
- Family History
- Medication History
- Risk Assessments
- Suicide
- Emotional abuse
- Sexual promiscuity
- Hallucination
- Others
- Current status
- Mood
- Behavior
- Appearance
- Hygiene
- Speech
- Affect
- others
The bottom line is that you need to end up with consistently updated patient charts that tell a single and accurate story about each patient. The most effective way to do this is to use an electronic clinical record like eCR™ that can keep track of all patient information and reconcile all answers to similar questions.
Whatever method your agency works out, having one story per patient is critical to making the best possible treatment decisions in inpatient and residential treatment programs.
