Writing Your First Report

Posted on January 11, 2014 | 2 comments

There is no “correct” way to write a consultative report, and so much depends upon what your attorney wants.  What do you think the attorney needs to see?

This is just my personal style. The first thing I write is an introductory paragraph that cites the patient’s name, claimed injury, and brief description of that injury and residual damages. I end it with my opinion, right up front. This may be the last sentence I actually write, but it should be prominent, with any disclaimers.

I might then have a section that lists the supportive evidence. Bullets are great for this. I follow with mitigating information that may work against the claim, probably in paragraph form, to allow your positive bullet points to take center stage.

I also have a bullet list of pre-existing or comorbid conditions that influenced the outcome of the injury. If these conditions are likely to be unfamiliar to the attorney, I will footnote rather than clutter up this section with parenthetical references. If there is a complicated concept I may use a graphic (who wants to describe a foot orthotic or a fundoplication or ICP screw when a simple image says everything). I only use one or at the most two to maximize the impact without my report resembling a comic book.

What comes after depends upon the type of report. If I have done a chronology, I do not include all that data into the report – that is why I wrote a chronology. If it is a stand-alone report, I will include more information about the timeline of events and injury, but a chronology is always preferred.

This is where I would address standards of care, if applicable, contributory negligence, and how the case might have resolved but for those issues, whatever they may be.

If I can clearly see the opposing position, I will point that out and offer any counter points.

I end with a list of considerations for the attorney to pursue. This includes the experts that he will need to support his case; specific records to request (always get the ones that predate the event and the most recent since you will rarely have all of either). No matter how strong the evidence, I know that an expert “will be needed to confirm the…” because the attorney cannot base his case upon my opinion. Attorneys will often go forward with a mediation without an expert, and with great success. The decision is theirs.

Elements I like:

• Bullets, as mentioned – using phrases instead of complete sentence structuring allows me to express things succinctly and with more impact

• The use of only one font unless I do something different in a section header

• Bolded headers in a larger font, usually in dark gray so that it stands out but isn’t too heavy

• Sentences that are no longer than the ones in this blog

• A header beginning on page two that lists “Confidential Attorney Work Product”, with case name under that and the page number under that.

• A complete absence of the use of first person – my opinion is based upon objective evidence, not my feelings

• Absence of emotional input – state the facts clearly and strongly and they will speak for themselves – “this poor dear lady” is just not my style and does nothing to support the case. The attorney will often use that language in his pleading.

• I end with appreciation for the consult, state my availability for further communication, and offer to review further medical records as they arise or fulfill other needs such as expert location

• I sign with “Respectfully Submitted” even if it is an attorney I work with all the time, because it is respectfully submitted

• If I used reference materials for the report, I will cite them.

It is a “process”, and you will find a way that works best for you. There was a time when my reports were in paper, like a portfolio. But in those days, records came in banker’s boxes. Shudder. For quite some time, all data exchange has been electronic between the attorney and me. Records have to be in pdf form; a product like Adobe Distiller AC with its ability to OCR, combine files and reorganize pages, is a must.

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Posted in New LNC Advice

What Your Attorney Needs from You

Posted on January 10, 2014 | Leave a comment

You should ask this question at the start of each new attorney-client relationship. I am not referring to the attorney’s area of specialization or their orientation towards defense or plaintiff work. I am speaking about their business and personal preferences, their personality, their desires. Despite having your own (no doubt strong) personality, you must adapt yourself to the communication and business style of the attorney.

I have a good rapport with some attorneys who like to share personal information and do not bother to begin and end emails with salutations. They encourage independent thought, brainstorming of theories; we have a mutually respectful and somewhat casual relationship.

There are also very formal attorneys, recognized immediately by their communication style. Respond to them in the same manner they address you. Begin your emails formally, pay close attention to your grammar and do not try to woo them with your witty asides. These attorneys may have a sense of humor but they do not know you well enough to share it.

Most attorneys have a very specific idea of what they need. They may want a detailed chronology and your personal opinion, but they will keep your opinion in-house. They may ask for a second chronology that does not have your name on the report, or your opinion in that optional column. You are their private resource and they need the opinions of experts to be based on clinical facts, not your intuition or experience. Your value is in your invisibility even though/because they are relying heavily upon you.

Some attorneys simply do not know what they want. They may have a case that falls outside their comfort zone. They may ask you how to proceed with experts, and dependently seek input. While this may be flattering, it is the trickiest case to manage because you cannot cross the line between nursing and the law. You are never responsible for their legal decision-making and you certainly don’t want to be responsible for the wrong opinion.

Be comfortable with yourself. Never accept demeaning or verbally abusive behavior even when putting your ego on the back shelf. This is a challenge for most nurses. We are an opinionated bunch and our opinion is what gives us value. Nonetheless, remember that no matter how close your affiliation with an attorney may become, it is first and foremost a business relationship. Their chief goal is to advise and satisfy their client. You will be most helpful if you ask them what kind of report, what kind of information, and what type of presentation they need from you. Then deliver a product that is unequivocal and fact-based, because the one thing all attorneys need is the truth.

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Posted in Attorney-Talk, LNC Skill Development, New LNC Advice

The Mental Health Divide, Part II

Posted on November 11, 2013 | Leave a comment

continued from October 24, 2013)

More about the five axes of the DSM-IV-TR:

• Axis I relates to Clinical Disorders, which include all forms of depression (severity and recurrence), anxiety and mood disorders, PTSD, schizophrenia and psychoses. Think of these as disorders that are acute or chronic, biologic or reactive, but generally responsive to psychotherapy alone or in combination with medication. • Axis II reflects Personality Disorders, or features and traits that are lifelong characteristics that often interfere with daily functioning, relationships, and adaptability. Depending upon the patient’s insight and motivation, these traits are addressed via a range of psychotherapeutic approaches, either alone or in combination. Examples include Dependent, Avoidant, Obsessive-Compulsive and Narcissistic Personality Disorders. The most commonly used diagnosis is 301.9 – Personality Disorder NOS with (fill in the blank) Features when more than one trait is problematic. An IQ that falls below a certain threshold is also listed under Axis II. • Axis III lists the physical conditions present in the individual, and these are particularly pertinent to patients with chronic pain, injury or serious illness. • Axis IV outlines the psychosocial factors such as family dynamics, housing, occupation and finance that are affecting, or affected by, the individual. • Axis V measures the Global Assessment of Functioning (GAF), a numerical scale that assesses an individual’s ability to function in all areas of life, based upon the combination of Axes I-IV.

The DSM-IV-TR vs the DSM-V

Since its inception in 1952 and throughout its revisions, the accuracy and validity of the Diagnostic Statistical Manual (DSM) for classification of psychological symptoms has been challenged. Dr. Allen J. Frances, Professor Emeritus at Duke University, chaired the DSM-IV-TR task force (year 2000 Text Revision) and publicly objects to the impending release of the DSM-V.

An active blogger for the Huffington Post, he urges clinicians to ignore it’s changes altogether, asserting that the new version is vaguer than ever and will lead to labeling healthy individuals with its lowered threshold for criteria. In one of his blogs he states that the DSM-V is “offering its untested new diagnoses that will mislabel millions of the worried well as mentally ill”.  Parents of autistic children have the opposite concern, that their child will no longer fit in that diagnostic category and be denied access to medication and therapy.

Frances states that the DSM-V offers no leeway in differentiating, for instance, alcohol addiction vs dependence vs social use. The manual’s authors counter that early recognition will result in early intervention, but many practicing clinicians fear that the endpoint will be over-diagnosis that misidentifies normal variations in behavior.

The National Institute of Mental Health (NIMH)

On July 3, 1946, President Harry Truman signed the National Mental Health Act, which called for the establishment of a National Institute of Mental Health (NIMH). The process of diagnosing without etiology is the fundamental distinction between the DSM’s function and the conceptual model now proposed by the National Institute of Mental Health.

NIMH rejects all DSM versions and is devoting its considerable financial and scientific resources to the premise that all psychological conditions are biologic or chemical in nature, originating in specific regions of the brain, and thus amenable to medical intervention.  The stakes are significant – for insurance reimbursement, financial grants for research, pharmaceutical financing, and one hopes, the well-being of patients. Citing the difficulty in properly diagnosing mental health disorders when forced to choose an ICD code, in 2008 NIMH implemented its Strategic Plan, a diagnostic process using Research Domain Criteria (RDoc).

This plan utilizes a matrix of Constructs (rows) that are grouped into five Domains of Functioning, and seven classes of Variables (columns) with an eighth column for paradigms. The goal is to classify mental disorders along a continuum of biologic and genetic markers, neurological circuitry and specific regions of the brain. The attempt is not to diagnose a mental disorder by looking at the overall patient presentation, but to find one symptom that is present across a variety of disorders, eventually pinpointing the physical location of the symptom. This intersection would identify the origins of disease, and science (psychopharmacology) would intervene to avert mental disorder. This theory ignores the empirical research on the greater efficacy of “talking therapies” either alone or in combination with psychopharmacology, and even NIMH agrees that this lengthy research offers no immediate relief to patients.

Opponents to RDoc fear that severe illness (schizophrenia, bipolar disorder) may go untreated if the affected individual does not express a specific gene. They question the validity of research that is conducted solely in laboratories and does not involve practitioners in the field. NIMH counters that RDoc is an open document for which they have sought input from the medical community.

The term “Ivory Tower” designates an environment or atmosphere where intellectuals engage in pursuits that are disconnected from the practical concerns of everyday life” . The last sentence in the first paragraph of Draft 3.1: June, 2011 states that one of RDoc’s goals is “…to facilitate commentary from scientists and other interested stakeholders…” Should there be concern that patients and practicing clinicians are not mentioned in this sentence?

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Your Attorney Knows this – Do You?

Posted on October 13, 2013 | Leave a comment

Regardless of which side retains you as a legal nurse consultant, you are working on issues of defense.

The public is perpetually confused about the term “defense” in a lawsuit, but the distinctions are clear. Civil torts encompass personal injury in all its non-criminal forms of malpractice, negligence, product/premises liability and toxic torts, and every area of business disputes. Defense and plaintiff attorneys are mirror images of each other and can reliably predict the opposition’s plan of attack.

In a civil tort, the accused party is represented by defense counsel; the accusing party is the plaintiff.  Resolution for the successful plaintiff involves financial restitution to make the injured party “whole” either through mediation, arbitration or trial. The exception occurs when the case is dismissed in summary judgment by the judge who finds inadequate support for accusations. If dismissed with prejudice, the accusation cannot be brought again; without prejudice allows the claimant to re-file with a different set of facts and accusations.

In a criminal tort, the person who has been accused of a crime is also represented by the defense. The accusing party is the prosecutor who represents not the victim, but the People in crimes against society. Resolution comes in the form of punishment if the accused is found guilty. Society as a whole is the “plaintiff” since the behavior of the accused is a threat to all, not just the intended party.  This distinction leaves the victim free to file a civil tort against the accused whether or not he/she is found guilty of criminal behavior.

In both civil and criminal torts, the need for a defense is predicated upon an accusation. As a plaintiff LNC, you will defend the injured party in civil torts by mounting an offensive that verifies the four “D”s and is bolstered by research and expert testimony. As a defense LNC, you will defend the accused party with an offense of mitigating factors, intervening/superseding proximate causes or outright proof of no wrongdoing.

The Defense Department protects the United States with a proactive offense, as much as the government allows. The old adage that the best defense is a good offense is the application of this basic principle.

It is imperative that legal nurses understand both sides of every case in order to be to be equally comfortable in both worlds and proficient in our nursing roles.

Irrespective of which side engages you as a consultant, you are playing both offense and defense.

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Posted in New LNC Advice

The Mental Health Divide, Part One

Posted on July 28, 2013 | 1 comment

The Mental Health Divide

-Alice M. Adams, RN
Atlanta, Georgia

 

(Disclosure: I have worked fulltime for 20 years and now part time in a clinical psychological practice. As a nurse and patient advocate interfacing with physicians, nurse case managers and attorneys, dealing with insurance reimbursement was once 5% of one day a week; now it is closer to 20% of every day. Personal experience flavors objectivity in all of us.)

 

During the past month, the news has made the public aware of what mental health professionals have long been aware: the diagnosis of mental disorders is inexact, and treatment often proceeds without a known etiology.  In the real world of patient care, clinicians measure success in terms of empirical progress; has my patient improved, plateaued, or worsened? The answer is derived by objective observation and the patient’s self-reporting. But even objective observation contains an element of subjectivity, accounting for the diagnostic variability among clinicians examining the same patient.

Insurance and Pharmaceutical Influences in Diagnosis

The International Classification of Diseases’ (ICD) diagnostic codes govern the reimbursement of all care. Insurance companies require ICD-9 (and 10) codes from the DSM-IV-TR before they will authorize the evaluation or treatment of any mental disorder.  Psychologists and psychiatrists must choose a code that most closely matches the symptoms. A depressive episode is coded and further refined by duration, intensity of symptoms, single episode vs recurrent, and weighed against alternative diagnoses. The accuracy of diagnosis is largely dependent upon honest and complete disclosure from the patient.

But diagnoses fall in and out of favor; in favor they are overly utilized and can result in excessive labeling. Such labels facilitate insurance reimbursement and garner the attention of pharmaceutical companies. Recall when Ritalin was the only drug for ADHD replete with side effects and adverse reactions. Pharmaceutical companies took notice and funded extensive studies and trials that resulted in more targeted drug regimens. More funding and medication options in turn resulted in more ADHD diagnoses. And so on.

The DSM-IV-TR vs the DSM-V

Since its inception in 1952 and throughout its revisions, the accuracy and validity of the Diagnostic Statistical Manual (DSM) for classification of psychological symptoms has been challenged. Dr. Allen J. Frances, Professor Emeritus at Duke University, chaired the DSM-IV-TR task force (year 2000 Text Revision) and publicly objects to the impending release of the DSM-V.

An active blogger for the Huffington Post, he urges clinicians to ignore it’s changes altogether, asserting that the new version is vaguer than ever and will lead to labeling healthy individuals with its lowered threshold for criteria. In one of his blogs he states that the DSM-V is “offering its untested new diagnoses that will mislabel millions of the worried well as mentally ill”.[1] Parents of autistic children have the opposite concern, that their child will no longer fit in that diagnostic category and be denied access to medication and therapy.

Frances states that the DSM-V offers no leeway in differentiating, for instance, alcohol addiction vs dependence vs social use. The manual’s authors counter that early recognition will result in early intervention, but many practicing clinicians fear that the endpoint will be over-diagnosis that that misidentifies normal variations in behavior.

The National Institute of Mental Health (NIMH)

On July 3, 1946, President Harry Truman signed the National Mental Health Act, which called for the establishment of a National Institute of Mental Health (NIMH). The process of diagnosing without etiology is the fundamental distinction between the DSM’s function and the conceptual model now proposed by the National Institute of Mental Health.

NIMH rejects all DSM versions and is devoting its considerable financial and scientific resources to the premise that all psychological conditions are biologic or chemical in nature, originating in specific regions of the brain, and thus amenable to medical intervention.  The stakes are significant – for insurance reimbursement, financial grants for research, pharmaceutical financing, and one hopes, the well-being of patients.

Citing the difficulty in properly diagnosing mental health disorders when forced to choose an ICD code, in 2008 NIMH implemented its Strategic Plan, a diagnostic process using Research Domain Criteria (RDoc).

This plan utilizes a matrix of Constructs (rows) that are grouped into five Domains of Functioning, and seven classes of Variables (columns) with an eighth column for paradigms. The goal is to classify mental disorders along a continuum of biologic and genetic markers, neurological circuitry and specific regions of the brain. The attempt is not to diagnose a mental disorder by looking at the overall patient presentation, but to find one symptom that is present across a variety of disorders, eventually pinpointing the physical location of the symptom. This intersection would identify the origins of disease, and science (psychopharmacology) would intervene to avert mental disorder. This theory ignores the empirical research on the greater efficacy of “talking therapies” either alone or in combination with psychopharmacology, and even NIMH agrees that this lengthy research offers no immediate relief to patients.

Opponents to RDoc fear that severe illness (schizophrenia, bipolar disorder) may go untreated if the affected individual does not express a specific gene. They question the validity of research that is conducted solely in laboratories and does not involve practitioners in the field. NIMH counters that RDoc is an open document for which they have sought input from the medical community.  To be continued…

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Posted in Mental Health & Brain Games

How Much Time Does it Take to Create a Chronology?

Posted on June 27, 2013 | Leave a comment

How long does it take to compile a chronology from 5000 pages of medical records? It really does vary with each case. Sometimes a law firm will ask me not to produce a chronology with the goal of saving money; “just focus on xyz”. That is fine for an expert witness, but not for a legal nurse who is responsible for knowing about and explaining the medical issues of a case.  Invariably in a complex case, searching for a piece of data down the road or even later in the week will consume much more time than documenting it in the beginning.  This is true for pdf or paper records.

In medical malpractice, 5000 pages means hospital records and a range of healthcare provider data. Sometimes the sentinel event is clearly defined in a narrow time frame; healthcare prior to that point, while important to know, may be irrelevant to a wrongful death. When I receive a large paper case, the  first thing I do is heave it on the table and begin rapidly sorting into a stack that I know I will not need (but will keep), a stack that does not look important but may become so, and a stack that requires close scrutiny.

I work from the scrutiny pile in detail. Eventually, I will see a reference to something in my “maybe” stack so I return there to pull the page. By now, I have a feel for the case and will spot other important pages to pull. Every piece of paper that I reference in the chronology is retained in a new stack that is now taking shape. When all the data is entered, I sort it chronologically and read it again from a fresh perspective; chronological order makes it easier to identify missing records or redundant care.

I make a copy of that pertinent reference stack for the attorney. Oftentimes, my attorneys do not use or want Bates stamping unless it is mass tort (although it usually makes everyone’s job easier).  Either way, if they do not know the source of data, they or their paralegal will be wasting precious time trying to find it without this copy.

The chronology forms the basis of any research or articles that support, refute, or simply clarify my case.

Only then do I sit down and compose the report, which may only require a few hours initially. I always sleep on my report, re-read it the next morning and again later in the day. I then print it to see possible errors that were not evident on the computer. I repeatedly proof, determine that the ease of readability is appropriate and that the percentage of passive sentences is reasonable. I tweak it to death but I do not charge for this obsessive behavior – perfection is a relative term.

I present the data in a professional folder and off it goes, although the attorney may need the summary report immediately. If so, I protect the file so it cannot be altered and email it in advance.

From personal experience, the average time required to work up a case of this size is ~ 20 hours. The time may be more or less depending upon the event in question.  If the patient died in the first day or week of an event, it takes far less time to document than when tracking health changes over the course of time.

Large or small, the chronology is the basis for medical conclusions that may lay dormant for a year for legal reasons. A year down the road, everyone is grateful for this key document.

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Posted in LNC Skill Development, New LNC Advice

Still looking at those records?

Posted on June 15, 2013 | 1 comment

I do not question any MD’s ability to review a medical record; that would be questioning their intelligence. But physicians do not think like nurses. In hospitals, they assess medical conditions; listen to the observations of support personnel, order the care they believe is appropriate, and move on to the next patient.

If all errors arose from the wrong order or a misdiagnosis, then physicians would be excellent in the role of chart review.

When things go wrong, it touches many disciplines. Mistakes are not neatly typed and easily seen in the record – oftentimes they are found in a barely legible note on the corner of a page that does not translate into scanned text.

Physicians rightly assume their orders will be understood and executed, and that the rest of the hospital team – nurses, respiratory therapists, physical therapists, radiologists, pharmacists, wound care specialists, etc., will take care of the patient and assess the effect of what the MD has ordered.

They rely entirely upon nursing staff to report deviations, labs that are out of range, subtle changes in vital signs, breath sounds and condition, unplanned outcomes – in short, everything that the physician is not there to see with his own eyes. If a change in the patient goes unnoticed, whose fault is it? Always the nurse – follow the chain of command from CNA to bedside nurse, charge nurse, even Director of Nursing – mistakes flow uphill.

Who is responsible for charting, medicating, listening to patient and family complaints, ensuring proper nutrition, accurate IV administration and knowing when the I&O indicates fluid overload or the patient is having an adverse reaction to medications or blood, or seeing a discrepancy between a malfunctioning monitor and what the patient exhibits? Who knows when to question a physician’s order and is responsible for calling that doctor and expressing their concern? Who is responsible for knowing every section of a chart and what is missing?

This is what nurses do every day at the bedside. This is not the role of a physician, and a physician cannot see a chart from the perspective of a nurse.

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Can Anyone Create a Chronology?

Posted on June 2, 2013 | 3 comments

[Encarta Dictionary: English (North America) chro-nol-o-gy (noun) 1. Order of events: the order in which events occur, or their arrangement according to this order.]

This simple definition is what many professionals conceptualize when they think “chronology”. If it were that simple, I could present a high school student with 1000 pages of medical records from physicians, facilities, hospitals, etc., and instruct them as follow:

• Create a basic four column table with headers across the top for the Date, Page Reference, Facility, and Event
• Enter every doctor’s order, every medication given, and the results of all x-rays and lab work.
• Include all vital signs, and every diagnosis that is made along with the physician and date.
• Use a separate row for each type of event and be certain not to miss any of the above.
• Write down the abbreviations and terms as you find them, but do not look them up
• After entering all information, sort by date, spell check your work and review the formatting
• Email the chronology to me within the next ten days

The result would be a 100 page chronology filled with errors and minutiae, faithfully recorded without knowledge of its bearing on the case, deviations from standard of care, definitions of medical terminology, or ability to connect the many dots.

A legal nurse doing the same chronology would be seeing the case unfold in her imagination, having walked those hospital halls, cared for the injured patient with comorbidities, understanding policy and procedure while juggling physicians, ancillary staff and family.

A nurse doing the same chronology would likely produce only 20 pages of data after sifting through the information that is not relevant to the case. There would be a fifth column with observations, definitions, research data and identification of unrelated conditions.

This chronology would be not an endpoint, but merely the first stage of organizing the course of events to allow a pattern to emerge. Only when the pattern of care is established will the inconsistencies become apparent to the medical eye.

Can anyone create a chronology? Yes. Does that make it meaningful? No.

Length does not equal quality, and recitation without filtering is a waste of time, resources, and a client’s money.

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Posted in Attorney-Talk, New LNC Advice

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The Changing Face of Body Language

Posted on May 14, 2013 | 12 comments

As the daughter of an Army Drill Sergeant, I grew up around Fort Jackson, SC. We shopped at the PX, attended the Roman Catholic church on base, bought 29 cent gasoline and went to the movies for a quarter. But the place I seemed to spend most of my time was in the outpatient infirmary. I remember the wooden structures that were meant to be temporary when first constructed, the highly polished wooden flooring and ramps, the “shot” room where I received more than my share of Pen V for recurrent pneumonia and tonsillitis…many decades later it still feels like yesterday.

My most vivid memory though, is the nurses. All wore Army issue 100% cotton uniforms, starched and white, with sharp caps and polished shoes. From my vantage point, I could see little beyond large bosoms in sharp Playtex bras that preceded them into the room like the prow of a ship.  They terrified me. I remember hiding behind the medicine refrigerator when I knew a shot was imminent.

These nurses were tough, and a pediatric department was nonexistent. No lollipops for good behavior (and I would not have earned one in any event). I was expected to behave like a small soldier.

Many of these women had served overseas and their pride was evident in their bearing as they marched down the polished hallways, shoulders back and snapping salutes from the brow of their stern faces. They were subordinate only to God and outranking physicians. The distinction between the two was not always clear but my inferior position was never in doubt. My mom was also a nurse, and I secretly thought she identified with them more than me, her youngest national treasure. Of one thing I was certain; I would never become a nurse.

So much for that resolution. I too grew up to wear polished shoes and cap for graduation, but the hospital I worked for had a wonderful pediatric floor. Body language had changed.  I wore child-friendly smocks, tossed the cap after I kept losing it in the nebulizer tents, and there was a rocker in every room. No scary nurses allowed. Gently approaching children instead of pinning them down like feral cats was a solution the military had never conceived. Sheltering in mom’s embrace for injections took away some of the sting, and parents were calmed by having their own hands held after a particularly hard night.

When I transferred to ICU, body language was equally if not more central to the care of adults. They scrutinized our faces for indication of bad news as did their families. Amidst their lines, wires and tubing, they were vulnerable. Their spirits were buoyed by unhurried baths and clean bedding. Their families were less apprehensive when their loved ones looked well-cared for, and sometimes they needed a hug. They wanted to know we cared and that we would be there when the call light was not on, and that our shift ended when the work was done and not before.

In the latter 70s and early 80s, you did not wear gloves to start IVs, give baths, take vital signs or draw blood. Gloves were only required for trach and wound care, suctioning, Foley insertions, continent care and when isolation demanded it. Although today’s MRSA-resistant hospital environment demands protection for staff and patients, those gloves also communicate “unclean” to patients who crave human contact. Now more than ever, smiles and reassuring body language are indispensable to good patient care.

And honestly, who needs frown lines?

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Posted in Personal Thoughts and Experiences

Do I Have Your Attention?

Posted on April 25, 2013 | Leave a comment

I don’t know – do you have mine?

I was strolling through Costco a few days ago (if I miss a week the staff become anxious) when I overheard a young man speaking at a moderate volume into his earphone. He was speaking, but he was not listening. He was providing IT support to a client who either could not follow his instructions or was utilizing a wholly different program than the one under discussion.

I am not an eavesdropper, usually, but it was clear that he was shopping for groceries and envisioning a computer screen concurrently, and not doing either effectively. He repeatedly misinterpreted the problem and provided incorrect troubleshooting. He resembled many IT technicians who have stolen hours of my life without resolving my problem.

How do you know if you have someone’s attention, and are you also guilty of not listening effectively?

Here a few telltale and annoying signs of inattention on the other end of the phone:
• Papers rustling in the background – either the person is going through their mail, lost an important document or has vermin on their desk
• The conversation is one-sided but for the occasional “mm hmm” that passes for “I hear you”
• The same information is requested more than once
• You clearly hear the clatter of a keyboard that is not in sync with the conversation

Most of us can multitask to some extent, but none of us can anticipate the critical points in a conversation that require our full attention. If you miss that key sentence and find yourself fumbling to catch up, you have dropped the ball. Concentrate on the caller, or ask if you can call them back (the attorney, the expert, your mother). No one likes to repeat themselves.

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Posted in Personal Thoughts and Experiences

The Words We Choose

Posted on March 23, 2013 | 1 comment

A nurse’s comment on last week’s blog prompted this week’s content. She asked me how an attorney could be impressed by her writing style if she had never submitted a report for his review. The reality is that others form opinions of us with the first contact that occurs, whether that is through verbal or written communication.

One of the hardest things to write is an introductory email to a potential referral source. What do we say to catch someone’s attention? How do we present ourselves in a positive fashion and highlight our strongest features? No matter how highly we value our services or believe in ourselves, the person we need to impress has his or her own priority. And it is not us.

Attorneys are no different from anyone else; their own needs take precedence. Ideally, your email to a potential referral source arrives in their inbox at the exact same moment they need what you have to offer. If your expertise is not needed, your offer of service may go unnoticed.

If your email includes a link to a site/article/story relevant to the attorney’s practice area, it may marinate in his Inbox like an electronic Postit, but that is far preferable to being ignored, or even worse, deleted. These are surefire ways to have your email deleted or ignored:

  • Writing a novella about your background
  • Failing to research his practice, so you offer him medmal services when he only does product liability
  • Describing yourself in superlatives or absolutes
  • Using poor grammar, misspelling words or otherwise appearing less intelligent than you really are
  • Saying the same thing everyone else does (like listing all the 40 skills you have that will make his practice run smoother, give him more time, make him more money and win him cases.

Keep that first email short, pointed, and professional; this says you respect his time. Making it longer will not ensure a response and might land you in the Trash no matter how well it is written. 

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Posted in Attorney-Talk, New LNC Advice, Personal Thoughts and Experiences

Grammar & Composition 101

Posted on March 13, 2013 | 2 comments

I have read a number of first time reports sent to me for review by new LNCs. In the strictest sense, all of these reports were accurate representations of fact. In the literary sense, some were disasters.

When you compose a consultative report for an attorney, assume your reader is someone with no medical knowledge of the disease/injury/event/terminology. This is not true but it will help you write more clearly and avoid the use of medical abbreviations that are clear to healthcare personnel and no one else.

Many attorneys, particularly those who specialize in niche areas, are quite well informed about their client’s condition. Others make it their business to spend an inordinate amount of time researching the event around which their case revolves. Since most are quite bright, they can understand how a surgery should have proceeded, whether or not a delayed diagnosis made a difference in outcome or why the ER screening for pulmonary embolus might cause harm to a patient in the throes of pulmonary edema.

But no matter how well informed, they probably do not know why elevated BNP with CP radiating to the LUE might be a sign of STEMI. Nor should they have to. We walk the fine line between not talking down to our attorney while not assuming an unrealistic level of knowledge.

The point I am getting to (finally) is that no matter how skilled a nurse is in her medical charting, that skill does not enhance report composition and in fact, gets in the way of effective report writing. Your report may be the only contact some attorney clients ever have because they are out of state. I work with one attorney whose father was the editor for a national newspaper for 40 years. He avoided using LNCs “because they couldn’t write worth a damn” the few times he had worked with them. Regardless of their knowledge base, he could not respect professionals who had no knowledge of basic grammar and composition.

I’ll talk about how to let your fingers do the talking next week…and maybe the next few weeks after that…

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Posted in New LNC Advice, Personal Thoughts and Experiences

Deadlines & Commitments: What to Leave In, What to Leave Out (Bob Segar)

Posted on February 28, 2013 | Leave a comment

I know one good reason why there is a statute of limitations, and it has nothing to do with the law.

It has to do with human nature. Apparently, most of us were born with a dominant procrastination gene that expresses itself at every opportunity. Given the option of infinity, how long do you think some people would wait to file a claim? Just count the number of times someone calls us and declares “the statute is tolling!” (i.e., the sky is falling).

Why is it tolling? Most often, the deadline is looming because the claimant waited until the last minute to find an attorney, or the attorney waited until the last minute to address merit, or the expert took too long to review the records and prepare an affidavit, or in general, life happened and it is human nature to save the hardest work for last.

We have a statute of limitations because someone had to take control of this gene.
We have final exams because without them, most students would study for the immediacy of one test rather than retain the data for a “final” test. Trust me on this; I have four children.

There is a time to punch the clock, a time beyond which we are tardy, an alarm clock that awakens us, and a snooze button that apologizes for waking us up.

I need deadlines. I do. I need goals and objectives because without them, I am at sea. If I find it difficult to prioritize work or decide what onerous task needs doing first, I can let deadlines be my guide. But I always know that what I am really doing is finding a rational reason to put off until tomorrow what I should have done yesterday.

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Posted in Attorney-Talk, New LNC Advice

I’ll take jurors for 100, Alex

Posted on February 14, 2013 | Leave a comment

Jurors are called upon to make incredibly important decisions, and while they may be instructed to “stick to the facts”, those facts can be difficult to parse out. Both sides will argue for their client, and they will use every weapon from accusation to rationalization to “make their case”.

A good trial attorney knows that keeping it simple is best; that is why they pick a “theme”, a central point around which to build their case, independent of how many people are being fingered for wrongdoing. The theme should be constant: “This man would be alive today but for the negligence of xyz in monitoring basic vital signs.”

Behind this simple statement is an extremely complex and highly developed game plan geared towards subtly asking jurors to apply their own sense of right and wrong to their decision. Once the facts are clearly laid out, and all has been presented to them, jurors are asked to make difficult choices independent of personal morality (but who can really do that?).

I have talked about clinical nurses serving as testifying expert witnesses, and legal nurse consultants working behind the scenes to analyze medical records and develop a case. In many states, there is a third way to become involved in the legal world of healthcare, and that is choosing to serve as a fact witness about your review of medical records.

In this role, you take what you know about a medical situation and explain it to the jurors in a way that makes sense to them. You are not testifying against another healthcare provider; you are merely relaying the information found in the record, and explaining the more complex medical issues to jurors as lay people. This sounds a lot like talking to family members in the hospital, and in a way it is.

You are not rendering an opinion; you are informing, and your information can help clear the fog of legal arguments in the minds of those oh-so important jurors.

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Posted in Attorney-Talk, New LNC Advice

Sleep is good. Work is good. Working without sleep…not so good

Posted on February 5, 2013 | Leave a comment

Sleep and work. We spend more time doing these two activities than anything else in life.

The need for a good night’s sleep is evident in the number of medications, therapies and sleep aids that promulgate the market. But we do not need advertising to tell us what we already know – a bad night’s sleep makes us miserable the next day, less efficient, moody and irritable. No sleep at all makes us dangerous at the wheel and to our patients.

For years I saw medical and surgical residents come through my ICU, sleep deprived, complete with bed-head and stumbling gait, reaching for a cup of coffee to jolt their nervous system. I never understood how being on call for 24-36 hours was a good thing for anyone but the attendings who were getting a good night’s sleep. It certainly wasn’t necessary to prepare students for being in private practice, and it occasionally put patients’ welfare in danger.

I could relate. I alternated between (3) shifts every two weeks. The coveted morning shift was bustling with activity, diagnostic studies, lab draws, ventilator weaning, PT, OT, breakfast and lunch. No way was I falling asleep on that shift. The afternoon shift was quieter, family more present, bedside and surgical procedures occurring when they could not wait until the next day, but never scheduled for 8pm. It was a time, with any luck, of relative respite for patients and staff.

But those night shifts. I well remember charting at 5am, standing up because I was trying to stay alert and literally sleeping on my feet. The circadian rhythm of my brain was not attuned to working at night. I could not sleep during the day for more than two hours, and felt like a zombie the rest of the time. Oh yes – I fell asleep at the morning wheel on more than one occasion. Thank goodness for that part of the brain that never truly sleeps.

“The stream of information (to the brain during sleep) is considerably reduced, but the brain is not fully disconnected from the environment. An inspection of the environment takes place to optimize safety during sleep. Stimuli…signaling danger are recognized, and may enter awareness, leading to a wake-up call, which allows the individual to react. This subconscious stimulus evaluation is regarded as having a guardian function for sleep.”

It’s no wonder that we spend so much time thinking about our work and worrying about our sleep. When either or both are out of balance, we are miserable and unable to enjoy everything that happens between these two activities – like family and friends, recreation and exercise.

Bones grow during sleep, brains recharge, and unless we have nightmares, a good night’s sleep cures many ills. Let sleeping dogs lie. Sleeping like a baby. Shhh! the baby (nurse, patient, doctor) is sleeping.

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BYOB – Part III of III – Making it all Work

Posted on January 20, 2013 | 1 comment

You can minimize your expenses as a legal nurse consultant if you are willing to learn and work. But if you buy “stuff” first, I promise you will purchase things you do not need. It is akin to stocking your first nursery without ever being around babies; what looks good doesn’t always work well.

Sad is the nurse who finishes a program and immediately begins to hemorrhage money – either to pay for that program, or for an accountant to track their future billing and give them tax advice, an attorney to set up their corporation, a separate phone line for the calls that might come in, stationery coordinated with business cards, postcards, and brochures that cost way more than they are worth. Computers, fax machines, copiers…gifts to leave at the offices of cold-call attorneys…everyone and everything is more than happy to take your hard-earned money.

With Microsoft Word, you can easily create your own stationery, business cards and envelopes. They will not look homemade, and if you are anything like me, you will change your design a number of times before you settle into your own “look.” There have been many times when I change the wording on my business cards just prior to an attorney meeting or conference. So, you do need a printer, but get one that prints in color, can be fed hunks of paper for copying and faxes on your home line.

If you don’t want to use your home line, there are HIPAA compliant internet fax services. I use one. All my faxes go out through my computer and come in through my email. My LLC cost and business license cost…maybe 125.00; QuickBooks keeps track of my income better than an accountant, and I file my taxes as an addendum to my personal 1040. I have never paid a mentor but I have had many generous nurses in my life that served that role.

For many people, it is easier to spend money on things than it is to spend time on learning. But your letterhead, presentation folder and business cards will not create an exemplary work product – they will just make it look good.

A successful business gives the customers what they want. Your customers are the attorneys. You cannot produce a work product for them until you know in advance their needs and expectations. What you need is to know is the attorney’s expectations in terms of billed hours. You may not know what to tell him (1000 pages looks like a heck of a lot of work and didn’t you read somewhere that you should charge by the ½ inch?).

At first, it may feel safer and more productive to obsess about how to structure the report, rather than figuring out what to tell the attorney about billing. Bullets? Indentations? Outline or chart chronology? Should those references be footnotes or endnotes and do I need a reference list at the end?

These thoughts can be distractions from concentrating on meeting the attorney’s needs and expectations.
Over time, you will develop a report format that works for you and a style of reviewing medical records that decreases the chances of missing important data. Until then, your business will grow faster if you concentrate on satisfying the customers’ needs.

Everyone travels a different path even if the end goal is the same. All successful LNCs were new, afraid, skeptical, and unsure of everything except believing that an attorney would pull back the curtain and find the Wizard of Oz.

Insecurities never go away completely.

Times of doubt and fear will come regardless of how successful your business may be. There will be stretches when your phone doesn’t ring and you question your own work product. Your work universe may be much like the phases of the moon: sometimes the tide brings work in faster than you can keep up, and sometimes it all goes out to sea at the same time.

But if you are meant to surf and ride that wave – just get started.

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Posted in LNC Practice Building

BYOB Part II of III: Putting your nose to the grindstone

Posted on January 5, 2013 | Leave a comment

This post will delve more deeply into what to expect in legal nurse consulting.

First, expect to do a LOT of research.

Unlike testifying experts who specialize in a nursing niche, legal nurse consultants are asked to assist in many types of healthcare claims. No two are alike and I have never worked on a case that did not require a great deal of research on injuries or conditions. For me, learning is one of the perks of this field, and you really have to enjoy the process of discovery (not in the legal sense).

Your responsibility does not change with the side of the claim you are on, because your job is to find facts without preconceived notions of causation. You need solid research on this disease, its incubation and likely sources of exposure, the preferred treatment, the long term effects and cure rate, and the medical history of the patient before and after exposure. You need to open those records and find out what’s missing so you can inform your attorney immediately what he needs to request from other sources.

This brings up the second point:

Expect to look at medical issues from completely different angles.

You have a case. You have the stationery to write the report. You have all the equipment to produce it.

Suddenly, you don’t know where to start. This is puzzling because, after all, you are a nurse, and you do know about the standard of care, how to spot a deteriorating patient, when to challenge a questionable order, and what the inside of a hospital chart looks like.

The problem is that the case may not concern the delivery of care. For example, the claimant is a heating and cooling maintenance man who has worked in his field for 15 years without a hitch. Now he says that one blast of air from an older home has resulted in aspergillum lung infection with encapsulating scar tissue and he can never work again. That may be true, but as a legal nurse consultant you never accept a claim at face value. This man is not a patient, he is a claimant. You need to learn everything you can about this disease even though you are not the testifying expert.

Third, give aspirations time…and feed them with hard work.

I get many emails from aspiring LNCs who want advice on getting started. Some just want a nudge in the right direction so they can find things out for themselves. Some have not pursued any training programs. Some have completed a program but complain that “I read the books, took the test at the end, started emailing attorneys and it’s been three whole weeks without a nibble. What am I doing wrong? Just tell me what to do.” Or, “Let me work for you”. Or, “Do you know anyone who needs my help…I’m so discouraged.”

Do you know what these situations remind me of? Weddings. Two people love each other and plan a formal wedding. The sheer amount of work and money that goes into this event is staggering. They (she) get caught up in reservations, gift registries, invitations, flowers, catering, the dress, the dress rehearsal, and oh my God—the bride’s maids’ dresses. You can lose sight of what this wedding is for – the beginning of a new life with challenges and rewards, neither of which depends upon the wedding itself.

But eventually you do get married or you do get that first case and it is so exciting! You can tell your family you haven’t been wasting money, neglecting the house and starving the cat in vain. There’s nothing like the thrill of a new referral…and “putting your nose to the grindstone” to turn out an excellent report.

It’s time to work.

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BYOB: Building Your Own Business: Part I of III

Posted on December 18, 2012 | Leave a comment

Career complacency is something that sneaks up on you. The years pass quickly and you are comfortable in your secure job, attending the requisite training seminars and extremely competent in your niche.

But maybe you peeked out from under your rock and found that legal nurse consulting was a blossoming field of interest. Thanks to the internet, this once flying-under-the-radar career is now prominent. Even though you may be excellent in your office/clinic/hospital/job, you may be ready for change. Does a sense of urgency well up within you because everyone seems to know something you do not, and you cannot get started fast enough?

Just because you can do a thing does not mean you should do that thing.

It’s hard to be patient, but easy to get caught up in what others are doing because of the fascination (and desperation to escape less-than-desirable working conditions?).

Before jumping into starting your own business as an LNC, let me help you pick my brain for advice. These next few weeks, I’ll be covering a few things that you should consider before or during your transition into having your own business as a legal nurse consultant.

In planning this new career move, ask yourself if this is what you really want to do. Why do you want to be an LNC, and are you willing to put in the hours of learning that will truly never stop? Because even though this is a career you can step into without extra licensing or certification, becoming an LNC is not a lateral move from nursing. Success in your current job does not guarantee success in becoming a legal nurse consultant.

These are two different worlds.

Wrong preconceptions and bad reasons for pursuing a career in legal nurse consulting:

• You are tired of your current job and just want something new
• You know the hourly rate is triple what you make in a hospital and zowie, that sounds great
• You always wanted to practice law
• You assume it can’t be that difficult or no one would be doing it
• You have been documenting care for years, so writing a consult letter can’t be all that different
• There is just enough credit left on your card to stock a home office

While this post may have emphasized more negative points about becoming an LNC, next week’s post will bring to light some positive points about the world of legal nurse consulting.

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Posted in LNC Practice Building

When the shoe is on the other appendage

Posted on November 28, 2012 | Leave a comment

A nurse under fire deserves our support whenever possible. But is it always possible, and would you feel like a Benedict Arnold if you testified against another nurse’s care?

Think of it this way: when a person is harmed by negligence, you are not attacking another nurse; you are defending a patient.

Consider this recent case: An elderly woman with Alzheimer’s disease was in hospice and had been minimally responsive for several months. But then her physician decreased her sedation and she began talking with family, responding to her environment, and eating solid food. Her children were delighted with this gift of quality time and even her physician documented the marked change in her behavior. He did not connect the dots that he had overmedicated her (but that is another issue).

One night, a float nurse placed a high dose fentanyl patch on this lady’s chest, who had no order for any type of narcotic and no complaints of pain. Exactly how did that happen?

  • Why did the nurse not look for an old patch before placing a new one?
  • On whose chart did she document having applied the patch?
  • What was the effect on the patient who missed her rightful dose?
  • What is this nurse’s work history?
  • Did the facility report this event to the State Board of Nursing or Medicare?
  • Could this have been an attempted mercy killing?
  • Did this act result in permanent damages?

The patch was applied at 9am. At 9:45pm the patient was noted to have fluid-filled lungs and was given atropine, but the patch was not found for another 13 hours. By then it was too late to save her.

I ask you, who monitors pulmonary congestion for 25 hours and doesn’t see a patient’s chest while listening to lungs? If any nurse had looked, she would have found the patch. This case had many unacceptable breaches in care, resulting in death 70 hours after the patch was applied.

What do you think? Is this a family complaint you could get behind? Do you think the nurse’s action resulted in damages that ended in her premature death?

Remember, your job would not be to opine on causation, but to simply and objectively state your understanding of the standard of care in medication administration. Tell the attorney/jury what would constitute good care, and why failure to do so constituted negligence.

You can do that.

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Posted in LNC Skill Development, New LNC Advice

Thoughts for the New Nurse

Posted on November 22, 2012 | Leave a comment

1. Lay hands on your patient as often as you can – not just for auscultation or checking an armband as you dispense meds; see them, and know they are probably afraid

2. Sometimes a back rub or a foot massage offers more relief than a Vicodin – warm the lotion first

3. Respect your nursing assistants and make sure they know how much you value their input – tell them your concerns about a patient so they know what to look for, and compare their observations to your own.

4. You will never have a clearer memory of what you learned in school than you do right now – but you will know more about life, and nursing, with every day that passes.

5. Keep reading, studying, learning, and subscribing to free email alerts from places like WebMD. Go to conferences and stay connected with positive people who love what they do.

6. Don’t believe everything you read from medical blogs. The chemical/food/ beverage that causes cancer one week will probably be its cure six months from now.

7. The nursing process is a great blueprint that you will always remember and follow, but make sure your care plans are more than canned entries. Of course we want to “prevent skin breakdown” – add that back rub and foot massage to your care plan!

8. Keep your eye on theI&0, know your patient’s normal appetite and bowel habits, be aware that a suddenly confused patient with a Foley may have a UTI, and that the patient who pulls off their oxygen usually needs it the most.

9. Never let a shift end without a narrative about your patient despite (or because of) electronic documentation.

10. Be proud of your degree, but
      a. do not let initials define you
      b. never minimize the nurse who has two years of schooling instead of four
      c. listen completely and respectfully to everyone, because their knowledge is not your knowledge…but it can be

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Posted in New LNC Advice