I read over the previous posts and, although I might have missed it, I was surprised that I did not see a mention of or link to the clinic note from the director of the Metabolism Program at Boston Children's (Korson's contemporary). This was posted on Beau Berman's FoxCT Facebook on December 23, 2013. Berman posted a statement that he could not reveal his source, but the details in the report appear genuine. I have seen references to it on a few news forums.
Dr Gerard Berry is a geneticist and expert in metabolic diseases (like Mitochondrial Disorders). He initially saw Justina at BCH on February 10, 2013 - the day she was admitted. Without access to the entire medical record, we do mot have any way to know if or how frequently he followed Justina after that date.
https://www.facebook.com/BeauBermanFOXCT
"From Boston Children's Hospital "Consultation Notes" dated 4/25/13 obtained by Fox CT News:
Metabolism Consult 013
Patient Name: Justina Pelletier
Originated by: Stephanie Newton MS on 2/10/13
Authenticated by: Gerard Berry MD on 2/13/13
Print Date/Time: 4/25/2013
"HISTORY OF PRESENT ILLNESS: Justina has a longstanding history of possible mitochondrial disease with abdominal pain, poor motility, headaches and fatigue. These concerns started becoming much more severe in October 2012 when she began having what is described as odd movements of her right leg which caused her foot to pronate. She was seen by an orthopedic doctor, Dr. Webster at Tufts who prescribed a brace for the leg. Over time Justina's abnormal movements began to affect the left leg and now the rest of the body is affected. Her mother reports that over the past week she has had increased weakness which cause (sic) her to not be able to walk. She is having significant leg pain. Her headaches are becoming worse with light and sound. She also has intermittent slurred speech and altered mental status. Her mother reports that over the last 6-8 weeks her slurred speech and 'gibberish language' has been getting worse. Justina was admitted to Connecticut Children's Hospital on Monday February 04 due to worsening neurological problems as noted above. Her mother reports that it was difficult to complete this admission as Justina was not felt to have a known identifiable diagnosis. Her mother chose to bring her home from the hospital on February 8 hoping that she would do better. After discharge she was still not doing well, complained of feeling weird was not eating and had abnormalities on swallowing. Her other physicians were consulted and it was recommended that she be admitted here at Boston Chidlren's Hospital. She has been here since February 10."
I actually landed in this forum by accident today, and read just a bit. I don't want to get into who's right and who's wrong, but I thought I could clear up what appears to be a misunderstanding of what this "clinic note" is, and what it isn't. I don't know how this reporter got this tiny portion of the record, but it isn't the whole note or document, not by a long shot!
In order to be paid for care (private insurance, Medicare, or Medicaid), medical providers must adhere to the 1997 E & M (Evaluation and Management) Documentation Guidelines in preparing the medical record. This particular "note" is not a progress or follow up note. It is the introduction to a much more lengthy H & P (History and Physical) with and MDM (medical decision making) plan. When a new doctor signs on to a case, or a patient has an initial visit, or is admitted to a new facility, the provider (which can be an MD, a NP, PA, or other licensed, qualified provider) must initiate this document.
All that is here is the HPI, which combines the CC (chief complaint) with the HPI. The CC and the HPI are taken in the words of the patient, therefore they are highly subjective. Where there is no CC, as in a patient transfer, there is a very brief summary of why and how the patient came to be in the care of this new provider. It is NOT a diagnosis -- that comes much further in the document.
As an example, a CC might be "Pt reports she fell in her bathroom last night, and has pain in her right hip."
It could also be something like: "Pt reports she was talking with aliens in her bathroom, when she fell while trying to climb out the window to fly to the mother ship."
Obviously, that would indicate some possible mental or emotional difficulties, in addition to the pain in the hip.
It could also be something like "Pt is self referring to new primary care provider today for concerns about inadequate treatment by previous provider."
It could also be: "Patient arrived by ambulance from XYZ medical center, where he was S/P (status post) emergency exploratory laparotomy with necrotic bowel resection 5-1-14, with postoperative hemorrhage, reoperation, and multisystem sequelae. Patient received 12 days of ICU care, 3 days of step down care, and is being admitted by transfer for further acute care management and acute rehabilitation."
None of the examples is necessarily "true" or comprehensive information-- it is a summary provided by the patient, or referring facility. It is the Prologue to the novel, to use a literary reference.
The categories of the 1997 E & M Documentation Guidelines (used by every provider-- this is absolutely standard of care documentation):
- CC/ HPI
- Past Family and Social History
- ROS (Review of Systems)
- PE (Physical Exam)
- Labs and diagnostic studies (reviewing available records)
- MDM (Medical decision making)
This category includes: All relevant diagnoses, management options, risks of significant complications, Morbidity and Mortality, treatment plan, referrals, labs and diagnostic studies to be obtained, next follow up visit or plan. This section often now includes a comment by the provider as to the total time spent in exam and consultation.
So my point with this post is just to demonstrate that what the document obtained by the reporter is, is NOT really a document at all. It is the opening statement to a far more comprehensive evaluation and management H & P note. It has to be taken in
proper context.
http://www.cms.gov/Outreach-and-Edu...N/MLNEdWebGuide/Downloads/97Docguidelines.pdf
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html
