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Effective Use of Medical Records in Administrative Hearings


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Effective Use of Medical Records in Administrative Hearings

  1. 1. Effective Use of Medical Records in Administrative Hearings
  2. 2. Presentation Roadmap <ul><li>Understanding the Medical Records </li></ul><ul><li>Exhibit Organization </li></ul><ul><li>Hearing Strategy </li></ul>
  3. 3. Understanding the Records <ul><li>What is a Medical Record? </li></ul><ul><ul><li>The portion of a client’s health record that is made by physicians and is a written transcribed history of various illnesses or injuries requiring medical care; </li></ul></ul><ul><ul><li>A chronological written account of a patient’s examination and treatment that includes: </li></ul></ul><ul><ul><ul><li>The patient’s medical history and complaints </li></ul></ul></ul><ul><ul><ul><li>The physician’s findings, the results of diagnostic tests and procedures </li></ul></ul></ul><ul><ul><ul><li>The results of therapeutic procedures </li></ul></ul></ul><ul><ul><ul><li>Medications </li></ul></ul></ul>
  4. 4. What else? <ul><li>Mental health records: </li></ul><ul><ul><li>Psychiatrist </li></ul></ul><ul><ul><li>Psychologist, Licensed Professional Counselor (L.P.C.), Licensed Social Worker, etc. </li></ul></ul>
  5. 5. Billing and Payment <ul><ul><li>Medicare/Medicaid records </li></ul></ul><ul><ul><li>Insurance claims </li></ul></ul><ul><ul><li>Self-pay records </li></ul></ul>
  6. 6. Example 1: Dr. Telephone Orders
  7. 7. Example 2: Nursing Notes
  8. 8. Medical Record? OIG Medicaid Utilization Review
  9. 9. Understanding the Condition/Treatments <ul><li>What is this condition? </li></ul><ul><li>What causes it? </li></ul><ul><li>What are the symptoms? </li></ul><ul><li>How is it treated? </li></ul><ul><li>Similar diagnoses? </li></ul><ul><li>Comorbidities? </li></ul><ul><li>ICD-9-CM Codes/ ICD-10-CM Codes </li></ul>
  10. 10. Internet Resources <ul><li>Results </li></ul><ul><li>Plantar fasciitis - Wikipedia , the free encyclopedia </li></ul><ul><li>Plantar fasciitis is a painful inflammatory condition of the foot caused by excessive wear to the plantar fascia that supports the arch or by biomechanical ... Plantar _ fasciitis - 58k - Cached - Similar pages </li></ul><ul><li>Plantar fasciitis - </li></ul><ul><li>Plantar fasciitis — Comprehensive overview covers causes, prevention, self-care of this common type of heel pain. plantar - fasciitis /DS00508 - 26k - Cached - Similar pages </li></ul><ul><li>Your Orthopaedic Connection: Plantar Fasciitis </li></ul><ul><li>When your first few steps out of bed in the morning cause severe pain in the heel of your foot, you may have plantar fasciitis (fashee-EYE-tiss). ... - 15k - Cached - Similar pages </li></ul><ul><li>plantar fasciitis : Information from </li></ul><ul><li>plantar fasciitis Inflammation of the plantar fascia (the thick band of tissue along the sole of the foot) at its attachment point to the heel bone. plantar - fasciitis - 84k - Cached - Similar pages </li></ul><ul><li>Plantar Fasciitis - Information About Plantar Fasciitis </li></ul><ul><li>Plantar fasciitis is a condition that causes heel and arch pain </li></ul>
  11. 11. Exhibit Presentation <ul><li>Focus on the Right Records </li></ul><ul><li>Attack the Stack </li></ul><ul><li>More Research Required </li></ul><ul><li>Looks Matter </li></ul>
  12. 12. Focus Questions <ul><li>What elements do I need to prove in this case? </li></ul><ul><li>What information could hurt my case? </li></ul>
  13. 13. Attack the Stack <ul><li>Remember what you are trying to prove </li></ul><ul><li>and… </li></ul><ul><li>Be RUTHLESS </li></ul><ul><li>This means… </li></ul><ul><li>Don’t dally! </li></ul><ul><li>and </li></ul><ul><li>Don’t be nosy ! </li></ul>
  14. 14. Organizing the Stack <ul><li>When you attacked the stack*, you might have: </li></ul><ul><li>Highlighted important text </li></ul><ul><li>Tabbed key documents </li></ul><ul><li>Taken notes </li></ul><ul><li>Organized the stack into folders </li></ul><ul><li>* YOU’VE KILLED 2 BIRDS WITH 1 STONE. THESE ARE YOUR EXHIBITS. </li></ul>
  15. 15. Problem Records: More Research Required <ul><li>Illegible </li></ul><ul><li>Unintelligible/ indecipherable </li></ul><ul><li>Expert report or other record does not say ‘magic words’ </li></ul><ul><li>Records that contradict legal theory </li></ul><ul><ul><li>Inconsistencies </li></ul></ul><ul><ul><li>Opposing expert opinions </li></ul></ul>
  16. 16. What to include? <ul><li>Records that tend to prove the elements of the case. </li></ul><ul><li>Records that might hurt your case, but need to be explained away. </li></ul><ul><li>That’s it. Pounds of paper will not make your case any better. </li></ul>
  17. 17. Comments from the Bench <ul><li>“ 2 inch rule” vs. Presenting incomplete record (game playing) </li></ul><ul><li>Misstating the information in the records (ethical concerns) </li></ul>
  18. 18. Examples
  19. 20. Appearances Count <ul><li>Please, please, could you tab the records? And, maybe you could highlight the good parts. Page numbers are nice, too. A list of the many doctors, their specialties, and relation to the case could be really helpful. Thank you!! </li></ul><ul><ul><li>Page numbers required. </li></ul></ul><ul><ul><li>Redact confidential PERSONAL HEALTH INFORMATION. </li></ul></ul><ul><ul><li>If many names involved, make a list witnesses and relation to the case. </li></ul></ul><ul><ul><li>Have an exhibit list. </li></ul></ul><ul><ul><li>Tab the exhibits/ use a binder/ use dividers </li></ul></ul>
  20. 21. Evidentiary Concerns <ul><li>Relevance </li></ul><ul><li>Mental Health Records </li></ul><ul><li>Rule of Optional Completeness </li></ul><ul><li>Hearsay Exceptions </li></ul><ul><li>Summaries </li></ul>
  21. 22. Relevance <ul><li>RULE 401. DEFINITION OF &quot;RELEVANT EVIDENCE&quot; </li></ul><ul><li>&quot;Relevant evidence&quot; means evidence having any tendency to make the existence of any fact that is of consequence to the determination of the action more probable or less probable than it would be without the evidence. </li></ul><ul><li>RULE 402. RELEVANT EVIDENCE GENERALLY ADMISSIBLE; IRRELEVANT EVIDENCE INADMISSIBLE </li></ul><ul><li>All relevant evidence is admissible, except as otherwise provided by Constitution, by statute, by these rules, or by other rules prescribed pursuant to statutory authority. Evidence which is not relevant is inadmissible. </li></ul>
  22. 23. RULE 510 C ONFIDENTIALITY OF MENTAL HEALTH INFORMATION IN CIVIL CASES <ul><li>Communication between a patient and a professional is confidential and shall not be disclosed in civil case </li></ul><ul><li>Unless : </li></ul><ul><ul><li>License revocation, medical malpractice </li></ul></ul><ul><ul><li>Waiver or claim for mental/emotional health services </li></ul></ul><ul><ul><li>Mental condition relevant to claim or defense </li></ul></ul><ul><ul><li>Abuse/neglect of Nursing Facility residents </li></ul></ul><ul><li>This rule only governs disclosures of patient-professional communications in judicial or administrative proceedings . Whether a professional may or must disclose such communications in other circumstances is governed by Tex. Health & Safety Code §611.001-611.008. </li></ul>
  23. 24. Rule of Optional Completeness (TRE 107) <ul><li>When part of an act , declaration, conversation, writing or recorded statement is given in evidence by one party, the whole on the same subject may be inquired into by the other , and any other act, declaration, writing or recorded statement which is necessary to make it fully understood or to explain the same may also be given in evidence, as when a letter is read, all letters on the same subject between the same parties may be given. &quot;Writing or recorded statement&quot; includes depositions . </li></ul>
  24. 25. Patel v. State, 856 S.W.2d 486    (Tex. App. - Houston [1st Dist.] 1993, pet. ref'd ) . <ul><li>“ The rule of optional completeness -- which permits a party to introduce the entire writing after the other party has introduced only part of it -- is meant to guard against the confusion, distortion, or false impression that can arise from the introduction of part of [**9]  a writing out of context . Livingston v. State , 739 S.W.2d 311, 331 (Tex.Crim.App.1987) ; Tex.R.Crim.Evid . 107 . 2 The purpose of the rule is to &quot;reduce the possibility of the fact finder receiving a false impression from hearing the evidence of only part of an act.&quot; Kinnamon v. State , 791 S.W.2d 84, 101 (Tex.Crim.App.1990) .” </li></ul>
  25. 26. Rule 803: Hearsay Exceptions <ul><li>Statements for Purposes of Medical Diagnosis or Treatment . Statements made for purposes of medical diagnosis or treatment and describing medical history, or past or present symptoms, pain, or sensations, or the inception or general character of the cause or external source thereof insofar as reasonably pertinent to diagnosis or treatment. </li></ul><ul><li>Learned Treatises . To the extent called to the attention of an expert witness upon cross-examination or relied upon by the expert in direct examination, statements contained in published treatises, periodicals, or pamphlets on a subject of history, medicine, or other science or art established as a reliable authority by the testimony or admission of the witness or by other expert testimony or by judicial notice. If admitted, the statements may be read into evidence but may not be received as exhibits . </li></ul>
  26. 27. Learned Treatise Exxon Corp. v. Makofski , 116 S.W.3d 176, 188 (Tex. App.--Houston [14th Dist.] 2003, pet. denied) <ul><li>“ Unfortunately , almost none of the relevant epidemiological studies appear in the trial court record, though several were marked for identification and discussed at length during the trial. As learned treatises, excerpts from these studies could be read to jurors, but none were admitted as exhibits for jurors' independent review . But while the rules of evidence withhold learned treatises from jurors, that does not mean they should be withheld entirely from the record.” </li></ul>
  27. 28. Rule 1006: Summaries <ul><li>The contents of voluminous writings, recordings, or photographs, otherwise admissible, which cannot conveniently be examined in court may be presented in the form of a chart, summary, or calculation . The originals, or duplicates, shall be made available for examination or copying, or both, by other parties at a reasonable time and place. The court may order that they be produced in court. </li></ul>
  28. 29. In re B.B. , No. 05-98-02042-CV, COURT OF APPEALS OF TEXAS, FIFTH DISTRICT, DALLAS, 1999 Tex. App. LEXIS 9353, December 17, 1999, Opinion Filed (Unpublished) <ul><li>There is no  [*14]   dispute either that the underlying medical records , constituting 119 pages of the reporter's record, are voluminous or that Exhibit No. 3 is a summary of those records. Furthermore, the underlying medical records were admitted without objection. Thus, we conclude the State laid a proper predicate for admission of Exhibit No. 3, and the trial court did not abuse its discretion in admitting it. See State v. Buckner Constr . Co. , 704 S.W.2d 837, 842-43 (Tex. App.-Houston [14th Dist.] 1985, writ ref'd n.r.e.); Moore v. Moore , 430 S.W.2d 247, 251-52 (Tex. Civ. App.-Dallas 1968, writ ref'd n.r.e.). We overrule Topkins's second issue. </li></ul>
  29. 30. Other Summary Cases <ul><li>Moore v. Moore , 430 S.W.2d 247, 251-52 Summary of microfilmed checks with accompanying microfilm. </li></ul><ul><li>State v. Buckner Constr . Co. , 704 S.W.2d 837, 842-43 Summary of checks and invoices along with boxes of the checks. </li></ul>
  30. 31. Hearing Strategy <ul><li>Experts </li></ul><ul><li>Fact witnesses </li></ul><ul><li>Opening/Closing remarks </li></ul><ul><li>Trial Briefs and Written Closing Statements </li></ul>
  31. 32. Dealing with Experts: This is not a Jury Trial <ul><li>Hearing Officer/ ALJ/ Board already understands that the expert is being paid for their opinion. </li></ul><ul><li>Reputation matters: If this is a frequent-flyer expert, there may be baggage. </li></ul><ul><li>In some forums, testimony is not only unnecessary but also unwanted. </li></ul>
  32. 33. Do you really need that expert testimony? <ul><li>DWC rule (28 TAC 142.8): </li></ul><ul><li>(a) In order to expedite the presentation of a case, the hearing officer may allow summary procedures, including, but not limited to, the use of: </li></ul><ul><li>   (1) sworn witness statements ; </li></ul><ul><li>   (2) summaries of evidence; </li></ul><ul><li>   (3) medical reports ; </li></ul><ul><li>   (4) agreements; and </li></ul><ul><li>   (5) stipulations. </li></ul>
  33. 34. Applicable cases <ul><li>Blankership v. Mirick , 984 S.W. 2d 771 (Tex. App.—Waco 1999, pet. denied). </li></ul><ul><ul><li>Non-expert testimony sufficient to support medical causation because the testimony established, “…a sequence of events which provides a strong, logically traceable connection between the [collision] and the condition.” </li></ul></ul><ul><li>Morgan v. Compugraphci Corp. , 674 S.W. 2d 729 (Tex. 1984). </li></ul><ul><ul><li>General human experience and common sense to establish medical causation. </li></ul></ul>
  34. 35. Fact witnesses <ul><li>Ask yourself, do I really need this person to testify? </li></ul><ul><li>Is it cumulative of the medical records? </li></ul><ul><ul><li>Garza v. Minyards, No. 05-95-01668-CV COURT OF APPEALS OF TEXAS, FIFTH DISTRICT, DALLAS (Unpublished) </li></ul></ul><ul><ul><li>Garza had difficulty at trial understanding and answering questions about her injuries. She refused the assistance of an interpreter. Instead, she wished to read a portion of her medical records into evidence. </li></ul></ul><ul><ul><li>“ The trial court denied the request because it concluded that reading the records to the jury would be cumulative and inefficient, and would raise issues of optional completeness.” </li></ul></ul>
  35. 36. Necessary and Helpful <ul><li>Nurse surveyors, investigators, complaint coordinators, etc. </li></ul><ul><li>Don’t have them read the medical regulation into the record—have them summarize the regulation and its meaning. </li></ul><ul><li>Do have them clarify the medical records and how they relate to the regulations. </li></ul>
  36. 37. Opening and Closing <ul><li>Use these as your opportunity to highlight specific records of particular importance. </li></ul><ul><li>In some cases, once the records are in evidence, a combined opening and closing could be sufficient. Some considerations: </li></ul><ul><ul><li>Does this case revolve around the contents of the medical records? </li></ul></ul><ul><ul><li>Would testimony be presented for sympathy/ empathy alone? </li></ul></ul><ul><ul><li>Could you do this via telephonic hearing procedures? </li></ul></ul><ul><ul><li>Could you do this via a Motion for Summary Disposition? </li></ul></ul>
  37. 38. Trial Briefs/ Written Closing <ul><li>Can be very helpful to the ALJ/ HO to clarify the dispute and the supporting documentation. </li></ul><ul><li>Can avoid reopening of the record and subsequent delay of decision. </li></ul>
  38. 39. Please remember… <ul><li>ALJ/HO are trained professionals who may be very familiar with the subject in dispute. </li></ul><ul><li>They may even know more than you do about the subject! </li></ul><ul><li>But, that doesn’t mean you get to dump on them and hope they will figure it out. </li></ul>