Life Care Planning
Supportive Documentation and Data Collection: Patient Assessment
Supportive Documentation and Records Review
Supportive Documentation and Records Review
To supplement the life care plan, the planner develops a narrative report incorporating information from the clinical interview, records review, and analysis, and concluding remarks. Within the narrative report, the life care planner has the opportunity to explain why he or she made specific recommendations and provide those involved in the case with a detailed account of the needs of the patient. When referred to a case, the life care planner should request all the available patient records (as described below) and expect to acquire specific documentation directly from the patient, if necessary.
The first step in a thorough evaluation of the patient is to gather all of the pertinent records. For the life care planner, this process often goes beyond the basic medical records. Certainly this effort should begin with all the available hospital records, including handwritten nursing notes, surgical records, therapy notes, and physician records. The planner should also gather all post-acute rehabilitation records as well as physician and health-related professional records. Generally, this is just a starting point for the life care planner. A range of variables including, but not limited to, the disability, the age of the patient, and the vocational status and history of the patient will determine the nature of additional records.
Educational Records
A disproportionately high number of disability patients are in younger age groups, so it is often appropriate to request school records, wherever possible. This retrieval will aid the life care planner in both rehabilitation decisions and educational decision-making. When reviewing school records, the most important data for comparison is end of year achievement test results. These results are the best indicator of what a student has retained over time and how he or she compared against age-related peers both regionally and nationally. Next, review school psychological assessments if they are contained within the file. Then, review any teacher comments. Look closely for information regarding learning disabilities or learning problems. Be sure that in brain injury cases, the life care plan is not outlining a rehabilitation program designed to help an individual learn to regain reading skills only to find out later that the patient had severe reading deficits pre-morbidly. Finally, review the student’s grades. Although of interest, they are not the best indicator of a student’s progress or a student’s mastery of material. They often reflect student-teacher relationships, however, and even what is going on, in general, at that point in a student’s life.
Psychological Records
The planner should obtain and review clinical psychological, neuropsychological, developmental psychological, behavioral psychological, or related records as well as psychiatric records. In the instance of psychological testing, the planner should give consideration to requesting raw test data if he or she is familiar with how to utilize this data.
Employment Records
The planner should request employment records. Such data can provide important insight into pre-morbid levels of function and achievement. The records also will be critical in working with the patient in rehabilitation planning. In addition, the planner should obtain income tax returns because they serve as a record for the patient’s actual earnings.
Depositions of Witnesses
If the casework involves forensic consultation, then the planner should request and review all depositions of damages witnesses. This would include depositions of the treating physicians, therapists, psychologists, and related team members as well as any consulting professionals whose depositions were taken. The planner should also review depositions of the patient and family members. If billing information is available, the life care planner should also obtain that data.
Medical Records Summary
Once the life care planner has gathered and reviewed all records, the next step is to write a summary designed to accomplish two goals. The first goal is to communicate what you have read to those who may be reading your report in the future. The second goal is to create a history that will allow you to quickly pick up the file and get back into the record without having to wade through hundreds of pages of medical, health-related professional, rehabilitation, educational, and employment records over and over again. The summary should be brief, accurate, and highlight key points that will easily refresh your memory about this patient. The medical records summary will comprise one component of the patient’s narrative report. Key points to include in the summary are outlined below:
Hospitalization Days
List all hospital and treatment programs. Summarize the dates and general participation activities for each program. Include the number of days in specialized care such as ICU or rehabilitation. In addition to incorporating this information in narrative form in the body of the summary, also provide a list of the records reviewed and their inclusive dates at the end of the summary.
Operative Procedures
Note all operations performed, the date each was performed, and by whom. List the specific procedure with the ICD code, if it can be clearly identified. Note the surgeon’s specialty, such as orthopedics, neurosurgery, plastic surgery, or ophthalmology. Note the type of anesthesia used, (local or general). Note the length of the procedure and any complications encountered.
Post-Acute Hospitalization or Rehabilitation Programs
List all post-acute hospitalization, rehabilitation programs, or transitional living programs. Note the admission and discharge dates, the services provided (including all therapies), the goals set and achieved, and a brief summary of function at discharge.
Medications
Provide a history of medications administered, why they have been administered, and whether any problems have been encountered. Has the patient become addicted to pain medications? Has there been any history of infections, pain, bowel or bladder programming requiring medication, or treatment with psychotropic mediation? Include the name of the medication, the dosage, and the route of administration (oral, IV, IM, sublingual, catheter). Note any abnormal reactions or long-term effects.
Complications
List all complications along with the date of occurrence, severity of occurrence, duration of occurrence, and, if known, the costs of treatment. Note whether the physician has given any indication of future risk factors for a recurrence of the complication. The life care plan can have a significant impact on reducing the incidence and severity of complications. It is likely the physician has indicated the steps that must be taken to reduce a recurrence of the complication, and these recommendations should be recorded and integrated into the plan.
Treatment Team
Clearly identify all treating physicians, both current and past, since the onset of the disability. Note the name, address, telephone number, and specialty from the records, and list them in one location at the end of the summary. Separately identify all consulting physicians in the same fashion. Perform the same exercise with all treating and consulting health-related professionals. Do not exclude any specialists, regardless of how distant from the primary treatment team they may appear.
Current Care Requirements
Based on the currently available medical record, list the levels of care required and expected level of independence of the patient. For example, list the bladder program requirements, bowel program requirements, feeding program requirements, medication regimen, and support care requirements as stated in the records. Do not speculate or guess. State only what is contained in discharge summaries from the acute care hospital, post-acute rehabilitation program, or transitional living program.
Report Writing
Remember that your medical records summary is going to be incorporated into the body of your narrative report. As a result, it is going to be reviewed by both professionals and the lay population, including the patient. Therefore, although it is acceptable to use professional terminology, try to write in a clear, understandable fashion and to define terminology. Consider attaching a glossary to assist those readers who may not be comfortable with technical medical terminology.