PUBLICATIONS - LIFE CARE PLANNING
Supportive Documentation and Data Collection:
Patient Assessment
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.
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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.
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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.
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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.
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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.
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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.
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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.
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