Tailoring the Chart

To the Editor: I applaud Drs. Dwyer and Shih (1) for their article in the October 1998 issue on tailoring the patient's chart, which is an ethical issue that confronts us all on a daily basis. When writing anything, it is prudent to maintain an awareness of what audience will read it and how the information will be used. Each of us tries to tailor what we say to communicate effectively with our audience—in charts, in discussions with patients, in speeches, and in daily life.

When does effective, audience-directed communication become deception? I suspect we all draw this line in a slightly different place. Except at the extremes, such as an overt and totally fabricated lie, the line between thoughtful communication and deceit is open to significant debate. When am I justified in saying that I am concerned about a particular patient's potential for self-injury? Must he say, "I intend to kill myself tonight?" What if he has a history of past suicide attempts and reports dreams about dying violently? What if he's having suicidal thoughts but says, "I don't think I have the nerve to do it"? The interpretation of clinical data is not an exact science, nor is the written expression of that interpretation.

I would add to this ethical discussion the dilemma of how to communicate with a party that is known (or believed) to be intentionally deceitful and very willing to purposely misinterpret data. While the stereotype of deceitful and unprincipled lawyers is unfair and inaccurate, all too often lawsuits are initiated for questionable reasons, and the outcomes may turn on a casually chosen word or phrase in a chart, purposely taken out of context.

Similarly, we have all had experiences with certain utilization reviewers who are searching not for the truth but for a phrase or other excuse that will allow them to justify a predetermined intention to deny care. Should the way you play the game change if you know (or believe) the other players are cheating?

Dwyer and Shih point out that when a doctor tailors charts to try to get a service covered, "He shifts a burden onto this population [others who are covered by that company] by forcing the insurance company to pay for treatment it did not agree to cover." However, often the treatment being requested is covered (or is believed to be) by the insurance policy, as when the hospital benefit period is 30 days but further coverage is disallowed after six days. The ensuing debate often hinges on what is meant by "medical necessity" and whether each word in the chart does or does not support an assertion of medical necessity.

Finally, the authors mention that the down side to some of their suggestions is "more work: extra notes, letters, phone calls, and appeals." Many feel that the inconveniences of disagreeing with utilization reviewers and managed care companies are created purposely as a means to discourage disagreement. Is this or is this not a valid justification for trying to circumvent policies that are believed to be unreasonable?

Except at the extremes, the ethical dilemmas of charting are complex and multifaceted. The authors have raised some questions and offered some answers. I have added a few comments and some additional questions; unfortunately, it is easier to find questions than answers.

Dr. Melnick is a psychiatrist in Philadelphia.