IT'S ALL FREE! Focused Analysis

Some new legal nurse consultants have difficulty focusing their analysis on the case issues. As a clinical nurse, all medical information is important in treating the patient. But in a legal case, some information is more important than others.  LNC case analysis requires a healthy dose of critical thinking and judgment. It's very frustrating to read through a huge summary or chronology that's chock full of information that has no bearing on the case.

For example, let's say that the LNC reviews a case involving an 80-year-old man in a nursing home with a history of Alzheimer's, prostate cancer, diabetes, and heart disease. The man also had a history of wandering. He eloped from the nursing home, was hit by a car, and died from his injuries. In this case, the important issues are safety, wandering, Alzheimer's and elopement. His age, prostate cancer, diabetes and heart disease aren't the focus of the analysis.

To keep yourself on track, you might want to write a brief synopsis of case issues. The synopsis can help guide you in your analysis and can also be used in a summary for the attorney.  Below is a paragraph written by M. Lucero in the American journal of Alzheimer's disease and other dementias that can serve as a synopsis for wandering and elopement. The last sentence was altered to include case-specific information.

*Wandering is a behavioral problem of Alzheimers patients. Serious safety problems for residents can result because they often wander into unsafe areas, handle unsafe objects, disassemble objects (exposing hazardous parts), or try to ingest inedible objects. In the institutional setting, these safety problems also raise significant issues of facility liability. Nuisance problems for institutional caregivers occur when residents rummage through the personal possessions of other residents, get into storage areas, walk away with nursing records, and get into the bed of another resident sometimes with the resident in it. Residents who elope from the facility are often trying to go home. Elopement from the facility has led to the death of residents who have walked in front of cars and trains which is what happened to Mr. Cowles when he was struck by a car and died from his injuries.

Can you see how the synopsis can help guide your analysis? It identifies the common problems of wandering and elopement for Alzheimer's patients. The second part of a good analysis is focusing on the areas of the chart that will provide the information that you need.  Of course, you will look at the entire chart but focusing on specific chart areas will help you sift through information and pinpoint your analysis.

What parts of the chart should you focus on? That will depend on the case issues. If you're new, you might want to develop a "Where to Look" sheet before you start your review. Below is one that I developed for new LNCs for the problems of wandering and elopement from nursing homes. It outlines the places in the chart and elsewhere to review for wandering and elopement problems.

*Prior Records - Date of diagnosis of Alzheimers (life expectancy), progression of Alzheimers / dementia

*Physician Orders - Medications for Alzheimer's, psychotropic medications, medications that might cause restlessness

*Physician Progress Notes - Review all progress notes but focus specifically on mentation, response to wandering episodes

*MDS - Sections C (cognitive patterns), D (mood), E (behavior), F (customary routine and activities), I (active diagnoses), N (medications), O (special treatments and procedures), and P (restraints). Note: These section letters correspond to the 2010 resident assessment instrument (RAI). Other versions of the RAI may have different section letters.

*Care Plans - To maintain safety of wandering patient

*Nursing Assessment, Nurses Notes, Monthly Summaries _ Wandering, environmental modifications (such as signs, wanderers lounge, halls free of clutter), alarm  devices (WanderGuard), evidence of supervision, evidence of redirection, anything specified in Care Plan

*CNA/ADL - Snacks provided, supervision of walks

*Medication Administration Records - Cholinesterase inhibitors (e.g., Aricept, NMDA inhibitors (e.g., Namenda), medications for agitation, anxiety

*Restraints/Side Rails/Falls - Evidence of restraints assessment, use of restraints only for medical conditions (not to prevent wandering)

*Vital Signs/Weights/Intake and Output - Weekly/monthly weight (weight loss due to wandering)

*Dietary - Dietary assessments and progress notes - to determine if resident maintained adequate nutrition, such as supplements and snacks, while wandering

*Social Services - Social issues related to wandering, efforts to make room homelike, all family interactions

*Activities/Recreational Therapy - Diversional activities

*Other Reports - Incident reports (if available) related to wandering (compare to documentation of wandering in medical record), state inspection surveys, staff education about wandering / elopement prevention, policies and procedures related to wandering and elopement, staffing sheets to determine if any staff were assigned to security, alarm records, police records (to determine if / when police were notified of missing resident), internet search for media reports of missing resident.

After you have created a first draft of your report, review it for extraneous information. Should you identify the patient's past medical conditions of heart disease, prostate cancer and diabetes? Of course. But you don't need to mention the labs, x-rays, and other information related to those conditions unless they contributed to the patient's wandering and elopement.  Now that you know how to focus your analysis, your reports will be more meaningful for attorneys.

...Katy Jones