As every day is different, so is every medical record. Hidden gems keep me excited about the incredible journey that is medical documentation review.
A Day in the Life of Certified Legal Nurse Consultant Caryn Jaffe
by Caryn “CJ” Jaffe, RN, BS, CLNC
When I became a Certified Legal Nurse Consultant in 2007, it was one of the first career moves that I researched before I took the plunge into the wild world of legal nurse consulting.
RNs are born investigators. We also need an unrelenting sense of humor to perform our job in both the good times and bad. Those qualities served as the foundation for my practice as a CLNC consultant in a health insurance special investigations unit (SIU). I became one of the few Certified Legal Nurse Consultants with a specialty in healthcare fraud, waste and abuse. My job duties involved domestic and international claims and medical record review, which introduced me to healthcare systems and practices throughout the world.
I learned to read fluent medical Spanish by necessity, though my colleagues will surely tell you that I cannot pronounce a lick of it. I became an expert in the medical language we all know well, “Chicken scratch hieroglyphics.” I learned to question the strangest procedure and diagnosis codes.
On a Friday evening after a very eventful and long work week, I upheld a Friday night tradition of staying late in the office with another SIU nurse colleague. The flexible schedule allowed us to miss the extra end of workweek, DC beltway traffic that extends rush hour by three hours. No matter when we tried to leave the office, we’d never arrive home before 9pm, so it made more sense to stay and do something productive. Our week-ending celebration was inclusive of Twizzler Cherry Bites and tasty M&Ms. On this evening, my dramatic and candid response to a medical record almost made me choke on my chocolate.
Certified Legal Nurse Consultants are experts in documentation and medical record systems. I served as an overseas claim reviewer and quickly discovered that no matter where you are in the world, a SOAP note is a SOAP note is a SOAP note. It’s a common and predictable method of documenting healthcare encounters.
Subjective information is what the patient tells you. Objective information is what you assess using your 5 senses. Assessment is a definitive or suspected cause of issues or statement of why services were rendered. Plan is what you did or intend to do for that patient. It’s organized and used the same way by medical professionals all over the world, in every language known to man. One blatantly obvious exception was the doctor who typed the record on my desk that evening. His formatting was interesting and unusual, bordering on weird and hilarious.
I felt like I could hear the physician’s mind working. The assessment findings that led the physician to make a psychiatry referral were not in the note. Outside of vital signs, there was nothing objective documented. There was no Assessment section in the note. It was a SOP note, not a SOAP note.
My analysis revealed that the mental illness theory was the wrong diagnosis, and the patient should have been referred to a neurologist, not a psychiatrist. He was having focal impaired awareness seizures. The presentation of this neurological problem was classic and well described by the patient’s wife. The doctor missed it.
Medical record reviews I’ve performed in a CLNC role have made me smarter. This case reminded me why SIUs need Certified Legal Nurse Consultants. If a doctor has made an incorrect assessment, non-nursing analysts are less likely to identify the documentation anomaly. My CLNC and nursing assessment skills allowed me to communicate the strong suspicion of a serious misdiagnosis, so this patient could get the specialty care he needed.
As every day is different, so is every medical record. Hidden gems keep me excited about the incredible journey that is medical documentation review. As Certified Legal Nurse Consultants, we have everything it takes to be a valuable and successful SIU member as long as we report for duty with a healthy sense of humor. As a nurse leader in the SIU field, I encourage you to plan to have fun with your CLNC career. If you expect to enjoy what you do, you will!
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