What Is a Medical History? Forensic Relevance
Psychological and/or medical impairment could influence your client’s case, regardless of plaintiff, defense, prosecution or administrative private sector role.
In my experience, attorneys hope my answers will help them decide whether to accept a client in the first place, or perhaps develop a case strategy.
> You seek clarity about a person’s mental state and importance/lack of importance to the matter at hand.
> Opposing counsel has a mental health expert witness; is there a reason to get an independent review by an expert you have retained?
> Confusion about the correct qualified expert witness. Is a Forensic Psychiatrist the doctor appropriately qualified. Logical and strategic reasons drive that choice, versus a psychologist, LCSW or even the litigant’s own personal doctor.
> Is the plaintiff’s treating doctor a good choice to testify about their own patient? There are important and concerns with consequences, highlighted in a rubric below.
GETTING ANSWERS
The attorney, and trier of fact are well-served by an informed and objective medical-legal opinion, at any stage of a case’s evolution.
“Informed” is the topic explored here.
This article is intended to clarify and discuss sources of information that might contribute to the basis of those opinions.
- I form a forensic impression of a person’s mental status or mental state by drawing on information from many quarters.
- Medical records, like provider notes, are only one resource for my inquiry.
EXPANDED DEFINITION AND FACT-FINDING
Attorneys will sometimes submit to me physician notes as a starting point. While provider notes may help me, or even prove to be conclusive, tapping a larger body of information reveals the bigger picture.
That bigger picture is the Medical History.
A “Medical History” includes and exceeds chart notes. In a forensic setting, the history is developed from an array of material: medical, legal and verbal.
To fully flesh out the medical history and render robust findings, a Forensic Psychiatrist applies a unique perspective and leverages specialized techniques, like a forensic timeline, to the familiar “records review.”
- The medical expert witness is an objective investigator.
- The forensic lens is an indispensable element.
- Forensic Psychiatrists draw on training and experience, to apply that lens.
5 SOURCES
The focus of this article is to describe in greater detail 5 types of information which I may be asked to consider in my role as a forensic psychiatric examiner and physician expert witness.[1]
Each section below highlights a focus to demonstrate what information may be present and how it can be informative:
1. Medical records.
Examples below: Outpatient Behavioral Health, Physician Records and diagnostic tools, Pharmacy Records.
2. Independent Medical Examination or IME)
This is a forensic interview with the evaluee. I will describe features of an IME and its role.
3. Medically informative, but not a medical provider’s direct records.
Legal records. Depositions of a provider, the evaluee themself, or a family member or observer. If it’s relevant, the testimony can be compared against the medical and ancillary records. Jump to content.
Collateral interviews. I may interview family, friends or anyone whose observations and other information might be relevant.
4. Ancillary records germane to certain types of cases.
Sample application: Testamentary Capacity, Undue Influence, Standard of Care, Elder Abuse or any case where the mental status or care of an elderly person is at issue:
Assisted Living and/or Nursing Home records. interesting but attorneys may want to know why.
5. Audio, video, and photographs.
Media is informative. I do not discuss it in this article given the varied types and purposes which are generally case-specific.
First, I will discuss (a) the timeline as a forensic tool preparatory to a medical-legal review of a person’s medical history and (b) distinctions between the medical provider vs. a forensic evaluator who is a physician.
- A timeline is helpful because medical-legal opinions center around an alleged concrete event.
- Medical conditions unfold over time.
- Prequel, Present Day, Sequel.
RESTORING CHRONOLOGY
Records are not always provided chronologically. During my review, I construct a timeline by cross-referencing what I learn and what raises questions.
My investigation “picture” on the timeline includes:
> Medically recorded symptoms, diagnoses and treatment. When, Where, How, Why. It includes psychiatric and non-psychiatric disease, i.e., “somatic” or “bodily” diseases. Physical injuries are somatic. (Note: “psychosomatic” is something different.)
> Diagnoses rendered during psychotherapy.
> Reports from family, friends, caregivers, or anyone in the orbit of the examinee during the period in focus.
> Narrative. Evaluee’s recitation of their medical history. (Evaluee, e.g. litigant or decedent.)
BEHAVIORAL CLUES
I examine reports of behavior such as those found in a treating therapist’s notes, or observations recorded by others–and consider it in the context of medical and psychiatric health, and response to treatment over time. Behavior is one clue in assessing mental health:
> Behavior that raises a flag for a psychiatric or other medical condition might belong on the timeline.
> Treater observations, e.g. a non-psychiatrist doctor notes their patient is distracted and confused or seems despondent.
> Indicia of a Personality Disorder (DSM5TR)[2][3] which are “defined traits that can drive behavior…to be classified as a personality disorder, one’s way of thinking, feeling and behaving deviates from the expectations of the culture, causes distress or problems functioning, and lasts over time.” – American Psychiatic Association.
MEDICAL RECORDS: DIFFERENT PURPOSES
TREATER VS. FORENSIC PSYCHIATRIST
Treating Doctor=Patient Advocate
Medical Records to Help Treat and Relieve Syptoms
The provider is tasked to diagnose, treat and alleviate uncomfortable or painful symptoms, and pursue recovery for their patient’s well-being.
Treating physicians generally think of the medical history as the documents, or electronic records, that are accessible and relevant to that role.
The provider’s focus is on the progress notes of other doctors (daily updates on the patient’s condition, assessment, and plan of care), laboratory and radiology studies and reports, even notes by allied providers (e.g., social workers, hospital administrators, and discharge planners).
Do No Harm: Medically or Legally
Giving testimony on their patient’s behalf violates Patient Rights under AMA ethical guidelines [4] and the Hippocratic Oath because the case outcome could, in fact, do harm to the patient.
The treater is not a good choice as an Expert Witness in their patient’s lawsuit.
Expert Witness=Objective Analysis
A forensic psychiatrist’s task is to examine the medical history which draws information from many quarters, medical and legal.
There is no doctor-patient confidentiality as there is no doctor-patient relationship.
Objectivity vs. Advocacy
The forensic psychiatrist strives for objectivity. There is no obligation to plaintiff, defense, or legal outcome. Nor is there an obligation to someone’s health outcome.
A forensic psychiatrist also approaches information as a physician with medical-legal training and a defined scope.
They may review the same progress notes and laboratory studies as the treating provider.
The purpose is to apply their findings about matters within their expertise [5] to a legal controversy and identify what is material to the court.
A Forensic Psychiatrist is qualified and appropriate to serve as an Expert Witness, about matters within their expertise.
ABOUT THE AUTHOR: Dr. Pia Quimson-Guevarra
Dr. Quimson-Guevarra is a Board-Certified Psychiatrist and Forensic Psychiatrist practicing medicine in Oregon.
She renders medical opinions in legal matters and treats patients in private practice.
Dr. Quimson-Guevarra understands the confusion faced by attorneys and employers who do not know what happens in an IME where legal issues are at stake vs. what a doctor does in an exam with a patient.
Dr. Quimson-Guevarra wrote this article to help readers understand the nature of a psychiatric medical-legal IME and the distinctions from the examination in a treatment/clinical psychiatric or psychological examination.
Copyright Dr. Pia Quimson-Guevarra
Disclaimer: While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer.For specific technical or legal advice on the information provided and related topics, please contact the author.
