How do you describle a patient with Mental Disabilities on a PCR

[cosgrojo]

Again... if Dx not known, a generic term I like to use is "developmental disorder." It is a pretty far reaching and all encompassing term, and combined with a thorough assessment, will suffice in most cases. My wife is a Special Education teacher and assures me that it is legal and appropriate to use "MR" in your documentation to denote "Mental Retardation." I have used it once or twice... but I prefer "developmental disorder."

[Dustdevil]

?????

x2! WTF? Did a post get deleted that I never saw?

[VentMedic]

x2! WTF? Did a post get deleted that I never saw?

Look at the quoted reference in my post from the one just above mine with the "?????".

It looks like he brought a quote about cancer patients over from another thread. I just didn't see the relevance of cancer patients and mental disability unless it is from depression which I did post about later.

[Dustdevil]

I noticed. I just can't figure out how the heck he managed to do that, or why.

[cosgrojo]

I noticed. I just can't figure out how the heck he managed to do that, or why.

It has happened before. I've noticed it in a few other threads. May be user error, but it would be a weird error to make... I'm thinking it has to be some sort of glitch in the system.

[Richard B the EMT]

Did our patient make any statement that they felt like killing themselves, others, or both?

Any emotional trauma, like missing a promotion at work, getting fired, blowing a career starting final class exam, or having Maury Povich tell them they are/are not the father? Did they damage the "daddy-lac"? Close family member died? Rich close family member NOT die, and the patient needs money? Is, or was, the patient "acting out"? Did you and your partner witness any of this, or did the patient say so themselves? Or is the information totally from the friends/family/bystanders, and possibly not accurate?

Possibilities are endless. Document what the patient, family or bystanders tell you that may seem to be relevant to the case at hand.

Momma B just reminded me that I am not a psychiatrist. What information I get, however, I document, and hope it will help the "shrink" with making a diagnosis.

Edited July 19, 2009 by Richard B the EMT

[mobey]

Special Education teacher and assures me that it is legal and appropriate to use "MR" in your documentation to denote "Mental Retardation."

Legal...... Yes

Appropriate.... No

Special Ed teacher does not validate this nonsense at all.

Mental health is a slow moving underfunded entity. Any progress they make is very important and the "R" word has been thrown out years ago.

Developmentally challenged is the preferred term.

[FL_Medic]

How would you guys Professionally describle a patient with Mental Disabilities on a PCR ? I had a patient last night with that and just could not figure it out.

Mentally Delayed

[Eydawn]

Mental Retardation is in fact a valid diagnosis. While I don't disagree that the terminology is somewhat behind the curve, I also take no offense at the term. I prefer Developmentally Disabled, personally... but if you get someone's med sheet and it has their diagnoses listed and mental retardation is one of them, you better reproduce it in your trip sheet, whether you like the term or not.

And let's not forget that they go in and change what's "appropriate" about every 4 months in the DD field... "client" changes to "consumer" changes to "client" again... MR changes to DD back to MR...

Wendy

CO EMT-B

[croaker260]

Back on topic...

I have two basic principles on these touchy subjects....

1) As mentioned above, I document it objectively and specifically..slow or delayed speech, no eye contact, inability to relate person, place, or time, etc, just the same way I would if this was a patient I had never met before, or a child, and had no idea of their history.

2) If there is someone around who is familiar with the patient, then I include whether this mental status is a divination from their baseline (or is normal for them).

Diagnosis of Developmental delay, mental retardation, cancer, OBS, or even PMS, go in the subjective portion of my document. AT most I will add a statement like : "..... consistent with the patients reported history of organic brain syndrome"

Edited July 20, 2009 by croaker260