Three Types of Inadequate Documentation of PTSD

The diagnosis of PTSD occurs regularly in records I review in my forensic psychology practice. Typically, these are the records of psychological evaluation and treatment services that were provided to an individual (the litigant) in a personal injury, disability or worker's comp case in which a treating doctor or therapist has assigned a diagnosis of Posttraumatic Stress Disorder (PTSD) to a patient.

PTSD is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 4th Ed.). The DSM-IV criteria for PTSD require that the individual has experienced a severe traumatic stressor. There are examples in DSM-IV of the kinds of stressors that could reasonably meet the criterion for this disorder. It must also be established that the victim of the trauma experienced a specific emotional state as a result of the trauma. The individual must re-experience the traumatic event, defensively avoid exposure to reminders of the traumatic event and experience symptoms of increased arousal. The DSM-IV is specific on the the kinds and combinations of symptoms that must be present in order to substantiate a diagnosis of PTSD.

In addition, the DSM-IV indicates that malingering must be ruled out in those situations in which an external incentive (such as financial benefits) might play a role.

In many treatment records I review, but not all, the treating doctor does not adequately document all of the required criteria before assigning the diagnosis of PTSD. I say this, realizing that there may always be other records I haven't seen that may contain better documentation, and I always reserve the right to change my opinion should new information from a source be discovered. It not known to me why there is not more comprehensive documentation of PTSD in mental health treatment records. One reason may be that there is limited time to provide treatment and there are waiting lists. Preparation of comprehensive diagnostic notes is seen as a poor use of treatment time. Also, in a treatment setting, additional information about the patient and the diagnosis can be accrued as treatment progresses so there is no necessity for documenting all the criteria of a diagnosis at once. Many or most clinicians feel there is no need to assess for malingering and, further, that assessing for malingering could impair the crucial trust inherent in the doctor-patient alliance that is so important in psychotherapy treatment. In most cases there is no need to assess for malingering within the context of psychotherapy treatment and this is not a significant issue in the treatment record while the treatment record remains in the treatment setting.

However, incomplete documentation of PTSD and failure to rule out malingering can and does become a significant issue in legal cases when the doctor's treatment record is brought into the legal process. Recently, while reviewing mental health records in a disability case, I identified the following three types of inadequate documentation of PTSD.

Minimalist Type: This progress note is often one page in length or less and describes treatment with psychotherapy or psychopharmacology. The diagnosis of PTSD is often prominently noted at the top of the page. In the body of the report there is a discussion of an issue the patient is having, such as marital conflict or depression. There is no or almost no documentation of PTSD in the note. Treatment notes that list a diagnosis should, in my view, substantiate the diagnosis in the notes within a reasonable time after treatment begins.

Compliant Type: In this type of treatment progress note, the diagnosis of PTSD appears to be substantiated, but a closer look reveals that the documentation consists of a listing in the treatment notes of the criteria for DSM-IV as they appear in the DSM-IV. This, in my opinion, does not support a diagnosis of PTSD. Simply reiterating the criteria for PTSD, without elaboration with details from an examinee's history, current mental status data and psychological test results, does not suffice, in my opinion, to confirm a diagnosis. Compliant documentation seems designed to meet the letter of the law but lacks any indication of the treating doctor's knowledge of the patient's symptoms.

Teetering Type: In this kind of treatment note, the clinician discusses only one or two symptoms of PTSD but does not document all the required criteria for the disorder. For example, I might find a comprehensive discussion of the victim's accident and resulting emotional reaction that completely confirms that the individual meets the first set of criteria for the disorder. However, there is no subsequent attempt by the clinician to confirm the remaining required elements needed to confirm the diagnosis of PTSD. This diagnosis is "teetering" because it is like a four-legged table that only has two extended.

Conclusions: Treatment records are created for the purposes of documenting and improving treatment. When these records are moved into the legal arena in a personal injury, worker's compensation or disability case, they do not perform as well and can fail as proof of PTSD. In these kinds of cases, it can be helpful to consult with a psychologist who can conduct a forensic evaluation of the litigant which includes an assessment of malingering.

Stuart Clayman, Ph.D. practices forensic and clinical psychology in Boston, Massachusetts, USA. Tel: 617 782-8355. For more information, click on the "Articles" button on my website.