‘Medical Clearance’ of Psychiatric Patient Can be Legally Risky

By Stacey Kusterbeck, Special for ReliasMedia.com

What does "medical clearance" really mean? Does it indicate a patient has no acute issues, or that all the patient’s chronic issues are stable? Or is it both? “The answer is that it depends on who you ask, and the perspectives of the different types of facilities, teams, or providers,” says Kimberly Nordstrom, MD, JD, an emergency psychiatrist at the University of Colorado Anschutz.

A stand-alone psychiatric facility, with no lab facilities or pharmacy on site and limited availability of healthcare providers, may want every assurance the patient sent to them has no current medical issue, and is not likely to experience a major event while hospitalized. “From an ED [emergency department] perspective, that assurance is that of a fortune teller,” Nordstrom asserts. “That level of assurance cannot be given.” This might lead some hospitals to "cherry pick" younger, physically healthier patients.

Who is liable if a “medically cleared” patient experiences a medical emergency shortly after leaving the ED? “If all but the psychiatric condition was stabilized, the ED would have a good argument that the care was appropriate,” Nordstrom says.

However, a layperson will not understand the technical meaning of “medically cleared.” Nordstrom recommends using the term “medically stable."

“It is important that emergency physicians use this more thoughtful terminology and educate other providers, including psychiatric colleagues, to do the same,” Nordstrom says.

EDs should completely stop using the term "medically cleared" as it relates to transfer to psychiatric facilities, unless there is a regional protocol that specifically defines “medical clearance,” according to Nordstrom.

“It is quite reasonable to chart that a patient is ‘medically stable for transfer,’” Nordstrom explains. “The more that the outdated terminology is no longer used, the less likely the issue will come up between hospitals, providers, and courts.”

One overarching concern is there is no standard, accepted definition of what “medical clearance” must encompass. “There is a lot of room for interpretation,” notes Heather L. Brown, DMSc, PA-C, DFAAPA, owner and CEO of Roswell, GA-based HL Brown and Associates.

To most people, the term "medically cleared" suggests the ED has ruled out the possibility other medical issues are present and contributing to the patient's condition. However, many medical conditions mimic psychiatric diagnoses, and could go undetected despite evaluation and testing in the ED. “In essence, what the accepting facility is looking for is a certification that the patient is having no physical ailments that are causing or significantly contributing to their current presentation that appears to be behavioral health diagnosis,” Brown says.

The term "medically cleared" can be problematic for an emergency provider in a courtroom . “There is no standardized explanation of what this means in the setting of transfer to a behavioral health facility,” Brown explains.

In reality, medical problems likely exist with any patient. Medically clearing a patient is a process of determining that, at the time of the ED evaluation, it is unlikely that a medical issue is responsible for the patient’s psychological dysfunction. To a layperson, this concept can be quite confusing. “That may lead to legal complications for a clinician,” Brown cautions.

The term “medical clearance” can present problems for the defense of an ED claim if a behavioral health patient experienced a bad outcome shortly after leaving the department. “If the case goes to trial, a thorough, clear explanation of what this term means, and what it does not, to members of the jury is critical to avoid judgments based on a misunderstanding of the term itself,” Brown says.

The reality is medical care in a psychiatric facility often is limited in scope, availability, and resources. If an unexpected physical issue arises after transfer from the ED, the situation can become complicated quickly. Sometimes, the patient must be transported back to the ED to manage the problem. “Liability can be an issue for ED providers if the newly discovered medical concern was not fully investigated prior to the original transfer,” Brown says.

Documentation can be legally protective in this situation. Ideally, the medical record contains a detailed history and physical exam and a negative panel of diagnostics tailored to the patient’s specific symptoms. The chart should reflect that based on the ED evaluation, there is no indication that an organic, medical problem was the root of the issue at hand. “Utilizing screening lists to help identify potential unique risks for a patient can bolster confidence that a complete evaluation has been completed,” Brown suggests.

Additionally, clear communication between referring facilities and accepting institutions can aid in full vetting of patients before transfer. Brown recommends these practices:

• Before initiating the actual movement of any psychiatric patient to an outside facility, ED clinicians should, if possible, speak directly to a provider at the accepting location. “This is critical to ensure that all evaluations that are preferred have been completed,” Brown says.

• Just before transfer, ED providers should attempt to secure a final verbal consent from the accepting institution. By doing this, the ED is giving the receiving facility an opportunity to request supplementary testing, or refuse transport until the origin facility investigates certain items further by the ED. “This can limit a clinician's liability later, if issues arise,” Brown says.

• ED providers should document all communications with the receiving facility. “This is the clinician's protection against situations that may materialize after discharge,” Brown offers.

If providers take these steps, the risk of a later-discovered abnormality should be minimal. “Generally, an ED provider who has done their evaluation and chart documentation with diligence should not fear future events that may occur medically with a psychiatric patient,” Brown says.

(Editor's Note: The upcoming April 2023 edition of ED Management is a special issue on psychiatric patients. In this single-topic issue, we will report more on medical clearance, along with the biggest challenges EDs nationwide are facing and offer solutions for improving care, operating efficiently, and mitigating safety and legal risks.)