Medical Record Auditor: Documentation Rules and Rationales With Exercises
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Wendy was the mother of three children. Wendy had been feeling quite fretful lately and started to "medicate" herself by having a few martinis every evening after she tucked her children into bed. After roughly three weeks of this drinking routine, she at long last understood the fact that instead of helping her ”chill out" and ”handle” her problems, drinking made her feel more restless when she got up in the morning. This, in turn, made her feel increasingly more tense throughout the day.
After thinking about her circumstance for four or five days, Wendy decided to talk about her drinking situation with her best friend. In fact, approximately twenty-five minutes into their chat, Wendy’s friend, Esther, mentioned that she knew about an extremely helpful and skillful doctor at the local alcohol and drug treatment center. After talking to her friend, Wendy without much ado got motivated to call the treatment clinic and make an appointment.
Ten days later she eventually got to meet the psychiatrist her best friend had talked about. After their brief introduction, Wendy explained to the doctor that ever since her husband and she got divorced, she has been having an extremely difficult time financially, spiritually, and psychologically.
At times, she felt that the divorce was behind her. Recently, conversely, she has been feeling extremely depressed about the fact that she and her former husband couldn't stay married and “make it”. When asked by the psychiatrist how long she and her ex-husband dated before they got married, Wendy explained to the psychiatrist that her ex-husband and she dated for two years and then lived together for three years before they got married.
As Wendy was talking to the physician, she stressed the point that she honestly thought that she and her former husband waited long enough to know each other well enough before they got married. After the kids started to arrive, on the other hand, their lives appeared to deteriorate. Not only this but both Robert and she started to drink, and their abusive and unhealthy drinking adversely affected their finances, their relationship, and their love for one another.
When things became less than congenial between them, Robert got an attorney and filed for a divorce. Although things were apparently not going well and even though she was often depressed, Wendy told the physician that she did not want to put an end to their relationship. Once she was served the divorce papers, however, she knew that their relationship was over.
The psychiatrist told Wendy that the anxiety, tension, and stress that she has been going through regarding her excessive and unhealthy drinking are some of the more commonplace alcohol abuse effects and that the best solution for this state of affairs is rehab for one's alcohol abuse. In fact, getting alcohol abuse treatment is very important because continuous drinking can get the individual into even more serious alcohol and alcoholism problems.
After eleven or twelve therapy sessions with her psychiatrist, Wendy was little by little able to see that the real source of her anxiety and her depression was that she had not laid to rest her bitter feelings she has for her former husband who had divorced her two-and-a-half years ago. With these insights and with the drugs her psychiatrist prescribed, she eventually stopped drinking, she began to feel much less depressed, and she began making more time for social activities with her friends and family. A few months after receiving treatment from her physician, she even started to date once again.
It was clear that Wendy had come a long way. In fact, just about four months after she stopped her therapy, Wendy had finally laid the harmful thoughts of Robert, her former husband, to rest and was starting to feel more self worth and more spiritually "sound" and psychologically “together” than she had ever felt in her life.
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