Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient
CPT4 code
Name of the Procedure:
Interpretation or Explanation of Results of Psychiatric and Other Medical Examinations
Summary
This procedure involves a healthcare professional reviewing and explaining the results of psychiatric, medical examinations, and other accumulated data to the patient’s family or responsible persons. It also includes advising them on how they can assist and support the patient.
Purpose
The procedure addresses the need for family members or responsible persons to understand the medical and psychiatric status of the patient. The goal is to ensure that they are informed about the patient's condition and know how to provide appropriate support and assistance.
Indications
- Cognitive decline or mental health disorders
- Complex medical conditions that require coordinated care
- Need for family involvement in ongoing care and treatment plans
- Any situation where the patient is unable to fully understand or retain medical information
Preparation
- No specific preparation required for the family or responsible persons.
- Relevant diagnostic tests or assessments done beforehand should be available for review.
Procedure Description
- The healthcare professional reviews all pertinent medical and psychiatric examination results and accumulated data.
- A meeting is arranged with the family members or responsible persons.
- The healthcare professional explains the results in layman’s terms and addresses any questions or concerns.
- Advice is provided on how they can support the patient, including specific actions they can take, lifestyle modifications, and any necessary treatments.
- Resources for additional support, such as counseling or community services, may be provided.
Duration
Typically, 30 to 60 minutes, depending on the complexity of the information and the number of questions from the family.
Setting
This procedure is usually performed in a hospital, outpatient clinic, or the patient’s home, depending on the situation and mobility of the patient and family members.
Personnel
- Psychiatrist, psychologist, or physician
- Nurse or medical assistant (optional)
- Social worker or counselor (optional)
Risks and Complications
- Miscommunication or misunderstanding of medical information
- Emotional distress for the family members or responsible persons
Benefits
- Clear understanding of the patient’s medical and psychiatric condition
- Empowerment of family members to provide appropriate support
- Improved patient outcomes through coordinated care
Recovery
No physical recovery required. Emotional support may be necessary to help the family process the information and cope with the patient’s condition.
Alternatives
- Self-guided research using medical literature and online resources (less personalized and may lead to misinformation)
- Formal family counseling sessions (provides more emotional support but may not be as focused on medical facts)
Patient Experience
The patient may or may not be present during the explanation. If present, they may experience relief through clear communication but might also feel overwhelmed by the discussion. Measures such as breaks, simplified explanations, and supportive presence of family members can enhance comfort and understanding.