The Story of Twyla Roberts and Mary Louis

Twyla Roberts works as an occupational therapist for Marion Home Care Agency. Her patients are primarily elders, but she also occasionally treats children. All of Twyla’s visits are performed in the home setting. She evaluates and treats throughout the community, and the agency is interconnected with two of the area hospitals and several outpatient clinics. The organizations are well connected electronically in one patient care information system. This arrangement allows Twyla to enter her patient information into the hospital’s database and also to receive instant, thorough information on any activity her patients may have in the larger health care system. This electronic record also contains the patient health history and treatment activity. She refers to it many times each day and enters her own data each evening.

Thus, the clinical record of her patient, Mary Louis, is in “the system,” and her progress after a fall is narrated. Mary has just been discharged from the hospital after a fall at home. She was seen by a surgeon, several nurses, a physical therapist, an occupational therapist, and when she was preparing for discharge, a social worker. She is now referred to the home care agency for a home safety evaluation and for ongoing therapy to regain function of her right hand, which was injured in the fall.

Twyla has been taught to document all relevant information about a patient; therefore, she is surprised about her own reluctance to record a conversation that occurred with Mary today. During their treatment session, Mary blurts out that the reason for her injury was not a fall. She has fallen in the past; however, this time her injury was the result of a domestic dispute. Mary’s husband, who has middle-stage Alzheimer’s disease, has been showing more signs of agitation. He became confused one evening, and a struggle ensued. Mary tried her best, but she was neither able to effectively reorient her husband nor manage his aggressive behavior. The incident ended abruptly when Mary’s husband pushed her down the stairs. Despite her disorientation at the time, no one asked specifics regarding how she fell and so in the ambulance she told them she tripped rather than revealing the truth.

She says to Twyla, “I probably shouldn’t have told you about this either. Now my secret is out. Please don’t tell anyone. I am actually ashamed for my husband, you know. I don’t want anybody to know about this. I am really afraid it might affect his ability to stay home. If my daughter finds out, she will surely have him sent to a nursing home. I know he is getting worse, but I would just die if we could not be together. Promise me you won’t say anything!” Twyla does not promise, but neither does she tell Mary that her secret is not safe. Instead, she tries to talk with her about the importance of seeking respite care and of getting more assistance for her husband. But Mary says once again, “Please don’t tell anyone.”

Tywla completes her treatment and goes to the computer. She opens Mary’s record and notes that the social worker, Michael White, was concerned about the home situation. He found Mary’s husband to be quite irritable during hospital visits and so interviewed Mary several times without her husband but did not elicit any evidence that would classify him as a safety risk. Twyla realizes that if she documents this conversation, Mary’s secret will be out for everyone on the patient information system to read. Suddenly, she realizes that Mary has shared information with her that she really wishes she did not have. Now Twyla wishes, too, that when Mary started talking about it she would have stopped her and said she could not promise to keep it confidential. But she did not. Still, she fears that if she does not document their conversation, she could regret it later.