Wednesday, September 30, 2009

What's In That Chart?


In Maryland, the issue of patient charts and confidentiality is a heated topic...it's even made it to the state legislature.

I don't write the most exciting of notes. The first time I meet with a patient, I take a full and detailed history and I write the whole time, so my notes essentially say what patient says, ending with a mental status examine, then my impression, diagnosis, and a brief treatment plan. After that, I don't take notes during the session. And I don't generally write about the detailed content of therapy sessions. I may leave it as "Patient talked about activities and family matters." If I change a medication, I say why, especially if it wouldn't be obvious. If I do anything risky or unconventional, I write about why I'm choosing to do this, why other options aren't sufficient, and that I've discussed it with the patient. If I'm worried about someone, I may discuss what measures I've taken to insure their safety. I don't write process notes about the psychotherapy, I don't put in very personal information that isn't directly related to treatment decisions. I view the chart as a legal document and as a clinical reference-- if the patient tells me 3 years later that some medication worked great, I can look up why we stopped a medication that worked great.

Okay, so confidentiality. No one asks for my notes. Rare requests for information from physicians, but a treatment summary does a much better job. No patient has ever asked to see my chart. And if they did, I don't imagine it would be a problem (or a very interesting read).

What do other shrinks write about?