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?


17 comments:

Anonymous said...

Hi, Dinah. I am not a psychiatrist. I am a Licensed Professional Counselor in private practice -- originally in TX and now in CO.

Our Licensing board actually stipulates what must be included in mental health professionals' notes. For us here in CO that includes records of counseling including dates of service, session notes, test data, correspondence, electronic data storage, information concerning any disclosure of info made, info concerning each report made pursuant to legal duties, and a final closing statement.

I have written about several different formats for documenting records of counseling here at http://www.allthingsprivatepractice.com/how-to-take-clinical-notes/ .

Tamara G. Suttle, LPC
http://www.TamaraSuttle.com
http://www.AllThingsPrivatePractice.com

April said...

I requested a copy of my chart from my shrink when I moved and needed treatment at the local clinic. I was really interested to find out what he'd written. But it was pretty boring. About what you described - a lot of detailed notes the first visit and then just basic updates after that. I'm sure most pdocs realize those notes could be requested for legal use and I'm glad mine didn't write anything toooo revealing about what we actually talked about in session.

moviedoc said...

Am a psychiatrist, not a shrink (short for headshrinker, a psychoanalyst). But I think you're on the right track with notes. The only exception is the summary. Writing them wastes your time, and when I get one instead of the complete record to review for a forensic evaluation I tend to suspect the treater is hiding something that I need to see. Usually leads to costly delays as well, maybe in returning someone to work. Worst case is your patient might get fired for not cooperating with examination if you try to withhold the complete record.

Tigermom said...

I take similar notes during an intake - typically 10-12 handwritten pages of notes.

But for progress notes I do write details about the person's life. I find that very helpful for me and the patient as a reference tool. What was going on for them during the month 3 years ago when the good medication was stopped, for example.

I do obfuscate about certain excessively personal issues that have no bearing on treatment decisions. For example, I might write "intimacy" in the margin. Or "marital."

Keelah said...

I requested them upon leaving a state college...wanted to know exactly what was part of a my school records aswe'd discussed things that could be personally damaging.

Pretty boring/detailed notes of what I said. She req'd me to meet with her afterwards as a condition of her releasing them (not sure if legal, but I didn't care). Response to her was along the lines of "well, there were really no surprises." Just a few things she had gotten wrong was all that sticks in memory. Apparently having parents in the public eye and growing up on a lake translates into being Paris Hilton and being handed all I desire when even fully employed today I think twice about spending over $20-40. Irritated mea bit as I felt like she spent the entire time t hinking I was just a spoiled child whose greatest problem would be deciding which frappelatte to order every day, another habit I don't indulge in which my peers do.Also gave convenient excuse as to why she couldnt help me as she so entirely misunderstood my circumstances and worldview. Prolly not real problem, think it was that CBT was not the answer to my problem [or DBT because I "shared some traits with border lines" - only 1 actually and otherwise I'm the opposite and probably would have done bad things if forced to go to group).

Wow that was a different direction. Eh water under the brige. Time and quitting the self focused thought eventually fixed most of my head.

tracy said...

But....how do you know if "they", the therapist, pshchiatrist, etc, give you everything....? i have often wondered about this. It would be very simple for them to hold back whatever they wanted. The same with hospital records.
No offense, Dr. Dinah.
Paranoid, who m e ?

Anonymous said...

clearly, you are not of the psychoanalytic/dynamic variety! my psychoanalytically trained psychiatrist&therapist writes nonstop the entire session - regardless of how long i sit quietly without even moving. there have been times when i'm sure she must be assessing the angle of my crossed legs and recording that along with the color of my socks!

this is the one time in which i'm glad she's private pay as no insurance will ever be permitted access. i suspect that may make a difference in notes as well.

Dinah said...

Moviedoc, I know the forensic types like the whole chart, but for treatment purposes, I think the summary works better...especially for a long chart with years of notes and many different med trials and my handwritten scrawl.

Tigermom, I also just allude to overly personal details. For the first eval, I feel a need to write everything down, after that my memory is pretty good for the details of peoples' lives.

Anonymous: Now you've got me wondering what your analyst writes!

Keelah: Did your shrink really write in her notes that you're like Paris Hilton? Wow!

Rach said...

I've talked about this numerous times on my own blog, but I too have requested my notes from my shrink (and from previous hospitalizations). While I haven't seen his notes, I have received copies of both hospital files.

My shrink also writes almost non-stop for the whole session (and only stops when he's thinking about something). Maybe it's a Canadian vs. American thing? I dunno

Anonymous said...

from Sunny CA
My psychiatrist only writes down appointments. I have never seen him write a note. There is no chart. He has said that he used to write notes when he first was a psychiatrist but he does not feel he needs to any more. His memory is amazing. He will bring up something I said months ago and it always shocks me that his memory is so complete and accurate. He has almost never misquoted me or misremembered or misinterpreted. The previous pdoc I had that wrote all the time and never looked at me misquoted me all the time.

David said...

Not sure if this would help, but my company just released a product called DocWrite that allows secure dictation from an iPhone or iPod touch. We have heard from users that this allows them to create audio files from anywhere at anytime and still work within the HIPAA guidelines. Many healthcare specialists prefer verbally crafting their notes first and enjoy the freedom of picking up their phone whenever they have a thought to capture. The audio files are then accessible from any computer for manual transcription by an office assistant, front desk personnel or current transcription service. Check us out on http://www.docwrite.com.

Anonymous said...

If I didn't know better, I'd swear that Tigermom was my shrink! Almost every comment she makes, I think, "Dr. Whatshername does that, too."

BG said...

I had a psychopharmacologist who seemed to take really long notes--much longer than the ones the Mass Mental trained guy who saw me in college. The latter was only seeing me for drugs, but he did some psychotherapy.

My psycho-pharm guy did have a side practice in forensic psychiatry, so that may explain some of it, but I thought that it was helpful. He had very detailed notes on my moods and medication responses.

When I wanted to restart a med, he looked it over, and my earlier side-effect was one that wasn't reported.

I don't think that the person I now see for integrated treatment is as careful.

Anonymous said...

My bet is that the madly scribbling analyst is writing a novel.

mysadalterego said...

I think that what you do sounds like a very logical way of noting things. I've read some old files with DETAILED psychotherapy notes and it was basically worthless, and probably sort of condescending to the patient...for their massive angst to be reduced to "Talked for fifteen minutes about patient's relationship with father and his profession, patient continues to attribute x y z to a b c."

And my old shrink's refusal to release records (illegal, but what can I do) makes me wonder what the fuck was in there? If it would make the patient (or the shrink) uncomfortable to read - it probably shouldn't be in there.

I always write notes with the idea that the patient may read them (often even turn the screen toward the patient and ask at the end if they agree with what I've written or if I missed something). "Note as if you were sued over the visit" is some advice I got, and try to follow...not for a lawsuit, just because it keeps you thorough and professional.

Keelah said...

No Dinah she didn't use the name. But after finishing reading the overall sense was I had led a charmed life, would never have to work, was given anything I asked for- still can't imagine where she got that idea, was unappeciative of how lucky I was, etc.

Not saying I was born into poverty and had it rough, just we were only avg to upper middle class and there were occasonal $ concerns. Prestige of my dad's job was the only thing uncommon about my situiation. Only thing I can figure is her having a bit of a class warrior in her combined with my cageyness.
ANyway like I think I said it wasn't the main thrust of the notes, just something perception that came apparnet after reading them all.

anastasia said...

Maybe what some of your shrinks, the ones who write a lot, are writing is their next blogpost! ;)