Wednesday, September 07, 2011

What's in a Note? Psychiatrists and Medical Records

There's lots of talk about Electronic Health Records and where the information goes and who has access to it, with the assumption that easy communication is mostly a good thing.  EHR's, cloud storage, and all there is to argue about aside, let's put a question out there: What's in a psychiatrist's note, anyway?  For the sake of our hypothetical discussion here, let's skip the evaluation note, and just talk about progress notes.  Oh, if you'd like to know what's in a psychiatric evaluation, buy our book, we go on and on (and on) about what happens and what gets written.

The progress note is a different story, especially when the treatment includes psychotherapy.  Some psychiatrists write a lot, some write a little, and I wrote all about it over on our Shrink Rap News blog, so please do surf over to read "You Don't Say: Psychiatrists and Their Notes."  

If you're a psychiatrist, what do put in your progress notes?  If you're a patient, what do you imagine (or know) is in your chart?  If anyone worries about such things, please do tell us what your concerns are.