6 Clarify capacity. Jurors may believe that all psychiatric patients are incompetent, and plaintiff’s attorneys sometimes try to create the impression that patients are completely controlled by weird whims and aberrant thoughts. To counter this, when appropriate indicate in the chart that the patient can handle responsibilities such as reporting side effects, seeking emergency attention, or notifying you about changes in thought or mood.3,5
7 Manage appearance and content. Under Health Insurance Portability and Accountability Act (HIPAA) regulations, patients have the right to review their medical records.6 If a lawsuit occurs, the records might be read out loud in court. Documentation will make a better impression if it is clear, legible, and free of gratuitous comments.
8 Include quotations. Documenting verbatim statements from a patient, such as “I’ve never considered suicide,” can quickly convey key information that you considered when making a therapeutic decision.
Technical approaches
Table 27,8 lists several techniques and technologies that might improve documentation. For example, computer users can create templates or customize software to quickly produce thorough documentation for frequently encountered procedures or clinical events. Whether these approaches are useful and appropriate will depend on your work setting, but all aim to improve the speed and quality of clinical documentation.
Think creatively about improving documentation. Even if you’re never sued, better documentation helps you and your patients. For example, several years ago a colleague9 designed an emergency room form that allowed clinicians to complete in a few seconds a Brief Psychiatric Rating Scale on every patient we evaluated. This innovation shortened the time needed to document a systematic, comprehensive assessment and increased the quantity, quality, and reliability of information in patients’ records.
Table 2
Purposes of medical record documentation
| Idea | Comment |
|---|---|
| Use speech recognition | You speak faster than you write. Transcription software |
| Software | accuracy has improved in the last few years. |
| Use handouts and | Patients often do not remember or understand much of what |
| medication instructions | doctors tell them,7,8 so handouts may be more useful than verbal instructions. Good handouts about medications are available on the Internet. Note in the chart that you gave the patient the document. |
| Seek anonymous | Documenting consultations shows you are prudent and |
| consultations with colleagues | a colleague agreed with your treatment. |
| Ask patients to rate their | This practice may improve your information gathering |
| own symptoms and progress | and help document what the patient told you. |
| Use standard rating scales | Rating scales can help you record more information in a scientifically validated format. |
| Use macros and templates | Macros can reduce time needed for documentation. Your memory isn’t perfect, but templates can help you include everything you need to cover. |