Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 5: Examination and Diagnosis of the Psychiatric Patient

Table 5.2-3 Documentation Issues

ever, it may not be possible to do so. When litigation occurs, the entire medical record is subject to discovery. Psychotherapy notes are usually protected, but not always. If psychotherapy notes are ordered to be produced, the judge would probably review them privately and select what is relevant to the case in question. Blogs Blogs or web logs are used by persons who wish to record their day-to-day experiences or to express their thoughts and feelings about events. Physicians should be especially cautious about such activities because they are subject to discovery in lawsuits. Pseudonyms and aliases offer no protection because they can be traced. Writing about patients on blogs is a breach in confiden- tiality. In one case a doctor detailed his thoughts about a law- suit that included hostile comments about the plaintiff and his attorney. His blog was discovered inadvertently and was used against him in court. Physicians are advised not to use blogs to vent emotions and to write nothing that they would not write for attribution even if their identity were discovered. E-Mail E-mail is increasingly being used by physicians as a quick and efficient way to communicate not only with patients but also with other doctors about their patients; however, it is a public document and should be treated as such. The dictum of not diag- nosing or prescribing medication over the telephone to a patient one has not examined should also apply to e-mail. It is not only dangerous but also unethical. All e-mail messages should be printed to include with the paper chart unless electronic archives are regularly backed up and secure. Ethical Issues and the Medical Record Psychiatrists continually make judgments about what is appropri- ate material to include in the psychiatric report, the medical record, the case report, and other written communications about a patient. Such judgments often involve ethical issues. In a case report, for example, the patient should not be identifiable, a position made clear in the American Psychiatric Association’s (APA’s) Principles of Medical Ethics with Annotations Especially Applicable to Psy- chiatry, which states that published case reports must be suitably disguised to safeguard patient confidentiality without altering material to provide a less-than-complete portrayal of the patient’s actual condition. In some instances, obtaining a written release from the patient that allows the psychiatrist to publish the case may also be advisable, even if the patient is appropriately disguised. Psychiatrists sometimes include material in the medical record that is specifically directed toward warding off future culpability if liability issues are ever raised. This may include having advised the patient about specific adverse effects of med- ication to be prescribed. Health Insurance Portability and Accountability Act (HIPAA) The Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996 to address the medical deliv- ery system’s mounting complexity and its rising dependence on electronic communication. The act orders that the federal Department of Health and Human Services (HHS) develop rules

Patient Access to Records Patients have a legal right to access their medical records. This right represents society’s belief that the responsibility for medi- cal care has become a collaborative process between doctor and patient. Patients see many different physicians, and they can be more effective historians and coordinators of their own care with such information. Psychiatrists must be careful in releasing their records to the patient if, in their judgment, the patient can be harmed emotion- ally as a result. Under these circumstances, the psychiatrist may choose to prepare a summary of the patient’s course of treatment, holding back material that might be hurtful—especially if it were to get into the hands of third parties. In malpractice cases, how- Note: Documentation issues are of concern to third-party payers, such as insurance companies and health maintenance organizations who examine patients’ charts to see if the areas listed above are covered. In many cases, however, the review is conducted by persons with little or no background in psychiatry or psychology who do not recognize the complexities of psychiatric diagnosis and treatment. Payments to hospitals, doctors, and patients are often denied because of what such reviewers consider to be so-called inadequate documentation. Are patient’s areas of dysfunction described? From the biological, psychological, and social points of view? Is alcohol or substance abuse addressed? Do clinical activities happen at the expected time? If too late or never, why? Are issues identified in the treatment plan and followed in progress notes? When there is a variance in the patient’s outcome, is there a note in the progress notes to that effect? Is there also a note in the progress notes reflecting the clinical strategies recommended to overcome the impediments to the patient’s improvement? If new clinical strategies are implemented, how is their impact evaluated? When? Is there a sense of multidisciplinary input and coordination of treatment in the progress notes? Do progress notes indicate the patient’s functioning in the therapeutic community and its relationship to their discharge criteria? Can one extrapolate from the patient’s behavior in the therapeutic community how he or she will function in the community at large? Are there notes depicting the patient’s understanding of his or her discharge planning? Family participation in discharge planning must be entered in the progress notes with their reaction to the plan. Do attending progress notes bridge the differences in thinking of other disciplines? Are the patient’s needs addressed in the treatment plan? Are the patient’s family’s needs evaluated and implemented? Is patient and family satisfaction evaluated in any way? Is alcohol and substance abuse addressed as a possible contributor to readmission? If the patient was readmitted, are there indications that previous records were reviewed, and, if the patient is on medication other than that prescribed on discharge, is there a rationale for this change? Do the progress notes identify the type of medication used and the rationale for increase, decrease, discontinuation, or augmentation of medication? Are medication effects documented, including dosages, response, and adverse or other side effects?