Mental Health Consult

Clinical Segment 5: How candid should you be in your dictated notes?


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People in this video: Whitney McKnight, cohost and producer of Mental Health Consult; Dr. Lorenzo Norris, editorial board member of Clinical Psychiatry News and cohost of Mental Health Consult, and an assistant professor of psychiatry and behavioral sciences, assistant dean of student affairs, and the medical director of psychiatric and behavioral services at George Washington University Hospital, Washington; Dr. Lillian Beard, pediatrician with Children’s National Hospital Network, Washington, and a Pediatric News editorial board member; Dr. David Pickar, adjunct professor of psychiatry at Johns Hopkins University School of Medicine in Baltimore and at the Uniformed Services University of the Health Sciences in Bethesda, Md.

Dr. Lillian Beard: In fact, the written note is sometimes inhibiting to the communication because we are each so aware of what we put in writing [20:00] to even send to a colleague. We can have a conversation, a dialogue about the patient and glean a lot more information.

Whitney: Do you mean you actually omit things on purpose?

Dr. Beard: It is not about omitting, it is about how you state it, because first of all our patients will eventually have access to everything we have written. They are getting more and more access with patient portals. I find for instance even in my notes, so that even if my colleagues in my practice were to see this patient they would know there are certain code terms. I say "high risk for" or I will not do that now because much of that will go to the patient portal. I will come up with other kinds of words so they know to check with me to find out what I meant about that. There are some toxic families, I do not write "toxic family" in my notes.

Dr. Pickar: I agree with you. I could not agree with you more, and in psychiatry, actually there is some protection against not having to share notes. I do not know if you are aware of that. Medical records for sure, but your notes can remain private about a patient. Maybe you know more about that. Help me with that.

Dr. Norris: It is a little bit. Once you get into the problem of keeping dual records, which becomes an issue. You cannot do that. Particularly with electronic medical records, this is now one that patients do and should have access to it. It is a medical legal document and many different people can look at that, so as clinicians, we must be aware, not just for our patients and ourselves, what we put in the note. You cannot have team-based care unless you actually know your teammate. When I am working with a clinician, I want to know their thought process. I want to know a little bit of their philosophy. Do they like stimulants, do they believe in them? When they are also treating, do they screen for first-episode psychosis? Is it on their radar? Are they screening for comorbid depression and bipolar disorder?

Whitney: Should that be legislated or should that be the individual choice of the practice?

Dr. Norris: You can legislate it all you want. This gets into the duty that we as clinicians have to our patients and how we treat them. The first law is to do no harm. I am not saying anything fancy. This is just basic, solid medical care, which takes a certain amount of time, which is not usually 15 minutes.

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