The patient leaves and the psychiatrist writes a note. What does the doctor say? Does a psychiatrist write a standard medical SOAP note, a detailed process note, a quick few sentences, or no note at all? In hospitals and clinics, there are requirements for documentation that come from regulatory agencies, but in private practice there is no such oversight. Do you know what the standard of care requires?
There is a good deal of variety regarding what psychiatrists choose to document. Some write very detailed notes; others focus their notes on symptoms and medication but omit personal events they believe a patient would not want documented, and finally, some simply do not write notes on every psychotherapy session. The psychiatrist is faced with the questions of what is the purpose of the note and who might see it.
Medical notes are written with several potential “readers” in mind. The psychiatrist writes for himself so that he can review details of the patient’s life and treatment. He writes for the patient – that is, to enable continuity of care if the patient should later need to see another psychiatrist. Finally, the psychiatrist writes for his own protection, and he writes what he believes will be helpful to him in the event that he is sued or that his records are reviewed by a state licensing board. What benefits one audience may harm another.
Dr. Michael Spodak is the chair of the Maryland Psychiatric Society’s Peer Review Committee, which provides services to the Maryland Board of Physicians. Dr. Spodak writes: “To date, there is no agreement as to a standard for therapy notes. At a minimum, they probably should contain a date of service. We have felt the purpose of the note is for another psychiatrist to pick up where you left off if you suddenly became unavailable, such as through death. So if a patient is suicidal, a note should probably contain information on how that is being addressed.” Dr. Spodak says that for medication management, psychiatrists are held to the same standard that other physicians hold, and he faxed a one-paragraph statement from the medical board that states that physicians must keep “adequate” records. Such are records are defined to be legible and include “dates of visits, chief complaints, historical, physical and laboratory data, diagnosis and a treatment plan.” It further states that doctors should give reasons for ordering medications and tests.
What about the usefulness of notes when a psychiatrist is sued? Eric Marine, the vice president of claims and risk management for American Professional Agency, a medical malpractice insurer, says that few psychiatrists get sued. “There are about 100,000 psychiatrists in the United States, and there are less than 1,000 claims a year.”
“The biggest problem with notes,” Mr. Marine said, “is the disagreement about what is supposed to be in them. When you’re talking about these issues, it’s as if there is some mythical thing called ‘standard of care.’ What would a reasonable doctor do? But outcome is never guaranteed.”
So there is no standard and so the psychiatrist is left to guess at what might be important down the line. In the event that a patient dies of an unanticipated suicide and the family sues the psychiatrist, Mr. Marine confirms that it is helpful if the psychiatrist has documented that the patient was not suicidal. This may lead to the conclusion that every patient should be assessed for suicide at every visit, regardless of the relevance to the clinical issues at hand, or that a psychiatrist must be clairvoyant to predict which patients might sue him for what so that he can document accordingly. It also suggests that if the psychiatrist didn’t ask about suicidal ideation, then he was at fault in the case of a suicide!
Another concern is that information in a patient’s records might be used in a manner that is harmful to the patient. Jesse Hellman is a psychiatrist who has been in private practice in Towson, Md., for 35 years. Dr. Hellman worries about confidentiality with medical records. “The need to protect the patient is a primary issue, and since notes are really not confidential, the only way to protect the patient is to not record anything that you would not want known.”
Dr. Spodak agrees that the issue of keeping notes on therapy sessions can be problematic. “Do we have a duty to inform the patient that the notes may be disclosed to an insurance company, medical board and others? After that warning, will anyone disclose things of substance if the psychiatrist makes notes?”