Successfully navigating the 15-minute ‘med check’
Current Psychiatry. 2010 June;09(06):40-43
June 1, 2010|Psychiatry
Author and Disclosure Information
How to reduce malpractice risk with better documentation.
Tips to make documentation easier, faster, and more satisfying” (Current Psychiatry, February 2008), I discussed documentation techniques at length. Table 3 reprints principles that may be especially helpful in practices that consist primarily of med checks.
Table 3
Keys to better documentation
| Technique | Benefits |
|---|---|
| Time and date your notes | After an adverse event, establish when you saw the patient, recorded findings, wrote orders, reviewed lab results, or discussed problems with others can make a big difference in how your care is viewed |
| Sooner is better | Charting completed long after an adverse event occurred is vulnerable to accusations of fabrication |
| Brief quotes | Verbatim statements (‘I’ve never considered suicide’) quickly convey key factors in your therapeutic decision |
| Dictate or use speech recognition software | You speak faster than you write allowing you to document more |
| Provide handouts | Patients often do not remember or understand much of medication instructions doctors tell them |
| Use rating scales | Record more information in a scientifically validated format |
| Try macros and templates | These reduce documentation time and help you remember to cover everything you should |
| Source: Adapted from reference 18 | |
Acknowledgment
Thanks to James Knoll IV, MD for his helpful input on this article.
