Wednesday, September 07, 2011

What's in a Note? Psychiatrists and Medical Records

There's lots of talk about Electronic Health Records and where the information goes and who has access to it, with the assumption that easy communication is mostly a good thing.  EHR's, cloud storage, and all there is to argue about aside, let's put a question out there: What's in a psychiatrist's note, anyway?  For the sake of our hypothetical discussion here, let's skip the evaluation note, and just talk about progress notes.  Oh, if you'd like to know what's in a psychiatric evaluation, buy our book, we go on and on (and on) about what happens and what gets written.

The progress note is a different story, especially when the treatment includes psychotherapy.  Some psychiatrists write a lot, some write a little, and I wrote all about it over on our Shrink Rap News blog, so please do surf over to read "You Don't Say: Psychiatrists and Their Notes."  

If you're a psychiatrist, what do put in your progress notes?  If you're a patient, what do you imagine (or know) is in your chart?  If anyone worries about such things, please do tell us what your concerns are. 


Anonymous said...

I'm not a psychiatrist but a psychologist who practices therapy. Some of my colleagues, who are worried what might happen if their notes were made part of an inquest or law suit, write in a detached style, e.g., "the patient reported..." but I prefer a more narrative style. I write my notes imagining my patient or their family were reading them. And once, a patient did request his medical record as part of a complaint against the hospital, and said that out of all the various mental health professionals' mine were the only ones in which he could see himself reflected as a person. So I plan to stick to this as the most ethical option.

CatLover said...

I had to get all my notes in order to appeal a private disability insurance denial.

Any surprises came from hospital psychiatrists who didn't know me.

One psychiatrist insulted my vocabulary (apparently I used a couple of words that he was unfamiliar with).

Some got my patient history incorrect, but usually in minor details.

Many of the notes came off very judgmental. I suppose because they thought I had borderline, when in fact, I was having problems from medication side effects for years. As I was married for more and more years, and I pressured docs harder to talk to my husband, it seems that the docs got less and less judgmental. One doc wrote a long essay to protect me from involuntary commitment, which he feared would happen to me. I cried when I read that medical record.

One doc spoke such heavily accented english that his medical transcriptionist couldn't do a good job.

I worry very much that my medical records will get hacked somehow. I assume that it will eventually be public knowledge that I have bipolar and get social services help. I do not know how I will handle the shame if that happens.

It was very useful that I got all those years of notes because I was able to graph my mental health symptoms over time and find that seasonal variations account for almost all of my cycling. It was really quite shocking to look at those graphs. I had no idea the seasonal variations were so strong. I wonder if all bipolar patients or their doctors should be doing this with some handy computer application.

Dinah said...

Anon: We like hearing about the practices of psychologists, too.

CatLover: I like that the notes actually helped you to learn something about yourself.

I'm currently reading Howard Dulley's memoir "My Lobotomy" and he copies segments of the psychiatrist's -- Walter Freeman--notes. They are descriptive and thoughtful, perhaps the only thoughtful thing about Freeman who ran around indiscriminately hacking at peoples' brains with knitting needles.

Anonymous said...

What do psychiatrists think when patients request notes? Why is it weird to want to see what's written about oneself - or as Cat pointed out - to learn more or recognize patterns, etc?
Separately, I don't realyl understand why it's legitimate for a doctor/facility to refuse access to notes on the ground that it could be "harmful to patient." Thoughts?

p.s. Agreed with the comment on Walter Freeman, though the book had some really horrifying concepts.

CatLover said...

What was really awful was that some offices charged really high fees to get my notes, when I was already in financial crisis from losing much of my income. My therapist said that it is done on purpose, to discourage mental patients from getting their notes. None of the hospitals or large clinics did this. It was small therapy offices that charged large fees. They said the notes would be free if they sent them directly to my lawyer, which my lost income was not enough to interest a lawyer in an ERISA disability case. So I am sure my therapist was right, that the point was to discourage me from getting my notes.

I only had one provider refuse to send me the notes, and when I pressured them, they gave in and sent them. They had no basis to believe that it would be harmful for me to read the notes. the problem provider was a small business. Large businesses like clinics and hospitals, ZERO problems, and they charged fair fees for the copies.

Anonymous said...

I've recently gotten some of my records for a lawsuit--it is my burden to prove both the existence of handicap and emotional distress due to being fired for the handicap. The shrinks seem to be afraid to get involved with litigation at any level. The notes and hospital discharge summaries had little surprises in them but had many biographical errors in them as to whether a parent was living or dead, name of city I reside in, etc. Also, my husband was interviewed when I was in the throes of paranoia and psychosis, and some social worker took what my husband described as my stressors as gospel truth, when, in fact, my husband was talking about his OWN stressors or what he perceived to be mine (EXAMPLE: financial woes. Hubby was upset about financial pressures. I was not because I had my own money reserve).

My current psychiatrist once read a few lines from his last session notes, "Patient again denies . . . ." This was after I tried to explain to him that I had not posted confidential info onto the Internet at my last job (as my discharge summary stated) but rather had posted a link to a public lawsuit involving a television actress suing ABC. Why do you shrinks write that the patient denies. What are you looking for? Videotape proof?

CatLover said...

I don't think "patient denies" is supposed to be saying that the doctor does or doesn't believe you. I think that is just medical speak and nothing personal.

Anonymous said...

I have requested my notes from therapists in the past and it is always interesting to see what they write. I've found out about diagnoses in my notes that were never discussed with me. I've found errors in my height, weight, eye color, once even my gender. I've found erroneous medication records, food records, family members' names, places of residence, etc.

My biggest pet peeve is the use of the word "denies". "The patient denies having hallucinations. The patient denies suicidal ideation. The patient denies a personal or family history of heart problems or diabetes., etc." I know this is just doctor talk but it makes me feel like they think I'm lying. Why can't they just write "the patient reports no family history of depression..."?

I would have no problem at all with my doctors' notes being electronic provided I can review and approve them first for obvious errors.

Anonymous said...

How timely. Not 2 hours ago, I perused my first-ever psych report, written from my pdoc back to my LCSW. I've always been anti-eMHR with things psychiatric, but I never dreamed I was this right.

I bent over backwards in the past couple of weeks to keep my current work out of various eMHRs, including paying in cash. A bargain at any price.

Anonymous said...

In the US the cost of medical records are regulated - can only charge a copy fee not more then 75 cents per page. Of course that does add. The law also states that access to records can't be denied due to financial reasons, but that essentially only denies access, not the copies themselves.

Anonymous said...

None of my psychiatrists have ever let me see their notes.

After a particularly bad experience in a psych ward of a general hospital, I was permitted to read my chart at the hospital with supervision. (That was an eye-opener! Psychiatrist who prescribed a med that stopped me from urinating said I was a difficult patient. Yea, I wanted to go to the bathroom!)

My present psychologist lets me see her notes at any time. She has declined only twice in fifteen years, and I trust she had a good reason--the content would upset me. She takes notes throughout a session, jotting key words in various places on a page with circles, arrows, and other doodads. If they were subpoenaed in a legal action, I think many people would find them incomprehensible.

I feel a great sense of trust and calm that my psychologist is not trying to hide anything from me. Her notes have been helpful when I've totally forgotten what happened in a previous session. She can explain what her concerns are. I think this is a terrific practice and shows she has great confidence in her work.

Randall said...

Merope3 sometimes it's just a matter of efficiency.
Instead of "the patient reports no SI," it's easier to jot "denies SI." It makes a difference when you're writing that note between patients. I can cover a lot of ground with, "Amy denies SI/HI, psychosis, obsessive-compulsive behaviors, or mania," for example.

jesse said...

Patients are often forced to release records in order to get insurance, or because of a legal action. The focus of note writing should be on what not to record rather than on what the doctor should record.

Anonymous said...

uI do worry as a health professional when applying or working in the public service, what stops my employer or colleagues accessing all my health records at anytime?
Also does this mean Insurance Agencies/Companies will be able to have unrestricted access now to all our personal information when we make a claim?

Lastly, won't this make people more guarded around what information they share in the therapeutic relationship?

Sunny CA said...

My psychiatrist told me at the beginning that he writes very little down. I have never seen him write anything down while I am in the office (for 50 minutes). He has an amazing memory, though, so brings up appropriate comments from other things I have told him. I don't know how he does it. He is accurate in his recollections whereas my previous (and first) psychiatrist who looked at his pad while writing the whole 15 minutes, got everything wrong when he told me what I had said.

I do NOT like the idea of things that I share with my psychiatrist being on electronic media for insurance people and admissions clerks to read. I would not go for therapy if such were the case.

Anonymous said...

Leaving aside the question of what is in the notes, i worry about who has or could gain access to the notes.

Dinah said...

No patient has ever asked to see my notes.

They aren't that exciting. If someone wants to know what I think about them, they may have to ask to see the transcribed contents of my mind. My notes are mostly about symptoms and medications. They do say why I'm using certain medicines.

My notes don't go anywhere unless a patient tells me it's okay. Otherwise they sit in a file cabinet where, over the years, very few people have cared about their contents.

Anonymous said...

What happens to your notes if something happens to you?

Anonymous said...

I'm a social worker, have been for 23 years. I have a bizarre style. My notes used to be very detailed, then I became aware of the risk of being called into court. At the point a legal sup--(I can't spell) arrives the record can not have anything added or removed. A co worker wrote "did drawing as for TF-CBT" (trauma focused cognitive behavioral therapy).

We as a team were horrified when the therapist was asked to produce those drawings. We have made it a policy we don't keep drawings, journals etc, and we now write "play/art based therapeutic interventions".

I often will show clients my notes and my assessment if they are paranoid, anxious or revealing things they are afraid of having others see. In this age of shared information client may not want his doctor to know the specifics of his childhood trauma.

I want my clients to feel safe with their words and art. I take steps to ensure they understand mandated reporting and Duty to warn. I also take steps to ensure that anything they see from my record is not going to horrify or confuse them.

My last comment is on our doctor speak, I will explain to them the 'denies' 'client reported'. I also tell my teen age clients when I have to write 2 sides to a story and explain to them I have to be profession.

Sorry for the long post, I've listened to you guys forever and just added the blog to RSS and this was the first topic that popped up.

My hobby is writing policy so I spend a great deal of time thinking about such topics.

nuts said...

Looking at all of these comments I get the impression that a psychiatrist can't help people who aren't mentally ill. They go by the book and this is why even though I feel a mess I wouldn't go to speak to someone. I can't trust a psychiatrist, and I'd also rather my notes not go down on paper in a way which could in someway work against me. Yes I'm quite paranoid about it but I think I have reason to be. If the patient can't even get hold of the notes for corrections then that just automatically assumes that all 'patients' are either in denial or are unaware of something which a Psychiatrist considers likely. As in, the patients are untrusted. If I knew a psychiatrist that didn't take notes I'd run to their office to discuss.

Anonymous said...

I request a copy of my last progress note every time I come in for a appointment. I think everyone should do this. There are almost always inaccuracies that need to be corrected.

One time one of my notes said that I was neglecting my child...when I don't even have kids!!! Obviously the doctor had someone else in mind when he wrote that note. He also indicated for 5 years straight that my diagnosis was Bipolar 1 when it was actually major depression. Apparently he assigned a diagnosis code one day without his book in front of him and then that code just carried on from visit to visit for five years... the result of mindless, careless charting. Bipolar 1 is very serious and it's not a label I want if it's not accurate. I requested that my chart reflect that the diagnosis was wrong and that anyone that received the diagnosis code over those years be informed that it was wrong (like my insurer), but the damage, to some extent, is already done. The only way I even found out about this is by calling the doctor's billing office and asking for my diagnosis code because my doctor has an odd habit of not discussing diagnoses with patients. This makes it rather difficult to take care of yourself if you don't even know what you have.

I cannot stress this enough - It's really important to be on top of what all of your doctors are writing about you and to request corrections to your medical record where necessary. These are legal documents and have the potential to do a lot of damage to you in the future if there are things like "she's neglecting her child" or other negative comments in them. Even "difficult patient" will haunt you and I believe doctors should avoid indicating that they believe a patient is difficult because this can taint that the affected patient's interactions with other providers who read the comment in the future. Besides, there are no difficult patients; only difficult interactions. It takes two to tango.

Too many people have the ability to access patients' medical charts. I believe that providers should write the absolute bare minimum. And if it's confidential and I don't want anyone to know about it, I just don't say it. You never know what they'll write and/or won't write. I did reveal something confidential once and specifically asked him not to put it in my chart. Wouldn't you know it... when I checked the note at my next appointment, there was the confidential information he promised he wouldn't put in the note.

Don't trust people. They're just people. They forget. They make mistakes. They are nosy. They do things to help themselves over protecting others. There are myriad reasons not to reveal all in ANY doctor's office. Sorry to be a downer.

Anonymous said...

I need the notes from my 1 psychiatrist visit and 2 LMHC visits, who are at the same location. All they both gave me was a cheesy summary. I need the actual notes for my SSDI hearing. Any advice?

Anonymous said...

I terminated therapy after a year & a half because my therapist 1.never partnered with me to set up a measurable treatment plan 2.Never worked with me to set up measurable points of progress 3.Never worked with me to define what success would look like. I take 50% of the blame for not waking out earlier.
Now that we're done, I want a copy of my file. She says I'm only the second patient in 20 years who's requested this from her; the other guy apparently was talked into believing it would not be "in his best interest" to see the entire file. So now I'm both worried and curious. What hasn't she told me and what is she afraid might happen (and I've asked her this exact question)?

Anonymous said...

I get my medical records periodically, mostly in case of moving or travel so that I can provide them to a new practitioner. But yes, I do read them.

Where I am my understanding (and what my psychiatrist told me) is that legally the records are mine. I was charged no fee for them.

I find them generally accurate, and detached. Are they the same as what I would write? No, but that's fine. I like that they are a bit impersonal, it makes me feel more protected. My dr says he does that deliberately to avoid potential problems in court.

Anonymous said...

I found out that the large Clinic in my area (they have around 20 clinics in my area) shares behavioral health chart notes with anyone in the clinic. Customer Service even has access to read these. I was so angry and felt so betrayed when I found this out. I discussed my most private issues with a therapist, thinking she would keep notes for herself. Little did I know that these went into their electronic record system and if someone has a need or reason to look at the notes they can. This is extremely unsettling and I have to wonder how they legally can do this. Patients don't know how the records are being handled and if they did, you can bet that NO ONE would go to this clinics therapists. Apparently employees signing hippa is supposed to make patients feel okay. Sorry but I don't feel okay about it!