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More on social entropy
As leaders of the American Psychiatric Association, we received dozens of communications from members who were shocked by the discriminatory and transphobic commentary in the recent editorial “The accelerating societal entropy undermines mental health” (
Specifically, citing “lack of certainty about gender identity in children and adults” as an indicator of societal turmoil that undermines mental health is contrary to the scientific understanding of gender identity. Physicians have professional obligations to advance patients’ well-being and do no harm.
The medical profession, including psychiatry, is at a critical juncture in coming to terms with and dismantling its longstanding history of systemic racism and discrimination. Authors and editors must be aware that harmful and divisive language negatively affects mental health, especially for people who have been subject to discrimination individually and/or as members of historically excluded and/or minoritized groups.
In publishing this editorial,
Rebecca W. Brendel, MD, JD, DFAPA
President
American Psychiatric Association
Saul Levin, MD, MPA, FRCP-E, FRCPsych
CEO and Medical Director
American Psychiatric Association
Disclosures
The authors report no financial relationships with any companies whose products are mentioned in this letter, or with manufacturers of competing products.
Dr. Nasrallah responds
I regret that the sentence about gender identity in my October editorial was regarded as transphobic and harmful. While the phrasing reflected my patients’ comments to me, I realize my unfortunate choice of words deeply offended individuals who are transgender, who have been subjected to ongoing discrimination and prejudice.
I apologize to our readers; to my American Psychiatric Association LGBTQAI+ friends, colleagues, and relatives; and to the LGBTQAI+ community at large. The sentence has been deleted from the online version of my editorial. This has been a teachable moment for me.
Henry A. Nasrallah, MD
Editor-In-Chief
Continue to: More on psychiatric documentation
More on psychiatric documentation
Dr. Joshi’s helpful discussion of clinical documentation strategies (“Medical record documentation: What to do, and what to avoid,”
The mental health record may not always be as confidential as psychiatrists think (or hope) it is. The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, for example, generally does not distinguish between medical and mental health information, nor does it provide special rules for the latter (although certain state laws may do so). HIPAA provides added protections for “psychotherapy notes,” but this category explicitly excludes progress notes that discuss treatment modalities, diagnosis, and clinical milestones. To retain their protected status, psychotherapists’ private, “desk-drawer memory joggers” must never be comingled with the patient chart.1 For mental health professionals, this distinction underscores the importance of keeping personal details broad in the progress note; scandalous or embarrassing narratives recounted in the medical record itself are routinely accessible to the patient and may be lawfully disclosed to others under specified circumstances.
In addition to avoiding speculation and including patient quotes when appropriate, documenting objectively and nonjudgmentally means annotating facts and observations that helped the clinician arrive at their conclusion. For example, “patient appears intoxicated” is less helpful than noting the patient’s slurred speech, impaired gait and/or coordination, and alcohol odor.
Clinical care and its associated documentation are so intertwined that they can become virtually indistinguishable. In a medical malpractice case, the burden is on the plaintiff to prove their injury resulted from substandard care. Some courts, however, have held that missing or incomplete records can effectively shift the burden from the recipient to the provider of care to show that the treatment at issue was rendered non-negligently.2 Statutes of limitations restricting the amount of time in which a patient can sue after an adverse event are sometimes triggered by the date on which they knew or should have known of the alleged malpractice.3 One of the best ways of ascertaining this date, and starting the statute of limitations clock, can be a clear annotation in the medical record that the patient was apprised of an unanticipated outcome or iatrogenic harm. In this way, a timely and thorough note can be critical not just to defending the physician’s quality of care, but potentially to precluding a cognizable lawsuit altogether.
Charles G. Kels, JD
Defense Health Agency
San Antonio, Texas
Disclosures
The views expressed are those of the author and do not necessarily reflect those of any government agency, nor do they constitute individualized legal advice. The author reports no financial relationships with any companies whose products are mentioned in this letter, or with manufacturers of competing products.
References
1. 45 CFR Parts 160 and 164, Subparts A and E.
2. Valcin v Public Health Trust, 473 So. 2d 1297 (1984).
3. US v Kubrick, 444 US 111 (1979).
As leaders of the American Psychiatric Association, we received dozens of communications from members who were shocked by the discriminatory and transphobic commentary in the recent editorial “The accelerating societal entropy undermines mental health” (
Specifically, citing “lack of certainty about gender identity in children and adults” as an indicator of societal turmoil that undermines mental health is contrary to the scientific understanding of gender identity. Physicians have professional obligations to advance patients’ well-being and do no harm.
The medical profession, including psychiatry, is at a critical juncture in coming to terms with and dismantling its longstanding history of systemic racism and discrimination. Authors and editors must be aware that harmful and divisive language negatively affects mental health, especially for people who have been subject to discrimination individually and/or as members of historically excluded and/or minoritized groups.
In publishing this editorial,
Rebecca W. Brendel, MD, JD, DFAPA
President
American Psychiatric Association
Saul Levin, MD, MPA, FRCP-E, FRCPsych
CEO and Medical Director
American Psychiatric Association
Disclosures
The authors report no financial relationships with any companies whose products are mentioned in this letter, or with manufacturers of competing products.
Dr. Nasrallah responds
I regret that the sentence about gender identity in my October editorial was regarded as transphobic and harmful. While the phrasing reflected my patients’ comments to me, I realize my unfortunate choice of words deeply offended individuals who are transgender, who have been subjected to ongoing discrimination and prejudice.
I apologize to our readers; to my American Psychiatric Association LGBTQAI+ friends, colleagues, and relatives; and to the LGBTQAI+ community at large. The sentence has been deleted from the online version of my editorial. This has been a teachable moment for me.
Henry A. Nasrallah, MD
Editor-In-Chief
Continue to: More on psychiatric documentation
More on psychiatric documentation
Dr. Joshi’s helpful discussion of clinical documentation strategies (“Medical record documentation: What to do, and what to avoid,”
The mental health record may not always be as confidential as psychiatrists think (or hope) it is. The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, for example, generally does not distinguish between medical and mental health information, nor does it provide special rules for the latter (although certain state laws may do so). HIPAA provides added protections for “psychotherapy notes,” but this category explicitly excludes progress notes that discuss treatment modalities, diagnosis, and clinical milestones. To retain their protected status, psychotherapists’ private, “desk-drawer memory joggers” must never be comingled with the patient chart.1 For mental health professionals, this distinction underscores the importance of keeping personal details broad in the progress note; scandalous or embarrassing narratives recounted in the medical record itself are routinely accessible to the patient and may be lawfully disclosed to others under specified circumstances.
In addition to avoiding speculation and including patient quotes when appropriate, documenting objectively and nonjudgmentally means annotating facts and observations that helped the clinician arrive at their conclusion. For example, “patient appears intoxicated” is less helpful than noting the patient’s slurred speech, impaired gait and/or coordination, and alcohol odor.
Clinical care and its associated documentation are so intertwined that they can become virtually indistinguishable. In a medical malpractice case, the burden is on the plaintiff to prove their injury resulted from substandard care. Some courts, however, have held that missing or incomplete records can effectively shift the burden from the recipient to the provider of care to show that the treatment at issue was rendered non-negligently.2 Statutes of limitations restricting the amount of time in which a patient can sue after an adverse event are sometimes triggered by the date on which they knew or should have known of the alleged malpractice.3 One of the best ways of ascertaining this date, and starting the statute of limitations clock, can be a clear annotation in the medical record that the patient was apprised of an unanticipated outcome or iatrogenic harm. In this way, a timely and thorough note can be critical not just to defending the physician’s quality of care, but potentially to precluding a cognizable lawsuit altogether.
Charles G. Kels, JD
Defense Health Agency
San Antonio, Texas
Disclosures
The views expressed are those of the author and do not necessarily reflect those of any government agency, nor do they constitute individualized legal advice. The author reports no financial relationships with any companies whose products are mentioned in this letter, or with manufacturers of competing products.
References
1. 45 CFR Parts 160 and 164, Subparts A and E.
2. Valcin v Public Health Trust, 473 So. 2d 1297 (1984).
3. US v Kubrick, 444 US 111 (1979).
As leaders of the American Psychiatric Association, we received dozens of communications from members who were shocked by the discriminatory and transphobic commentary in the recent editorial “The accelerating societal entropy undermines mental health” (
Specifically, citing “lack of certainty about gender identity in children and adults” as an indicator of societal turmoil that undermines mental health is contrary to the scientific understanding of gender identity. Physicians have professional obligations to advance patients’ well-being and do no harm.
The medical profession, including psychiatry, is at a critical juncture in coming to terms with and dismantling its longstanding history of systemic racism and discrimination. Authors and editors must be aware that harmful and divisive language negatively affects mental health, especially for people who have been subject to discrimination individually and/or as members of historically excluded and/or minoritized groups.
In publishing this editorial,
Rebecca W. Brendel, MD, JD, DFAPA
President
American Psychiatric Association
Saul Levin, MD, MPA, FRCP-E, FRCPsych
CEO and Medical Director
American Psychiatric Association
Disclosures
The authors report no financial relationships with any companies whose products are mentioned in this letter, or with manufacturers of competing products.
Dr. Nasrallah responds
I regret that the sentence about gender identity in my October editorial was regarded as transphobic and harmful. While the phrasing reflected my patients’ comments to me, I realize my unfortunate choice of words deeply offended individuals who are transgender, who have been subjected to ongoing discrimination and prejudice.
I apologize to our readers; to my American Psychiatric Association LGBTQAI+ friends, colleagues, and relatives; and to the LGBTQAI+ community at large. The sentence has been deleted from the online version of my editorial. This has been a teachable moment for me.
Henry A. Nasrallah, MD
Editor-In-Chief
Continue to: More on psychiatric documentation
More on psychiatric documentation
Dr. Joshi’s helpful discussion of clinical documentation strategies (“Medical record documentation: What to do, and what to avoid,”
The mental health record may not always be as confidential as psychiatrists think (or hope) it is. The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, for example, generally does not distinguish between medical and mental health information, nor does it provide special rules for the latter (although certain state laws may do so). HIPAA provides added protections for “psychotherapy notes,” but this category explicitly excludes progress notes that discuss treatment modalities, diagnosis, and clinical milestones. To retain their protected status, psychotherapists’ private, “desk-drawer memory joggers” must never be comingled with the patient chart.1 For mental health professionals, this distinction underscores the importance of keeping personal details broad in the progress note; scandalous or embarrassing narratives recounted in the medical record itself are routinely accessible to the patient and may be lawfully disclosed to others under specified circumstances.
In addition to avoiding speculation and including patient quotes when appropriate, documenting objectively and nonjudgmentally means annotating facts and observations that helped the clinician arrive at their conclusion. For example, “patient appears intoxicated” is less helpful than noting the patient’s slurred speech, impaired gait and/or coordination, and alcohol odor.
Clinical care and its associated documentation are so intertwined that they can become virtually indistinguishable. In a medical malpractice case, the burden is on the plaintiff to prove their injury resulted from substandard care. Some courts, however, have held that missing or incomplete records can effectively shift the burden from the recipient to the provider of care to show that the treatment at issue was rendered non-negligently.2 Statutes of limitations restricting the amount of time in which a patient can sue after an adverse event are sometimes triggered by the date on which they knew or should have known of the alleged malpractice.3 One of the best ways of ascertaining this date, and starting the statute of limitations clock, can be a clear annotation in the medical record that the patient was apprised of an unanticipated outcome or iatrogenic harm. In this way, a timely and thorough note can be critical not just to defending the physician’s quality of care, but potentially to precluding a cognizable lawsuit altogether.
Charles G. Kels, JD
Defense Health Agency
San Antonio, Texas
Disclosures
The views expressed are those of the author and do not necessarily reflect those of any government agency, nor do they constitute individualized legal advice. The author reports no financial relationships with any companies whose products are mentioned in this letter, or with manufacturers of competing products.
References
1. 45 CFR Parts 160 and 164, Subparts A and E.
2. Valcin v Public Health Trust, 473 So. 2d 1297 (1984).
3. US v Kubrick, 444 US 111 (1979).