User login
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.
1. Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008;65:962-970.
2. Lewis MH, Gohagan JK, Merenstein DJ. The locality rule and the physician’s dilemma: local medical practices vs the national standard of care. JAMA. 2007;297(23):2633-2637.
3. Gabbard GO. Deconstructing the “med check.” Psychiatric Times. September 3, 2009. Available at: http://www.psychiatrictimes.com/display/article/10168/1444238. Accessed April 28, 2010.
4. Pies RW. Psychiatrists, physicians, and the prescriptive bond. Psychiatric Times. April 16, 2010. Available at: http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1555057. Accessed April 28, 2010.
5. Carlat DJ. Unhinged: the trouble with psychiatry—a doctor’s revelations about a profession in crisis. New York, NY: Free Press; 2010.
6. Nemeroff CB. The myth of the med check in psychopharmacology. Presented at: Presidential Symposium, Annual Meeting of the American Psychiatric Association; May 7, 2008; Washington, DC.
7. Rush W, Gochfeli L, Minkov K, et al. Medication visits: visit time and quality—the connection. Compliance Watch. 2009;2(2):13-15.
8. Fine P. Psychodynamic psychiatry in community settings. J Am Acad Psychoanal Dyn Psychiatry. 2007;35:431-441.
9. Sherman C. Don’t forget therapeutic skills even during a “med check.” Clinical Psychiatry News. 2002;30(7):390.-Available at: http://findarticles.com/p/articles/mi_hb4345/is_7_30/ai_n28933329. Accessed April 28, 2010.
10. Ackerman SJ, Hilsenroth MJ. A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical Psychology Rev. 2003;23:1-33.
11. Guggenheim FG. Prime time: maximizing the therapeutic experience—a primer for psychiatric clinicians. New York, NY: Routledge; 2009.
12. Saks ER. The center cannot hold: my journey through madness. New York, NY: Hyperion; 2007.
13. Pincus HA, Tanielian TL, Marcus SC, et al. Prescribing trends in psychotropic medications: primary care, psychiatry, and other medical specialties. JAMA. 1998;279(7):526-531.
14. Harman JS, Veazie PJ, Lyness JM. Primary care physician office visits for depression by older Americans. J Gen Intern Med. 2006;21:926-930.
15. Chen LM, Farwell WR, Jha AK. Primary care visit duration and quality: does good care take longer? Arch Intern Med. 2009;169:1866-1872.
16. Gilchrist VJ, Stange KC, Flocke SA, et al. A comparison of the National Ambulatory Medical Care Survey (NAMCS) measurement approach with direct observation of outpatient visits. Med Care. 2004;42(3):276-280.
17. Moffic HS. Make the most of the “15-minute med-check.” Current Psychiatry. 2006;5(9):116.-
18. Mossman D. Tips to make documentation easier, faster, and more satisfying. Current Psychiatry. 2008;7(2):84-86.
Douglas Mossman, MD
Dr. Mossman is director, Glenn M. Weaver Institute of Law and Psychiatry, University of Cincinnati College of Law, and adjunct professor of clinical psychiatry and training director for the forensic psychiatry fellowship, University of Cincinnati College of Medicine.
Douglas Mossman, MD
Dr. Mossman is director, Glenn M. Weaver Institute of Law and Psychiatry, University of Cincinnati College of Law, and adjunct professor of clinical psychiatry and training director for the forensic psychiatry fellowship, University of Cincinnati College of Medicine.
Douglas Mossman, MD
Dr. Mossman is director, Glenn M. Weaver Institute of Law and Psychiatry, University of Cincinnati College of Law, and adjunct professor of clinical psychiatry and training director for the forensic psychiatry fellowship, University of Cincinnati College of Medicine.
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.
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.
1. Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008;65:962-970.
2. Lewis MH, Gohagan JK, Merenstein DJ. The locality rule and the physician’s dilemma: local medical practices vs the national standard of care. JAMA. 2007;297(23):2633-2637.
3. Gabbard GO. Deconstructing the “med check.” Psychiatric Times. September 3, 2009. Available at: http://www.psychiatrictimes.com/display/article/10168/1444238. Accessed April 28, 2010.
4. Pies RW. Psychiatrists, physicians, and the prescriptive bond. Psychiatric Times. April 16, 2010. Available at: http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1555057. Accessed April 28, 2010.
5. Carlat DJ. Unhinged: the trouble with psychiatry—a doctor’s revelations about a profession in crisis. New York, NY: Free Press; 2010.
6. Nemeroff CB. The myth of the med check in psychopharmacology. Presented at: Presidential Symposium, Annual Meeting of the American Psychiatric Association; May 7, 2008; Washington, DC.
7. Rush W, Gochfeli L, Minkov K, et al. Medication visits: visit time and quality—the connection. Compliance Watch. 2009;2(2):13-15.
8. Fine P. Psychodynamic psychiatry in community settings. J Am Acad Psychoanal Dyn Psychiatry. 2007;35:431-441.
9. Sherman C. Don’t forget therapeutic skills even during a “med check.” Clinical Psychiatry News. 2002;30(7):390.-Available at: http://findarticles.com/p/articles/mi_hb4345/is_7_30/ai_n28933329. Accessed April 28, 2010.
10. Ackerman SJ, Hilsenroth MJ. A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical Psychology Rev. 2003;23:1-33.
11. Guggenheim FG. Prime time: maximizing the therapeutic experience—a primer for psychiatric clinicians. New York, NY: Routledge; 2009.
12. Saks ER. The center cannot hold: my journey through madness. New York, NY: Hyperion; 2007.
13. Pincus HA, Tanielian TL, Marcus SC, et al. Prescribing trends in psychotropic medications: primary care, psychiatry, and other medical specialties. JAMA. 1998;279(7):526-531.
14. Harman JS, Veazie PJ, Lyness JM. Primary care physician office visits for depression by older Americans. J Gen Intern Med. 2006;21:926-930.
15. Chen LM, Farwell WR, Jha AK. Primary care visit duration and quality: does good care take longer? Arch Intern Med. 2009;169:1866-1872.
16. Gilchrist VJ, Stange KC, Flocke SA, et al. A comparison of the National Ambulatory Medical Care Survey (NAMCS) measurement approach with direct observation of outpatient visits. Med Care. 2004;42(3):276-280.
17. Moffic HS. Make the most of the “15-minute med-check.” Current Psychiatry. 2006;5(9):116.-
18. Mossman D. Tips to make documentation easier, faster, and more satisfying. Current Psychiatry. 2008;7(2):84-86.
1. Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008;65:962-970.
2. Lewis MH, Gohagan JK, Merenstein DJ. The locality rule and the physician’s dilemma: local medical practices vs the national standard of care. JAMA. 2007;297(23):2633-2637.
3. Gabbard GO. Deconstructing the “med check.” Psychiatric Times. September 3, 2009. Available at: http://www.psychiatrictimes.com/display/article/10168/1444238. Accessed April 28, 2010.
4. Pies RW. Psychiatrists, physicians, and the prescriptive bond. Psychiatric Times. April 16, 2010. Available at: http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1555057. Accessed April 28, 2010.
5. Carlat DJ. Unhinged: the trouble with psychiatry—a doctor’s revelations about a profession in crisis. New York, NY: Free Press; 2010.
6. Nemeroff CB. The myth of the med check in psychopharmacology. Presented at: Presidential Symposium, Annual Meeting of the American Psychiatric Association; May 7, 2008; Washington, DC.
7. Rush W, Gochfeli L, Minkov K, et al. Medication visits: visit time and quality—the connection. Compliance Watch. 2009;2(2):13-15.
8. Fine P. Psychodynamic psychiatry in community settings. J Am Acad Psychoanal Dyn Psychiatry. 2007;35:431-441.
9. Sherman C. Don’t forget therapeutic skills even during a “med check.” Clinical Psychiatry News. 2002;30(7):390.-Available at: http://findarticles.com/p/articles/mi_hb4345/is_7_30/ai_n28933329. Accessed April 28, 2010.
10. Ackerman SJ, Hilsenroth MJ. A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical Psychology Rev. 2003;23:1-33.
11. Guggenheim FG. Prime time: maximizing the therapeutic experience—a primer for psychiatric clinicians. New York, NY: Routledge; 2009.
12. Saks ER. The center cannot hold: my journey through madness. New York, NY: Hyperion; 2007.
13. Pincus HA, Tanielian TL, Marcus SC, et al. Prescribing trends in psychotropic medications: primary care, psychiatry, and other medical specialties. JAMA. 1998;279(7):526-531.
14. Harman JS, Veazie PJ, Lyness JM. Primary care physician office visits for depression by older Americans. J Gen Intern Med. 2006;21:926-930.
15. Chen LM, Farwell WR, Jha AK. Primary care visit duration and quality: does good care take longer? Arch Intern Med. 2009;169:1866-1872.
16. Gilchrist VJ, Stange KC, Flocke SA, et al. A comparison of the National Ambulatory Medical Care Survey (NAMCS) measurement approach with direct observation of outpatient visits. Med Care. 2004;42(3):276-280.
17. Moffic HS. Make the most of the “15-minute med-check.” Current Psychiatry. 2006;5(9):116.-
18. Mossman D. Tips to make documentation easier, faster, and more satisfying. Current Psychiatry. 2008;7(2):84-86.