How did your notes change after residency?

[Psychresy]

Right now I find my outpatient notes in particular are quite long. I think this is partly because our attendings want us to spell everything out, and perhaps also because they serve as good reminders for what I should be thinking about at the next visit. In either case, these multi-paragraph long A/P are getting a little tiresome to keep up with. Curious if this is how things remain for the majority of you after residency or if you are able to cut down and stream line.

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[Bartelby]

An outpatient follow-up note should not need multiple paragraphs in the assessment section except in rare cases such as explaining why you are not hospitalizing someone who is on the border of meeting criteria. My subjective section is typically a brief paragraph summarizing symptoms and stressors, mental status exam is standard, and my assessment is typically a few sentences. I then carry over and update the plan. Follow up notes should take less than 5 minutes, again except for those rare cases where you do need some more extensive documentation.

 

[adaptation1]

More information is not always better. Include only what is necessary and important. No need for editorializing. That's how my notes changed.

 

[Psychresy]

More information is not always better. Include only what is necessary and important. No need for editorializing. That's how my notes changed.

As a resident, do you think i'm (or my attendings by wanting to see such drawn out notes) are making an error? Or is this to be expected at this level of training?

 

[the5thelement]

Sleep +. Appetite ++, No SI/HI or AVH. Cont. meds

 

[adaptation1]

As a resident, do you think i'm (or my attendings by wanting to see such drawn out notes) are making an error? Or is this to be expected at this level of training?

I don't think it's a error, but often times a matter of experience, work environment, being in learning environment, and patient load. Look at your attending's notes for reference. What are they like?

 

[Psychresy]

I don't think it's a error, but often times a matter of experience, work environment, being in learning environment, and patient load. Look at your attending's notes for reference. What are they like?

Some of them are quite lengthy, for seemingly very simple patients. I wonder if this is something inherent to the nature of an academic program?

 

[adaptation1]

My personal rule of thumb is simple: Don't be indulgent and communicate effectively. If one can follow that rule and still write 3 paragraphs about a patient with first-episode depression and zero co-morbidities, more power to them!

 

[Candidate2017]

Attendings are rational actors given they are 100% liable for a patient even though (1) they don't know the patient, (2) the patient is being seen by an inexperienced trainee, and (3) the trainee's time costs them nothing. So they will demand trainees write detailed notes even though all you need is to cover the relevant signs/symptoms and diagnoses/plan (and hit billing codes accordingly) and risks/safety issues.

 

[whopper]

My notes now typically include a PHQ-9 or Beck Depression Scale, a GAD-7, an ASRS or Insomnia Severity Scale.

I've noticed that using such a scale adds a barometer to the person's problem, and cuts through the BS. They directly answer what need to know instead of going through minutes of BS I didn't have to know.

E.g.
Me: How are you?
Patient: Depressed, well you need to listen to this. There's this thing going on and it's so out there I can't even describe it. You see it's like this thing and it's really really you know. So do you understand why I'm depressed?
Me: No. You told me several non-descript things. Can you be more specific?
Patient: Well I told you man, it's like there's this thing man and it's a thing. Do you get me? It's a thing!

Well I pull out a PHQ-9 and here's the response.

PHQ-9
Over the last two weeks, how often have you been bothered by the following problems?

• (Not at all=0, Several days=1, More than half the days=2, Nearly every day=3)

1. Little interest or pleasure in doing things. (1)
2. Feeling down, depressed, or hopeless (1)
3. Trouble falling or staying asleep, or sleeping too much (1)
4. Feeling tired or having little energy (2)
5. Poor appetite or overeating (0)
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down (1)
7. Trouble concentrating on things, such as reading the newspaper or watching television (2)
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual (2)
9. Thoughts that you would be better off dead, or of hurting yourself in some way (1)
Total Score: (11)


Voila. I got all the relevant depression stuff in a nutshell. Now I can proceed to listen to the patient's context more instead of going in circles and getting nowhere.

Then correspondingly with repeat PHQ-9s in further visits I can track the patient is improving or getting worse. Of course yes someone's going to pull out that this isn't 100% accurate, but the PHQ-9 has been extensively studied and is a useful tool and I've found it a heck of a lot better than listen to patients when they go nowhere after minutes of discussion. Also of course the context of what's going on in the pt's life is relevant too but I'd like to get the relevant stuff done and out of the way so I can listen to that too.

 

[hebel]

My notes now typically include a PHQ-9 or Beck Depression Scale, a GAD-7, an ASRS or Insomnia Severity Scale.

I've noticed that using such a scale adds a barometer to the person's problem, and cuts through the BS. They directly answer what need to know instead of going through minutes of BS I didn't have to know.

E.g.
Me: How are you?
Patient: Depressed, well you need to listen to this. There's this thing going on and it's so out there I can't even describe it. You see it's like this thing and it's really really you know. So do you understand why I'm depressed?
Me: No. You told me several non-descript things. Can you be more specific?
Patient: Well I told you man, it's like there's this thing man and it's a thing. Do you get me? It's a thing!

Well I pull out a PHQ-9 and here's the response.

PHQ-9
Over the last two weeks, how often have you been bothered by the following problems?

• (Not at all=0, Several days=1, More than half the days=2, Nearly every day=3)

1. Little interest or pleasure in doing things. (1)
2. Feeling down, depressed, or hopeless (1)
3. Trouble falling or staying asleep, or sleeping too much (1)
4. Feeling tired or having little energy (2)
5. Poor appetite or overeating (0)
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down (1)
7. Trouble concentrating on things, such as reading the newspaper or watching television (2)
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual (2)
9. Thoughts that you would be better off dead, or of hurting yourself in some way (1)
Total Score: (11)


Voila. I got all the relevant depression stuff in a nutshell. Now I can proceed to listen to the patient's context more instead of going in circles and getting nowhere.

Then correspondingly with repeat PHQ-9s in further visits I can track the patient is improving or getting worse. Of course yes someone's going to pull out that this isn't 100% accurate, but the PHQ-9 has been extensively studied and is a useful tool and I've found it a heck of a lot better than listen to patients when they go nowhere after minutes of discussion. Also of course the context of what's going on in the pt's life is relevant too but I'd like to get the relevant stuff done and out of the way so I can listen to that too.

I was anti-scales until I started using them. They end up saving a lot of time.

 

[calvnandhobbs68]

My notes now typically include a PHQ-9 or Beck Depression Scale, a GAD-7, an ASRS or Insomnia Severity Scale.

I've noticed that using such a scale adds a barometer to the person's problem, and cuts through the BS. They directly answer what need to know instead of going through minutes of BS I didn't have to know.

E.g.
Me: How are you?
Patient: Depressed, well you need to listen to this. There's this thing going on and it's so out there I can't even describe it. You see it's like this thing and it's really really you know. So do you understand why I'm depressed?
Me: No. You told me several non-descript things. Can you be more specific?
Patient: Well I told you man, it's like there's this thing man and it's a thing. Do you get me? It's a thing!

Well I pull out a PHQ-9 and here's the response.

PHQ-9
Over the last two weeks, how often have you been bothered by the following problems?

• (Not at all=0, Several days=1, More than half the days=2, Nearly every day=3)

1. Little interest or pleasure in doing things. (1)
2. Feeling down, depressed, or hopeless (1)
3. Trouble falling or staying asleep, or sleeping too much (1)
4. Feeling tired or having little energy (2)
5. Poor appetite or overeating (0)
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down (1)
7. Trouble concentrating on things, such as reading the newspaper or watching television (2)
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual (2)
9. Thoughts that you would be better off dead, or of hurting yourself in some way (1)
Total Score: (11)


Voila. I got all the relevant depression stuff in a nutshell. Now I can proceed to listen to the patient's context more instead of going in circles and getting nowhere.

Then correspondingly with repeat PHQ-9s in further visits I can track the patient is improving or getting worse. Of course yes someone's going to pull out that this isn't 100% accurate, but the PHQ-9 has been extensively studied and is a useful tool and I've found it a heck of a lot better than listen to patients when they go nowhere after minutes of discussion. Also of course the context of what's going on in the pt's life is relevant too but I'd like to get the relevant stuff done and out of the way so I can listen to that too.

Totally agree. I now email most of my patients PHQ-9, GAD-7, ASRS (with the “adhd” part cut off lol so it’s not always obvious what it’s for) +- a PCL-5, and ask they return it before our telepsych visit.

One of the other majority utilities of the scales is that they allow you to quickly figure out what questions you DONT need to ask. So if someone has a PHQ9 of 12 and a GAD7 of 2....I’m not going through a whole anxiety ROS with them. Saves a ton of interview time and as you stated, allows you to dial down to what the problem is faster. I find that the PCL-5 also allows for a less threatening way of broaching the subject of trauma.

 

[hallowmann]

My notes are still long OP, but they are much shorter than they were intern year. You get better at interviewing, and therefore get better at only writing what you need. As for the formulation, as an intern I spent a lot of time listing a lot of things that were not necessary and didn't necessarily go into my thought process for fear of not being "complete". You can usually summarize virtually all formulations into a small to medium size paragraph and still have the content necessary for your thought process to be followed. I usually end with a sentence or two about the plan and why I chose it.

You'll get better at being concise. It'll still be much longer than any other department's notes.

My notes now typically include a PHQ-9 or Beck Depression Scale, a GAD-7, an ASRS or Insomnia Severity Scale.

I've noticed that using such a scale adds a barometer to the person's problem, and cuts through the BS. They directly answer what need to know instead of going through minutes of BS I didn't have to know.

E.g.
Me: How are you?
Patient: Depressed, well you need to listen to this. There's this thing going on and it's so out there I can't even describe it. You see it's like this thing and it's really really you know. So do you understand why I'm depressed?
Me: No. You told me several non-descript things. Can you be more specific?
Patient: Well I told you man, it's like there's this thing man and it's a thing. Do you get me? It's a thing!

Well I pull out a PHQ-9 and here's the response.

PHQ-9
Over the last two weeks, how often have you been bothered by the following problems?

• (Not at all=0, Several days=1, More than half the days=2, Nearly every day=3)

1. Little interest or pleasure in doing things. (1)
2. Feeling down, depressed, or hopeless (1)
3. Trouble falling or staying asleep, or sleeping too much (1)
4. Feeling tired or having little energy (2)
5. Poor appetite or overeating (0)
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down (1)
7. Trouble concentrating on things, such as reading the newspaper or watching television (2)
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual (2)
9. Thoughts that you would be better off dead, or of hurting yourself in some way (1)
Total Score: (11)


Voila. I got all the relevant depression stuff in a nutshell. Now I can proceed to listen to the patient's context more instead of going in circles and getting nowhere.

Then correspondingly with repeat PHQ-9s in further visits I can track the patient is improving or getting worse. Of course yes someone's going to pull out that this isn't 100% accurate, but the PHQ-9 has been extensively studied and is a useful tool and I've found it a heck of a lot better than listen to patients when they go nowhere after minutes of discussion. Also of course the context of what's going on in the pt's life is relevant too but I'd like to get the relevant stuff done and out of the way so I can listen to that too.

Legit had an encounter like the bolded this morning... 5 min in, so... what I've got is that you feel "depressed". I wish it wasn't at least a daily occurrence. You've been here before, you know what I ask you every time...

 

[shahseh22]

I spend anywhere from 10-20 minutes documenting follow up visits. I can spend 30-60 minutes writing a Psych Eval.

Regardless of what you do, PLEASE write in the plan what medication you are prescribing for what indication. For instance, please let me know why you are prescribing Gabapentin or Topamax for someone who only has an Anxiety disorder diagnosis. It's helpful for the next person that takes over your patient's care.

 

[clausewitz2]

I spend anywhere from 10-20 minutes documenting follow up visits. I can spend 30-60 minutes writing a Psych Eval.

Regardless of what you do, PLEASE write in the plan what medication you are prescribing for what indication. For instance, please let me know why you are prescribing Gabapentin or Topamax for someone who only has an Anxiety disorder diagnosis. It's helpful for the next person that takes over your patient's care.

If you make anything detailed in your note, the rationale for your medication choices is the best place to focus, I reckon. First, it prevents anyone coming along after you from upsetting the apple cart just because something is non-standard and they can't figure out why you did it and assume you're just a quack. Second, harder to argue you've been negligent to a jury when your reasoning is written right there plain as day.

I still need to become more efficient note-wise and I am getting there with ruthless templating but I do make a point of keeping a running list of previous medication trials in all notes. I make note of dosage and general efficacy/adverse effects wherever possible. A few minutes invested in the intake and a few seconds per f/u keeping it updated saves a tremendous amount of time and agita later.

 

[Central_SOULcus]

Regardless of what you do, PLEASE write in the plan what medication you are prescribing for what indication. For instance, please let me know why you are prescribing Gabapentin or Topamax for someone who only has an Anxiety disorder diagnosis. It's helpful for the next person that takes over your patient's care.

^ YES TO THIS!!

Also, in general, if I'm covering for someone (or am inheriting someone else's patient), I'd rather see notes that are too long vs those that are too short. I'm good at skimming and can read quickly, so I'd rather have more info to then decide on my own what isn't necessary. It annoys me read notes that are too short to be useful so I then have to start from scratch. For instance, I just saw a new patient that used to come to this clinic but was lost to follow-up for about 6 months until now. The attending notes were literally 4-5 (short) sentences each and were completely useless, particularly as this attending had the patient on a three-med regimen. Of course with every new patient, whether they've been previously seen by another psychiatrist or not, I always form my own diagnosis/formulation, but it still helps to know more about what the prior psychiatrist was thinking.

 

[romanticscience]

Everything you write has to have some relevance to either (1) billing, (2) treatment rationale, or (3) risk-management. No one wants to read a narrative about the person's life drama. Also, other than billing, no one cares about SIG-E CAPS. Put the effort into the assessment. Lastly, don't write anything that you would be uncomfortable having your patients read. People request their records all the time.

HPI/Symptom: Quality, timing, course, associated symptoms, aggravating factors.

PMH/SocHx/FHx: Medication sig, Tolerance?, Adherence?

ROS: [+/-] Relevant systems

MSE

Assessment: Diagnosis (ICD-10), Est/new?, mild/mod/severe exacerbation?

Plan: Change in treatment frame? (Diagnosis 1) Cont. Rx/change rx....rational. (Diagnosis 2) " "

Risk Assessment:
To consider: The Last Psychiatrist: How to Write A Suicide Note

Example of a typical follow-up note that can be copied and pasted.

HPI
Pt reports 2-weeks of sustained (lasting most of the time) mildly depressed mood aggravated by her work change a/w anxiety, fatigue, insomnia.

PMH/SocHx/FHx
Prozac 20mg qd. Tolerant. Adherent.

ROS
Constitutional: [+] Fatigue [+] Insomnia
Psychiatric: [-] SI
All other systems: [-]

MSE

Assessment (ICD-10)
FXXX, Recurrent Depression.

1. Est chronic condition (5+ MDE); stable (euthymic with residual mood lability/cyclothymic temp). Further assessment planned (HAMD). BPAD risks: Early-onset, SUD, post-partum, FHx, seasonal, short-duration (1-2 mo), recurrency.

FXXX, PTSD

2. Est chronic condition (what was the trauma); moderate exacerbation (what's happening now).

PROCEDURES (CPT)
99213
90833

PLAN

No obstacle to the treatment plan/Poor follow-up poses risk to tx continuation (MDD, HAMD 12) Cont. prozac [continuation phase]/ to aug w/ buspirone 2/2 residual sx of anxiety (PTSD, PCL 10) Cont. prozac and PT.

PSYCHOTHERAPY

Separate from the evaluation and management portion of today's visit, a psychotherapy procedure was performed. 20-minutes (Start XX:XX, Stop XX:XX) of individual CBT provided with a cognitive focus on restructuring beliefs of self-doubt and behavioral activation of good sleep hygiene.

RISK ASSESS

Protective factors ( list them) are more compelling than risk factors ( list them) and justify OP level of care as the least restrictive treatment setting.

 

[When is graduation again?]

My notes are about 2 paragraphs. The 1st paragraph rarely changes and operates as a condensed treatment course. I shorten my initial eval A/P and make it past tense. Then I only really update that paragraph every once in a while with a sentence or two to cover any important changes that happen. My 2nd paragraph is the update for the day and is usually about 3 sentences about basic psych ROS and any med changes.

This allows me to write A/Ps really quickly (10 minutes max for simple to moderate cases), while still having important info.

 

[FlowRate]

I don't think my notes have changed a ton since residency. The biggest thing is that I have more time pressure now so I'm less likely to write as involved an assessment (arguably the last place that should be cut but it's better than some of the docs in the group who just copy and paste the HPI as their "assessment.")

Currently, especially with virtual visits, I take notes while the patient talks to me. But I can't write full sentences while engaging with a pt, so it's mostly fragments. Once I wrap up the visit, I go back and basically rewrite that info info narrative form. Which can be time consuming if the patient was on the more complicated side.

I try to at least give some sort of indication/recap of WHY I think the patient has (or doesn't have) a given diagnosis in my assessment and that's my number 1 pet peeve with the notes on the patients I'm inheriting. So many people with "bipolar" for the only apparent reason being "told they had bipolar one time" yet says they've never had a hypomanic, manic, or major depressive episode. I similarly try to give some justification for why I'm choosing a given med although I don't think I always do the best job of that. I also try to give one or two sentences indicating where there may be a core psychological conflict. Now that our system is moving to "open notes," I'm a bit more reluctant to keep that in the assessment.

 

[Merovinge]

I don't think my notes have changed a ton since residency. The biggest thing is that I have more time pressure now so I'm less likely to write as involved an assessment (arguably the last place that should be cut but it's better than some of the docs in the group who just copy and paste the HPI as their "assessment.")

Currently, especially with virtual visits, I take notes while the patient talks to me. But I can't write full sentences while engaging with a pt, so it's mostly fragments. Once I wrap up the visit, I go back and basically rewrite that info info narrative form. Which can be time consuming if the patient was on the more complicated side.

I try to at least give some sort of indication/recap of WHY I think the patient has (or doesn't have) a given diagnosis in my assessment and that's my number 1 pet peeve with the notes on the patients I'm inheriting. So many people with "bipolar" for the only apparent reason being "told they had bipolar one time" yet says they've never had a hypomanic, manic, or major depressive episode. I similarly try to give some justification for why I'm choosing a given med although I don't think I always do the best job of that. I also try to give one or two sentences indicating where there may be a core psychological conflict. Now that our system is moving to "open notes," I'm a bit more reluctant to keep that in the assessment.

I'm similar and document my entire note except A/P during the session (this takes much less cortical engagement, I can't have a reasonable conversation and formulate a pt simultaneously). If I make a new diagnosis, I always explain why in one sentence. If I start a new medicine, I always explain why in one sentence. I always have one sentence to discuss the chief complaint/reason for visit. If there are major exacerbating psycho or social issues occurring, I point them out.

This style generally leaves me with 2-3 minutes to wrap-up a f/u visit after the patient leaves and 5-10 minutes for a new eval. I know some people are more efficient, but I'm pretty happy with how this workflows through the day.

 

[Stagg737]

Everything you write has to have some relevance to either (1) billing, (2) treatment rationale, or (3) risk-management. No one wants to read a narrative about the person's life drama. Also, other than billing, no one cares about SIG-E CAPS. Put the effort into the assessment. Lastly, don't write anything that you would be uncomfortable having your patients read. People request their records all the time.

HPI/Symptom: Quality, timing, course, associated symptoms, aggravating factors.

PMH/SocHx/FHx: Medication sig, Tolerance?, Adherence?

ROS: [+/-] Relevant systems

MSE

Assessment: Diagnosis (ICD-10), Est/new?, mild/mod/severe exacerbation?

Plan: Change in treatment frame? (Diagnosis 1) Cont. Rx/change rx....rational. (Diagnosis 2) " "

Risk Assessment:
To consider: The Last Psychiatrist: How to Write A Suicide Note

Example of a typical follow-up note that can be copied and pasted.

HPI
Pt reports 2-weeks of sustained (lasting most of the time) mildly depressed mood aggravated by her work change a/w anxiety, fatigue, insomnia.

PMH/SocHx/FHx
Prozac 20mg qd. Tolerant. Adherent.

ROS
Constitutional: [+] Fatigue [+] Insomnia
Psychiatric: [-] SI
All other systems: [-]

MSE

Assessment (ICD-10)
FXXX, Recurrent Depression.

1. Est chronic condition (5+ MDE); stable (euthymic with residual mood lability/cyclothymic temp). Further assessment planned (HAMD). BPAD risks: Early-onset, SUD, post-partum, FHx, seasonal, short-duration (1-2 mo), recurrency.

FXXX, PTSD

2. Est chronic condition (what was the trauma); moderate exacerbation (what's happening now).

PROCEDURES (CPT)
99213
90833

PLAN

No obstacle to the treatment plan/Poor follow-up poses risk to tx continuation (MDD, HAMD 12) Cont. prozac [continuation phase]/ to aug w/ buspirone 2/2 residual sx of anxiety (PTSD, PCL 10) Cont. prozac and PT.

PSYCHOTHERAPY

Separate from the evaluation and management portion of today's visit, a psychotherapy procedure was performed. 20-minutes (Start XX:XX, Stop XX:XX) of individual CBT provided with a cognitive focus on restructuring beliefs of self-doubt and behavioral activation of good sleep hygiene.

RISK ASSESS

Protective factors ( list them) are more compelling than risk factors ( list them) and justify OP level of care as the least restrictive treatment setting.

I really like the first sentence here, as it's probably the most concise, yet useful, advice I've seen on appropriate documentation. I also find the risk assessment portion of your note interesting, as I generally just write "Denies SI/HI/AVH, no acute safety concerns" for most patients unless it warrants further explanation (chronic SI, safety concern with good support/safety plan, etc).

Do you include the CPT section b/c you're in private practice and do in-office billing, or is this something you've done otherwise? Just curious because it's something I've never actually seen in an actual note and am curious if there's any risk/liability in doing this with many systems moving to open notes.

I'm similar and document my entire note except A/P during the session (this takes much less cortical engagement, I can't have a reasonable conversation and formulate a pt simultaneously).

Same, except I do a cliff-notes version of the plan (increase Prozac to 40mg, d/c Mirtazapine, therapy resources provided, continue all others) as I frequently end up wrapping up several notes over lunch or at the end of the day and don't always remember every specific thing I recommended.

 

[whopper]

For patients that see me in person...
I printed a color sheet of all of the scales I used and laminated them at a local office store. Patients when they come in are given the laminated scale and a dry erase marker. I worked at another place where they gave a sheet of paper the patient wrote on and said to myself it'd save a lot of paper and ink just to do the above instead.

A stack of paper is about $10, the ink to print upon it is about another $10. I'd use the scales about 10-15 times a day. At the end of the year that saves a few hundred dollars.

For telemedicine I give them a jpg or a link to open up.

 

[adaptation1]

For patients that see me in person...
I printed a color sheet of all of the scales I used and laminated them at a local office store. Patients when they come in are given the laminated scale and a dry erase marker. I worked at another place where they gave a sheet of paper the patient wrote on and said to myself it'd save a lot of paper and ink just to do the above instead.

A stack of paper is about $10, the ink to print upon it is about another $10. I'd use the scales about 10-15 times a day. At the end of the year that saves a few hundred dollars.

For telemedicine I give them a jpg or a link to open up.

Nice!

 

[romanticscience]

Do you include the CPT section b/c you're in private practice and do in-office billing, or is this something you've done otherwise?

It's a private practice billing thing. My software creates a claim from the note.

 

[Basis]

Imagine going to see a psychiatrist, starting to discuss your feelings and emotions, and they break eye contact, cease active listening, and hand you a piece of paper with Likert scales on it, thereby taking you both entirely out of the psychotherapeutic frame.

OP: Your notes will get shorter after residency when there isn't an attending looking over your shoulder. Brevity is the soul of wit. But, it's important to document enough so that another physician can understand what you're doing. It should also 'sound good' if read in front of a jury in court someday.

 

[WisNeuro]

Imagine going to see a psychiatrist, starting to discuss your feelings and emotions, and they break eye contact, cease active listening, and hand you a piece of paper with Likert scales on it, thereby taking you both entirely out of the psychotherapeutic frame.

OP: Your notes will get shorter after residency when there isn't an attending looking over your shoulder. Brevity is the soul of wit. But, it's important to document enough so that another physician can understand what you're doing. It should also 'sound good' if read in front of a jury in court someday.

I believe the above implications were that they fill these out prior to the visit ever starting. They can be referred to in session, but are not given in session. Which is good, because you can't bill for time watching a pt fill out paperwork for most codes.

 

[whopper]

Imagine going to see a psychiatrist, starting to discuss your feelings and emotions, and they break eye contact, cease active listening, and hand you a piece of paper with Likert scales on it, thereby taking you both entirely out of the psychotherapeutic frame.

Getting to know your patient for real, including their personality, SES, recent events are very important. The scales allow you to spend more time on these important issues instead if splitting hairs spending 20 minutes getting the same info a PHQ-9 would've given you in about 2-3 minutes.

 

[calvnandhobbs68]

Imagine going to see a psychiatrist, starting to discuss your feelings and emotions, and they break eye contact, cease active listening, and hand you a piece of paper with Likert scales on it, thereby taking you both entirely out of the psychotherapeutic frame.

OP: Your notes will get shorter after residency when there isn't an attending looking over your shoulder. Brevity is the soul of wit. But, it's important to document enough so that another physician can understand what you're doing. It should also 'sound good' if read in front of a jury in court someday.

You’ve obviously never worked in an office with a good workflow. Ever been to a doctors office before and had to fill out paperwork beforehand?

If you’re stopping halfway through an interview to give someone a PHQ9 you’re doing it all wrong bud.

 

[Alemo]

You’ve obviously never worked in an office with a good workflow. Ever been to a doctors office before and had to fill out paperwork beforehand?

If you’re stopping halfway through an interview to give someone a PHQ9 you’re doing it all wrong bud.

Yeah I’m kind of stunned this person knows all these psychiatry words but didn’t know the scales are filled out outside of the appointment. I mean maybe in a family medicine office they would give someone a PHQ9 mid-visit, but come on, they’re not even psychiatrists....

 

[whopper]

Here's what also is cool about a PHQ-9.
The top criteria for depression are anhedonia and a feeling of depression. So the top two are gauged in the scale. If they're both 0 this suggests it might not be depression. Of course plenty of the symptoms of depression could be coincidental or other disorders such as over or under-eating, insomnia, hypersomnia, etc.

So if the top 2 scores are close to 0 or are 0 you got a compass telling you rule out other things.

When using a PHQ-9 specifically ask if the appetite question is abnormal, "is your appetite higher than usual? normal? below? or something else? Same with sleep, because the scale doesn't specify.

 

[clausewitz2]

Here's what also is cool about a PHQ-9.
The top criteria for depression are anhedonia and a feeling of depression. So the top two are gauged in the scale. If they're both 0 this suggests it might not be depression. Of course plenty of the symptoms of depression could be coincidental or other disorders such as over or under-eating, insomnia, hypersomnia, etc.

So if the top 2 scores are close to 0 or are 0 you got a compass telling you rule out other things.

When using a PHQ-9 specifically ask if the appetite question is abnormal, "is your appetite higher than usual? normal? below? or something else? Same with sleep, because the scale doesn't specify.

Strictly speaking if you are going by DSM diagnosis categories depressed mood and anhedonia are not 'top criteria'. They are necessary criteria. It simply cannot be MDD if they are scoring those as 0.

I have many bones to pick with the unitary MDD concept but I am inclined to say that if their mood is not low and they aren't having a diminishment of pleasure you are simply not dealing with anything like depression.

 

[calvnandhobbs68]

Strictly speaking if you are going by DSM diagnosis categories depressed mood and anhedonia are not 'top criteria'. They are necessary criteria. It simply cannot be MDD if they are scoring those as 0.

I have many bones to pick with the unitary MDD concept but I am inclined to say that if their mood is not low and they aren't having a diminishment of pleasure you are simply not dealing with anything like depression.

I think he means they’re physically at the top of the PHQ-9 (they’re the first two questions). So it lets you know really quickly and easily if they’re having significant depressed mood or anhedonia.

 

[romanticscience]

I personally like the HAMD and MADRS, scales that have qualitive questions. I work these into my phenomenological/symptom assessment without the patient knowing they are being "rated".

In my experience, people appreciate these types of changes better than "going from a 5 to 1." It's definitely an art combining objective/descriptive with humanistic/dynamic/existential perspectives.

 

[thepoopologist]

Shorter and to the point. Symptom duration and intensity, course of treatment and whether it worked. If it didn't work, what else I'm thinking about.

In residency I wrote a lot more, but it was just to demonstrate my thought process to my attending.