Assessment / Plan Charting Style

[Sushirolls]

When I used Epic I would often document as follows:
1) GAD
-Continue zoloft 100mg Daily
-Continue with therapist XYZ
2) Alcohol Use Disorder, Moderate, In Sustained Remission
-Continue community support groups, sponsorship and further encouraged abstinence
-Continue Naltrexone 50mg Daily
etc.....

My current EMR has broken up the Assessment and Plan sections. So lately I listed the diagnosis:
1) Unspecified Depressive Disorder
2) OUD, Severe, Active
3) Tobacco Use Disorder, Moderate, Active
And then listed the Plans in similar fashion:
1a) Continue Zoloft 150mg Daily
1b) Continue Therapy with Zeta Alpha
2a) Continue Suboxone Films 12mg/3mg SL Daily
2b) UDS
2c) ...
2d) ...
3a) Declines pharmacotherapy or interventions for cessation today, will continue to reassess with motivational interviewing on future visits with goal towards cessation.
4a) Was active in treatment planning today, encouraged to ask questions and engage in care
4b) Follow up in next lunar cycle on the most auspicious of days

So, lately I've been considering ditching the fealty of diagnosis and linked treatment to it. Still will do an ordered list in Assessment, but in the Plan section just go bullet.
*continue zoloft 200mg Daily
*Continue Abilify 2mg Daily
*Continue Suboxone 8mg/2mg SL 2 Films daily
*UDS
*reviewed PHP/IOP programs for chemical dependency locally, declines
*Continue Wellbutrin XL 150mg for mixed smoking cessation and meth cravings
*Opts to continue therapy with CDP at Rocking Recovery
*Perform AIMs in 3 months
*...
*...
*Follow up in 2 weeks

Tobiko Topped Sushirolls, MBBS/MD/DO

So the question is, what are y'all doin'? Is there anything more than personal preference, EMR outline, or paper chart set up that dictates the A/P documentation?

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[NickNaylor]

As someone on the inpatient setting who sees a broad of variety of note styles in the community, the way you've suggested at the bottom just seems unclear and would be difficult to understand, particularly with patients of any degree of complexity. Personally, I'm a fan of how our IM folks write notes, which is a brief one-liner in the assessment, a problem-based plan (which includes a brief assessment for each problem explaining diagnosis, differentials, expected work-up, etc.), and the plan as it relates to that problem. This is often infeasible for psychiatry since our medications are used for many different "problems," and simply repeating the same plan for each "problem" makes no sense, but I do think there is value in linking the diagnosis/problem to the plan. As an alternative, being clear about indications and reasons for the treatment you've chosen can clarify this as well.

I just hate getting notes with a list of medications with no explanation or justification of what was done and why treatment is being provided in this way. It makes it difficult to make changes in the inpatient setting.

 

[Mass Effect]

I always write out my assessment (paragraph form) just because that's been the culture of the places I've trained, but I agree with @NickNaylor that I prefer it how our medicine colleagues do it.

 

[hamstergang]

I also think the problem based plan looks cleaner, but agree that it's more difficult in psych. Much of our assessment of the problems and our treatments overlap across the diagnoses that things would get repetitive. Listing indications for treatments, especially those with multiple potential indications, like the below, is a very helpful solution.

*Continue Wellbutrin XL 150mg for mixed smoking cessation and meth cravings

 

[clausewitz2]

As someone on the inpatient setting who sees a broad of variety of note styles in the clinic, the way you've suggested at the bottom just seems unclear and would be difficult to understand, particularly with patients of any degree of complexity. Personally, I'm a fan of how are IM folks write notes, which is a brief one-liner in the assessment, a problem-based plan (which includes a brief assessment for each problem explaining diagnosis, differentials, expected work-up, etc.), and the plan as it relates to that problem. This is often infeasible for psychiatry since our medications are used for many different "problems," and simply repeating the same plan for each "problem" makes no sense, but I do think there is value in linking the diagnosis/problem to the plan. As an alternative, being clear about indications and reasons for the treatment you've chosen can clarify this as well.

I just hate getting notes with a list of medications with no explanation or justification of what was done and why treatment is being provided in this way. It makes it difficult to make changes in the inpatient setting.

Agreed about the difficulties of assigning specific treatments to specific diagnoses but I also find a massive list of bullets difficult to interpret. Typically what I do is break the interventions up into categories (Psychiatric, Psychosocial, Medical, Behavioral etc).

So meds all end up in the same category for the most part. For each medication I try to say something about the rationale, not more than a clause or two. This to insure that anyone reading is at least aware there was a reason for the choices and I was not just throwing darts at a board covered with trade names.

I disagree about the one sentence assessment. Super long is not helpful but seeing just a little bit of reasoning helps me more confident that the previous treating psychiatrist was not mindlessly churning and may have meaningfully evaluated the patient at some point.

 

[Liquid8]

At each initial consultation I do a thorough assessment - this acts as both a letter for the referrer as well as a reminder for myself. That means I can make notes for future review appointments reasonably brief.

For reviews , my template headings are fairly simple:

Current Medications
Side Effects
Issues
MSE
Risks
Impression
Plan

In general the level of detail I put into these sections depends a lot on the individual patient.

I find keeping the medications updated allows a quick check of what the patient is actually doing (as opposed to what I have suggested they do), find out if new drugs have been started by other doctors, as well as allowing me to quickly look back at what has previously been tried and why it was stopped. Over time this section usually ends up containing annotations and observations about patterns of use too.

The plan has to tie into the impression/diagnosis otherwise there's not really much point. When training, I was taught to use a formulation based/biopsychosocial approach and while I don't necessarily stick rigidly to this model, I recall one of the best ways at presenting patients to examiners was to highlight the 3 most important features of a case and focus on those to structure individual management. In my private work most of my patients are fairly straightforward, but but I do find this approach quite useful to fall back on if I encounter a very complicated patient with a lot of different things going on.

If I'm putting a patient on a new medication, I'll often discuss and list a couple of alternative options to consider especially if they've had a history of past treatment failures, and I find this saves a lot of time in later consultations.

 

[deleted736562]

For assessment, I'm a big fan of bullet points (not many, 4/5) without a specific, rigid organization. Basically write out what you think is relevant/important about the case, starting from what you want people to notice first. Included somewhere in there would be a one/two sentence summary of relevant positives, your diagnostic impression and anything you find striking/worth pointing out.

When it comes to plan, it does make sense to make it more organized depending on the setting, and grouping all meds together makes sense with a few words to justify your choices.

I've learned this method from one of our CL attendings and i have adopted it ever since on all services. Found it really helpful in organizing my thoughts (precisely by not having to follow a preset rigid format).

 

[NickNaylor]

I disagree about the one sentence assessment. Super long is not helpful but seeing just a little bit of reasoning helps me more confident that the previous treating psychiatrist was not mindlessly churning and may have meaningfully evaluated the patient at some point.

I agree with you about this, and I just write a few sentences summarizing my diagnostic impressions and assessments rather than a simple one-linger. However, some attendings do this and do it well, and it's easy to see their thought process.

Ultimately I don't think the exact structure matters all that much as long as someone not familiar with the patient can understand what you think is going on (and why) and why you're doing the things that you're doing. As long as that's true - and there are many different ways to accomplish this - then it really doesn't matter.

 

[kopftonmd]

4b) Follow up in next lunar cycle on the most auspicious of days

And here I thought psych docs used the unisolar calendar... no wonder I'm just a lowly med student.

 

[FlowRate]

I like, but have not adopted, how one of my attendings charts in Epic. She actually uses the problem list. At each visit, she adds an update to the relevant problems with the thought process for that particular visit. The problem list makes it really easy to see prior updates to the problem, so you can review a treatment history pretty rapidly that way (instead of having to, in comparison, open equally as many entire progress notes, which would take much longer in epic.)

I don't recall whether she writes a separate assessment of the patient. Typical form around here is a paragraph of assessment (I guess some other residents who like to write a lot probably write more.)

 

[ridethecliche]

I also think the problem based plan looks cleaner, but agree that it's more difficult in psych. Much of our assessment of the problems and our treatments overlap across the diagnoses that things would get repetitive. Listing indications for treatments, especially those with multiple potential indications, like the below, is a very helpful solution.

Right, but you can just copy paste to repeat things. If it's relevant, it's relevant. Medicine does that as well. It's also more comprehensive, no?

 

[hamstergang]

Right, but you can just copy paste to repeat things. If it's relevant, it's relevant. Medicine does that as well. It's also more comprehensive, no?

I feel I already write too much to start repeating things.