Documentation Tips

[zenman]

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Any documentation tips for when you're in a community mental health center and seeing patients back to back for 20 min med checks and 1 hr evals? I can do it easily with paper check off charting but this is electronic charting.

 

[heyjack70]

Any documentation tips for when you're in a community mental health center and seeing patients back to back for 20 min med checks and 1 hr evals? I can do it easily with paper check off charting but this is electronic charting.

Maybe a word document with a personal template you can copy and paste into the computer. Space for symptoms you could place x's next to.

 

[Manicsleep]

Check off lists? Bleh.

Templates can work as long as the information you place in the chart has some real data to convey.

Get them to buy a dictation system like dragon or just learn to type faster. Its important to have a good formulation for every patient. One of the worst things about medicare. Makes people into drones. Do yourself a favor. Code a 90862 and actually do a good job on the interview and the note. Screw the checklist or incorporate a very basic checklist based on what your legal deparment says.

 

[nitemagi]

QIDS-SR.

Saves time, and keeps appointments from becoming addtl symptom checklists.

 

[Majesty]

Are you mandated to do a checklist or ask certain questions?

I have always wondered if there was any data on this. The constant suicide risk assessments often based on checklists and random other paper pushing tasks. For that matter, if there is any data on improvement in patient outcome with interdisciplinary treatment teams.

If often seems to me that it just gets in the way and there is perhaps more harm than good to the patient.

 

[Suedehead]

QIDS-SR.

Saves time, and keeps appointments from becoming addtl symptom checklists.

meaning have the pt fill out the QIDS-SR while in the waiting room?

 

[nitemagi]

meaning have the pt fill out the QIDS-SR while in the waiting room?

Yep.

 

[Chimed]

What are you guy's thoughts on typing the subjective part of your while a patient is talking--i.e. just type their answers to your questions directly into a note?

I have always been opposed to this, but I was thinking about it today and wonder if it's as bad as I previously thought. If you could have a small laptop, face the patient directly, and type while maintaining good eye contact, might that work?

Has anyone tried this?

 

[nitemagi]

I've done this before. My better system is to take brief notes for the subjective via sentence fragments here and there. Then fill it in at the end. It's also an opportunity to non-verbally emphasize what I view as important about what they're saying.

 

[zenman]

Check off lists? Bleh.

Templates can work as long as the information you place in the chart has some real data to convey.

Get them to buy a dictation system like dragon or just learn to type faster. Its important to have a good formulation for every patient. One of the worst things about medicare. Makes people into drones. Do yourself a favor. Code a 90862 and actually do a good job on the interview and the note. Screw the checklist or incorporate a very basic checklist based on what your legal deparment says.

They have Dragon but I've only been able to spend a short while on it my first day and I'm not up to speed on it. Second day I had a full load of patients while trying to learn their system. I'm using a SOAP template except for initial evals. I don't do the scheduling. I'm "presented" with a list of the days clients. I'm also a 2 finger typer, lol!

Last place I was at I had a 1 page mostly check-off page. It was handy because you could hold your clipboard while you faced the patient and made a few notes. I was basically finished when patient walked out the door. Paper charting does have it's benefits. I don't want to do anything on a computer while with a patient.

Been here 4 days and have yet to be introduced around nor even tour the entire building! I feel like a lackey thrown in a back room with patients herded to my office. But hey, I'm locums and will be gone in 3 months!

 

[Majesty]

They have Dragon but I've only been able to spend a short while on it my first day and I'm not up to speed on it. Second day I had a full load of patients while trying to learn their system. I'm using a SOAP template except for initial evals. I don't do the scheduling. I'm "presented" with a list of the days clients. I'm also a 2 finger typer, lol!

Last place I was at I had a 1 page mostly check-off page. It was handy because you could hold your clipboard while you faced the patient and made a few notes. I was basically finished when patient walked out the door. Paper charting does have it's benefits. I don't want to do anything on a computer while with a patient.

Been here 4 days and have yet to be introduced around nor even tour the entire building! I feel like a lackey thrown in a back room with patients herded to my office. But hey, I'm locums and will be gone in 3 months!

I am sure you know that computers are the way everything will go.
Those check off pages suck. It perpetuates the idea that psychiatrists don't do therapy even if you do therapy in the session. Unfortunately you can't do much in the locums setting.

 

[Majesty]

What are you guy's thoughts on typing the subjective part of your while a patient is talking--i.e. just type their answers to your questions directly into a note?

I have always been opposed to this, but I was thinking about it today and wonder if it's as bad as I previously thought. If you could have a small laptop, face the patient directly, and type while maintaining good eye contact, might that work?

Has anyone tried this?

Inpatient. Never.
Outpatient. Almost every patient. Its the only way I can finish by the end of the clinic. I also do chart review, write scripts and order labs. You won't be able to (usually) finish the whole note but you can do a hodge podge and clean it up later. I usually write out my plan while they are there.

 

[loveoforganic]

What are you guy's thoughts on typing the subjective part of your while a patient is talking--i.e. just type their answers to your questions directly into a note?

I have always been opposed to this, but I was thinking about it today and wonder if it's as bad as I previously thought. If you could have a small laptop, face the patient directly, and type while maintaining good eye contact, might that work?

Has anyone tried this?

I seem to remember reading a journal article a while back about the deleterious effect computer use during PCP visits had on patient-perceived quality of communication. I think the primary attribution made, though, was poor body language - lack of eye contact, etc. I'd imagine that if you could maintain eye contact, it probably wouldn't hurt (would probably help a lot if you had a silent keyboard).

 

[digitlnoize]

I seem to remember reading a journal article a while back about the deleterious effect computer use during PCP visits had on patient-perceived quality of communication. I think the primary attribution made, though, was poor body language - lack of eye contact, etc. I'd imagine that if you could maintain eye contact, it probably wouldn't hurt (would probably help a lot if you had a silent keyboard).

My favorite solution to this problem is to hire a scribe. I may be biased because I was one before med school (in an ED).

They can either be paid ($8/h) or volunteer. Local college students trying to get into medical school (which is really hard to do, for some reason) will do almost ANYTHING to improve their application. Including, being your slave. Of course, in psych, this means having someone else in your room, which may not work as well.

You could always use paper check off lists, then have the scribe convert that after the appt.

I would like an EMR that's mostly check off lists, modeled after the paper ones, iPad/tablet and laptop based, with the ability to add typed notes if needed. And accessible from anywhere.

 

[Manicsleep]

They say if you don't document it didn't happen.
I've been thinking, does this mean I can actually practice real medicine, never document and be good to go?

Or the other extreme...if all I do is document, I wouldn't have the chance to practice medicine. Seems that is the way medicine by (insert org/govt etc here) is going. If you never practice, you can't make a mistake. Brilliant really.

 

[393656]

I have a question for you folks. I have been playing around a bit with how I am documented a suicide risk assessment in consults or HPI's on a first time patient or an ER patient etc. Lately i have been using-

Diagnosis
Axis1-5

Safety assessment-discussing modifiable and non-modifiable and talking about what I am doing to address modifiable ones. Pharmacotherapy and psychotherapy to address current depression, rec AA to quit drinking, gave medication for insomnia and acute panic attacks. etc etc.

Plan-...

I have played around with tying it into my plan as well but this seemed to be a bit more organized. Any tips on how people incorporate this?

 

[kugel]

What are you guy's thoughts on typing the subjective part of your while a patient is talking--i.e. just type their answers to your questions directly into a note?

I have always been opposed to this, but I was thinking about it today and wonder if it's as bad as I previously thought. If you could have a small laptop, face the patient directly, and type while maintaining good eye contact, might that work?

Has anyone tried this?

In my R4 year, I worked in a couple different clinics where I did this.
It worked out fine after I got used to it for a couple weeks.
I generally looked at the computer when I was speaking (typing their answers to my last question while I was asking my next one), and looked at the patient while he was speaking. People want to see your gaze while THEY are talking. After 40 min of discussion with a new patient, and 10 min of discussion about a plan, they would often say, "So now you have to type up everything I said? That must take you another hour?" When I told them that I already typed it all and only had to fill in a few details, they were amazed. "When were you typing? I didn't see it!"

LOOK AT PATIENTS WHEN THEY ARE SPEAKING.

I did create some templates for myself, but really just category headings.

At the VA clinic, I had a template for combat-related PTSD interview that was designed exactly the same as the one the VA disability benefits examiners used. (A clever social worker "somehow" got his hands on it for me.) If I believed the pt had combat-related PTSD, then I always had the pt make a written request for my evaluation write-up. I told them to hand it to the benefits examiner before answering any questions. (Make a bureaucrat's life easier, and he will generally agree with you.) This worked like a charm. Almost every patient with true combat-related PTSD got benefits on the first try.

 

[zenman]

At the VA clinic, I had a template for combat-related PTSD interview that was designed exactly the same as the one the VA disability benefits examiners used. (A clever social worker "somehow" got his hands on it for me.) If I believed the pt had combat-related PTSD, then I always had the pt make a written request for my evaluation write-up. I told them to hand it to the benefits examiner before answering any questions. (Make a bureaucrat's life easier, and he will generally agree with you.) This worked like a charm. Almost every patient with true combat-related PTSD got benefits on the first try.

Don't you want to pass that around 😀

I'm a two finger typer and just don't want to do anything while talking with a patient. However, when I had a single page check list...with comment sections, I would ask them if I could make a few notes while talking. I was done when they walked out the door.

Here's the template I currently use in a mental health clinic (feel free to make comments):

Subjective:




Objective: (MSE) The client was casually dressed and appropriately groomed. They were pleasant, cooperative, and have appropriate eye contact. Speech was of normal rate, rhythm, volume. Mood was depressed with constricted affect. TP was linear, logical and goal-directed. TC was negative for SI/HI or any other behaviors suggestive of psychosis, obsessive themes, or mania. The client was AOx4 and their concentration, short, and long term memory were intact during the interview. The client displayed average ability to engage in abstract thought and intellectual reasoning during the interview. Their judgment and reliability are considered fair as is insight into symptoms, stressors, and condition.

Assessment:
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:

Allergies:

Adverse Reactions:

Current Meds:


Impression:




Client demonstrates enough practical judgment and impulse control to believe that they can self-monitor and access crisis care if needed.

Plan:
1.
2.
3.



Risks/benefits of medication therapy along with possible adverse effects discussed and patient verbalized understanding. Educated on realistic expectations from treatment and necessity for internal drive to recover as well as personal responsibility for compliance.

 

[393656]

I like the part of your MSE regarding TC. I always play around with how to word the TC. I used to put-denies AH/VH/Delusions/Paranoia, no evidence of obsessive or intrusive thoughts.

However I like the wording along the lines you use of-no behavior or expressed thoughts that were consistent with AH/VH/Delusions etc.

Subtle but I never thought the "pt denies" was a good one since often the patient will not admit to the psychosis! (clearly!)

Thanks!

p.s-for the love of God learn to type with all 10 fingers! If 2nd grade kids can learn surely you can pick it up quickly!! You will save yourself a LOT of grief!!

 

[kugel]

Don't you want to pass that around 😀

I absolutely would if I still had access.
Didn't think of saving it to my own computer back then.
sorry.

If you're in the VA system, ask for a copy of the examiner's record for a few vets who've applied for benefits. Like I said, an enterprising and clever social worker was the one who got his hands on a few write-ups. Then I dissected the template from those write-ups. That way, if the pt is denied, they can appeal with the psychiatrist's write-up as evidence. The appeal officer then has two evaluations in the same format, and only has to decide if he is going to believe the disability examiner or the treating psychiatrist. Sometimes it's good to have MD after your name.

 

[zenman]

I like the part of your MSE regarding TC. I always play around with how to word the TC. I used to put-denies AH/VH/Delusions/Paranoia, no evidence of obsessive or intrusive thoughts.

However I like the wording along the lines you use of-no behavior or expressed thoughts that were consistent with AH/VH/Delusions etc.

Subtle but I never thought the "pt denies" was a good one since often the patient will not admit to the psychosis! (clearly!)

Thanks!

p.s-for the love of God learn to type with all 10 fingers! If 2nd grade kids can learn surely you can pick it up quickly!! You will save yourself a LOT of grief!!

Thanks. You have 10 fingers? I do get a lot of abuse from my wife who can look in one direction while making the keyboard sound like an automatic weapon. But, but, when am I going to have time to take a class?

 

[Suedehead]

Thanks. You have 10 fingers? I do get a lot of abuse from my wife who can look in one direction while making the keyboard sound like an automatic weapon. But, but, when am I going to have time to take a class?

4 words will change your life. Mavis Beacon Teaches Typing. so rad.