Is this normal?

[trixter888]

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Joined a new group and reading notes of patients referred to me. I am new out of residency, so perhaps my expectations are too high. Typically nothing is written in the subjective except a few sentences why patient "meets" criteria for a diagnosis. Minimal history on past medications/psych history. No medical history. No assessment ever explaining why they think the patient has the diagnoses they attributed to them. Plan often time will include one quick blurb about what they intend to do.

During residency we would often describe as a means of communication to other providers why we thought a patient had a certain diagnosis in the assessment. Our subjective would talk about what the patient reported instead of what SIGECAPS criteria they meet.

I'm finding myself redoing an entire H&P in a follow up session because there is not much communicated in prior notes.

Am I just being too picky, or is this how psychiatrists in the community actually write notes?

 

[calvnandhobbs68]

Joined a new group and reading notes of patients referred to me. I am new out of residency, so perhaps my expectations are too high. Typically nothing is written in the subjective except a few sentences why patient "meets" criteria for a diagnosis. Minimal history on past medications/psych history. No medical history. No assessment ever explaining why they think the patient has the diagnoses they attributed to them. Plan often time will include one quick blurb about what they intend to do.

During residency we would often describe as a means of communication to other providers why we thought a patient had a certain diagnosis in the assessment. Our subjective would talk about what the patient reported instead of what SIGECAPS criteria they meet.

I'm finding myself redoing an entire H&P in a follow up session because there is not much communicated in prior notes.

Am I just being too picky, or is this how psychiatrists in the community actually write notes?

Meh not that uncommon in the community, especially where people are seeing their own patients for years and not handing them off to another resident/fellow every year. People are basically writing notes in these cases to make sure they hit criteria for insurance billing...it's not a consult service where you're trying to justify or explain a diagnosis to someone.

My notes are likely to start devolving into something similar to this at some point, otherwise you end up writing hours of notes every day after a full day of clinic. Gets old after a while.

I mean, why do you need to redo an entire H+P in a followup session? Either schedule them as a new intake if you really feel their med regimen is confusing and the diagnosis is unclear or just see them as a followup and don't try to figure out how exactly they hit DSM-5 criteria for generalized anxiety disorder.

 

[sloop]

Meh not that uncommon in the community, especially where people are seeing their own patients for years and not handing them off to another resident/fellow every year. People are basically writing notes in these cases to make sure they hit criteria for insurance billing...it's not a consult service where you're trying to justify or explain a diagnosis to someone.

My notes are likely to start devolving into something similar to this at some point, otherwise you end up writing hours of notes every day after a full day of clinic. Gets old after a while.

I mean, why do you need to redo an entire H+P in a followup session? Either schedule them as a new intake if you really feel their med regimen is confusing and the diagnosis is unclear or just see them as a followup and don't try to figure out how exactly they hit DSM-5 criteria for generalized anxiety disorder.

I mean, sure there is a streamlining of notes that goes on with the pressures of community practice, but I still think there are problems with this approach.

First, if you don’t know why they’ve been diagnosed to begin with, how do you know what symptoms to track? How do you know if the treatment is working? Are you just basically going “hey, do you think the medicine is helpful?” and calling it a visit? Seems like terrible care.

Second, if you don’t know why someone has a particular diagnosis, you could well be continuing to prescribe a medication that is not indicated or is contraindicated. You might increase the Zoloft on a misdiagnosed bipolar patient who then goes into a mixed state and kills herself.

Third, related to the above points, either of these problems are going to be hard to defend in court if your documentation sucks. When you get sued, the rule is generally that if you didn’t document it, it didn’t happen. If it turns out that the above bipolar patient had a bunch of records that indicated pretty clear manic episodes, and none of your notes indicate that you looked at those records or explain why you diagnosed MDD or whatever in spite of them, you’re pretty much ****ed.

I guess I would just caution against sinking to the lowest common denominator with the documentation. I am also probably biased when it comes to this issue because I’m regularly reading the past records of people who wound up in a state hospital after raping or murdering someone. Some of that documentation is terrible, and that’s definitely a bad look.

 

[calvnandhobbs68]

I mean, sure there is a streamlining of notes that goes on with the pressures of community practice, but I still think there are problems with this approach.

First, if you don’t know why they’ve been diagnosed to begin with, how do you know what symptoms to track? How do you know if the treatment is working? Are you just basically going “hey, do you think the medicine is helpful?” and calling it a visit? Seems like terrible care.

Second, if you don’t know why someone has a particular diagnosis, you could well be continuing to prescribe a medication that is not indicated or is contraindicated. You might increase the Zoloft on a misdiagnosed bipolar patient who then goes into a mixed state and kills herself.

Third, related to the above points, either of these problems are going to be hard to defend in court if your documentation sucks. When you get sued, the rule is generally that if you didn’t document it, it didn’t happen. If it turns out that the above bipolar patient had a bunch of records that indicated pretty clear manic episodes, and none of your notes indicate that you looked at those records or explain why you diagnosed MDD or whatever in spite of them, you’re pretty much ****ed.

I guess I would just caution against sinking to the lowest common denominator with the documentation. I am also probably biased when it comes to this issue because I’m regularly reading the past records of people who wound up in a state hospital after raping or murdering someone. Some of that documentation is terrible, and that’s definitely a bad look.

When you’re seeing 14 followups a day, it’s a bit hard for most of us to write forensic style notes 😉

Sure absolutely those are good points, however I’m not going to reiterate in every note why I think this person has major depressive disorder. That’s what the H+P is for. I will say that for basically all of your points, that’s what the H+P is for. If there’s data that makes me think the diagnosis needs to change, I say that in the progress note where I change or consider changing treatment and then move on. Like, if I get a phone call from the patients parents that my MDD patient is now suddenly staying awake for days wanting to be the next Kanye West, yes I will document that accordingly and justify the treatment modification. But I’m not going to sit around doing a differential diagnosis in every progress note about why I think this person has MDD single episode vs MDD recurrent vs PDD vs Bipolar 1 vs Bipolar 2 vs substance induced mood disorder.

About the misdiagnosis thing, that’s why you have a subjective and ROS each note I guess? Why would I think someone has bipolar disorder unless I have an indication they’re becoming manic? I don’t think you have to second guess the diagnosis for every patient every visit. Part of what Im assuming though is that you have a decent initial H+P.

Assessment does not have to be extensive every visit. It is perfectly normal for someone to write for instance “MDD- depressive sx improving. PHQ-9 notably improved from initial assessment as above, appetite, concentration, sleep patterns, guilt all improved. Minimal nausea with SSRI but patient feels this is tolerable, discussed ways to minimize this. Engaged in psychotherapy regularly and making behavioral modifications as well. Continue current management of xxxx.” I do have a separate little risk assessment in every note as well that I just copy forward and keep updated with static/dynamic risk factors.

This is why standardized questionaires like PHQ-9, GAD-7, self report YBOCS, PCL-5, etc are very helpful as well. OP is actually also complaining about the opposite thing. Ex. “our subjective would talk about what the patient reported instead of what SIGECAPS criteria they met”.

It’s also not that common to have whole sections of extensive past medical history in each followup note for instance unless it’s significant for some reason. Certainly you should have an updated list of meds and any changes to medical history in each followup note.

 

[sloop]

When you’re seeing 14 followups a day, it’s a bit hard for most of us to write forensic style notes 😉

Sure absolutely those are good points, however I’m not going to reiterate in every note why I think this person has major depressive disorder. That’s what the H+P is for. I will say that for basically all of your points, that’s what the H+P is for. If there’s data that makes me think the diagnosis needs to change, I say that in the progress note where I change or consider changing treatment and then move on. Like, if I get a phone call from the patients parents that my MDD patient is now suddenly staying awake for days wanting to be the next Kanye West, yes I will document that accordingly and justify the treatment modification. But I’m not going to sit around doing a differential diagnosis in every progress note about why I think this person has MDD single episode vs MDD recurrent vs PDD vs Bipolar 1 vs Bipolar 2 vs substance induced mood disorder.

About the misdiagnosis thing, that’s why you have a subjective and ROS each note I guess? Why would I think someone has bipolar disorder unless I have an indication they’re becoming manic? I don’t think you have to second guess the diagnosis for every patient every visit. Part of what Im assuming though is that you have a decent initial H+P.

Assessment does not have to be extensive every visit. It is perfectly normal for someone to write for instance “MDD- depressive sx improving. PHQ-9 notably improved from initial assessment as above, appetite, concentration, sleep patterns, guilt all improved. Minimal nausea with SSRI but patient feels this is tolerable, discussed ways to minimize this. Engaged in psychotherapy regularly and making behavioral modifications as well. Continue current management of xxxx.” I do have a separate little risk assessment in every note as well that I just copy forward and keep updated with static/dynamic risk factors.

This is why standardized questionaires like PHQ-9, GAD-7, self report YBOCS, PCL-5, etc are very helpful as well. OP is actually also complaining about the opposite thing. Ex. “our subjective would talk about what the patient reported instead of what SIGECAPS criteria they met”.

It’s also not that common to have whole sections of extensive past medical history in each followup note for instance unless it’s significant for some reason. Certainly you should have an updated list of meds and any changes to medical history in each followup note.

This is all fair, and I agree that, if there’s a good H&P, the subsequent documentation doesn’t have to be super detailed. If there’s a good starting point it’s easy to parse through what was going on in the treatment after that if you document the rationale for individual med changes, etc.

Perhaps I misread the situation, but I interpreted OP’s concern to be that the prior documentation, including H&P, was woefully inadequate and did not really explain the rationale for the diagnosis and treatment. In that case, I really think that you have to fix that this issue if you’re continuing to treat them. You’re not responsible for prior terrible care and/or documentation, but you become responsible for it if you just let everything ride and don’t fix it.

With the misdiagnosis, what I’m getting at is that it sounds like OP is reading the prior notes and there is not a good documentation of their psychiatric history, including pertinent negatives. You’re responsible for the diagnoses you give to patients, and I think that standard of care involves considering possible alternative diagnoses. For depression, bipolar disorder is obviously on the differential. If you were seeing a new patient and diagnosed them with depression and started an antidepressant without asking about whether they’ve ever been manic, that’s obviously not good care. If someone has a prior diagnosis of depression and the answers to those diagnostic questions are well-documented, I don’t think you have to reinvent the wheel. If, on the other hand, the prior documentation doesn’t talk about this at all, and you haven’t gotten collateral from the previous provider that clarifies this (and documented it), I think you really have to fix that issue before carrying forward the diagnosis and treatment plan.

 

[tr]

Joined a new group and reading notes of patients referred to me. I am new out of residency, so perhaps my expectations are too high. Typically nothing is written in the subjective except a few sentences why patient "meets" criteria for a diagnosis. Minimal history on past medications/psych history. No medical history. No assessment ever explaining why they think the patient has the diagnoses they attributed to them. Plan often time will include one quick blurb about what they intend to do.

During residency we would often describe as a means of communication to other providers why we thought a patient had a certain diagnosis in the assessment. Our subjective would talk about what the patient reported instead of what SIGECAPS criteria they meet.

I'm finding myself redoing an entire H&P in a follow up session because there is not much communicated in prior notes.

Am I just being too picky, or is this how psychiatrists in the community actually write notes?

Hard to know without seeing the notes, but based on the description here I'm leaning towards resident logorrhea syndrome.

SIGECAPs criteria (plus some kind of symptom scale as above) are exactly what I want to see in a note, if I'm trying to assess the severity or confirm the diagnosis.

Endless blithering about the details of the patient's family dispute or multiple paragraphs of CYA boilerplate on protective factors for someone who has no history of SI ever are just a waste of space and time, and can obscure the bits that are actually important because they're buried in a pile of unnecessary verbiage.

I agree with calvinandhobbs68. If you want to see the patient's full medical history or the detailed reasoning behind the initial diagnosis, go back to the H&P. I don't want to see the whole H&P copied forward to every SOAP note. It's distracting and a waste of time.

I will say that I think eliminating the multiaxial diagnosis format was a mistake. I still put a multiaxial diagnosis table in the assessment section of all my notes and it lets me (and anyone else) see the whole picture at a glance.

Axis I: MDD, recurrent. Binge eating disorder in remission
Axis II: n/a
Axis III: s/p gastric sleeve
Axis IV: marital conflict
Axis V: 61-70

Done, you know everything you need to know.

 

[trixter888]

Hard to know without seeing the notes, but based on the description here I'm leaning towards resident logorrhea syndrome.

SIGECAPs criteria (plus some kind of symptom scale as above) are exactly what I want to see in a note, if I'm trying to assess the severity or confirm the diagnosis.

Endless blithering about the details of the patient's family dispute or multiple paragraphs of CYA boilerplate on protective factors for someone who has no history of SI ever are just a waste of space and time, and can obscure the bits that are actually important because they're buried in a pile of unnecessary verbiage.

I agree with calvinandhobbs68. If you want to see the patient's full medical history or the detailed reasoning behind the initial diagnosis, go back to the H&P. I don't want to see the whole H&P copied forward to every SOAP note. It's distracting and a waste of time.

I will say that I think eliminating the multiaxial diagnosis format was a mistake. I still put a multiaxial diagnosis table in the assessment section of all my notes and it lets me (and anyone else) see the whole picture at a glance.

Axis I: MDD, recurrent. Binge eating disorder in remission
Axis II: n/a
Axis III: s/p gastric sleeve
Axis IV: marital conflict
Axis V: 61-70

Done, you know everything you need to know.

Agreed, that some of this could just be due to leaving residency. To address some questions, the H&P and F/u notes do not look any different. Maybe more information but still quite minimal. No detailed reasoning in the H&P that describes how or why they think patient has the initial diagnosis.

Sleep: more
Interests: less
Guilt: some
Energy: low
Concentration: low
Appetite: low
Psychomotor: N/a
Suicide: yes but no plan

 

[comp1]

You'll figure out your own groove. Your notes should be longest in residency and gradually you'll see what you need to actually accomplish your work and they will get shorter. To answer the OP's main question, is it normal? Absolutely. Is it good? Probably not. You're entering into the financial aspect of documenting now, not just the academic. Maybe it would be good to talk to a coder to see what insurance companies are looking for?

 

[clausewitz2]

It's definitely not how all community psychiatrists write notes, but I echo the others upthread who are saying it's not terribly uncommon. Working on efficiency and condensing notes is something that has been an ongoing project for me, as I also was trained to focus on reported phenomenology rather than listing of symptoms in the subjective portion of the good old SOAP. I just sent off the records of someone I have been working with for about a year and a half, and all the notes in one pdf ran to 118 pages. Granted, I've seen them...a lot and a fair amount gets copied forward, but still.

I have talked about it before but my compromise that has allowed me to cut back substantially is writing a solid assessment section at the end of H&P that then slowly morphs into a concise history of treatment and a lot of formulaic stuff gets copied from note to note, occasionally getting revised when something major comes to light. This is in no way necessary for insurers, but frankly for me to be able to remember how we arrived at whatever place we did in treatment. I don't do appointments shorter than 30 minutes and telehealth allows me to type during appointments in a way that people seem to be fine with so I don't end up with a lot of notes at the end of the day, new evals being an exception.

You'll figure out your own groove. Your notes should be longest in residency and gradually you'll see what you need to actually accomplish your work and they will get shorter. To answer the OP's main question, is it normal? Absolutely. Is it good? Probably not. You're entering into the financial aspect of documenting now, not just the academic. Maybe it would be good to talk to a coder to see what insurance companies are looking for?

I mean, that's fairly simple. The notes OP is describing probably are fine from an insurer's perspective. That's why people write them that way. I agree that it is awful to have to piece together anything meaningful from them but people respond to incentives. If no one's routinely reading them, I guess they figure, what is the reward for putting in the effort?

 

[robellis]

This is very normal

 

[tr]

I have talked about it before but my compromise that has allowed me to cut back substantially is writing a solid assessment section at the end of H&P that then slowly morphs into a concise history of treatment and a lot of formulaic stuff gets copied from note to note, occasionally getting revised when something major comes to light. This is in no way necessary for insurers, but frankly for me to be able to remember how we arrived at whatever place we did in treatment. I don't do appointments shorter than 30 minutes and telehealth allows me to type during appointments in a way that people seem to be fine with so I don't end up with a lot of notes at the end of the day, new evals being an exception.

Yes this is what I do also. My initial Assessment section is usually just a couple of sentences plus the multiaxial list, and over time I add significant developments (e.g., failed med trials, timing of any hospitalizations, etc). I have had a lot of appreciative comments on the perspicuity of my notes from other practitioners who have inherited, consulted on, or provided psychotherapy for my patients.

 

[splik]

I write fairly detailed initial notes since I see complex patients. For my progress notes, my subjective is usually one sentence or less. Now that billing is solely on MDM I don't feel the need to put all this additional fluff that I might have previously (and even then you didn;t need to write too much there). I don't do SIGECAPS or any such nonsense, I can't remember the last time I asked a pt about that.

 

[nexus73]

I prefer to do my own new assessment when I take over a patient. Bill 90792. No problems. Many times I’ve seen people with MDD, who also have OCD or PTSD that was completely missed by the prior MD.

 

[Stagg737]

Agreed, that some of this could just be due to leaving residency. To address some questions, the H&P and F/u notes do not look any different. Maybe more information but still quite minimal. No detailed reasoning in the H&P that describes how or why they think patient has the initial diagnosis.

Sleep: more
Interests: less
Guilt: some
Energy: low
Concentration: low
Appetite: low
Psychomotor: N/a
Suicide: yes but no plan

Seeing checklist stuff like this in notes drives me nuts. Just do a PHQ-9, GAD-7, or whatever and document the overall score. Idc about most of SIGECAPS other than perceived level of depression, sleep, and SI/hopelessness. I don't even ask about the others most of the time unless we're exploring new depression. I'd rather figure out what their level of functioning on a day to day basis looks like.

Things I DO appreciate when reading other people's f/up notes:
- One liner at the start of subjective or assessment with brief demographics, diagnoses, and what they're being treated for
- Current CC or major symptoms
- Safety (SI/HI)
- Efficacy of meds and side effects
- List of previous med trials and responses
- Clearly demarcated list of diagnoses in assessment section
- Reasons for the medication in the plan section (ie Wellbutrin XL 300mg QAM for depression and smoking cessation)

Most of the above can just be copied forward and it's annoying having to dig through the chart when copy-past takes 5 seconds. It also kills me when the whole plan section is just "continue meds as prescribed".

 

[deleted1100659]

I just assume that all diagnosis given to a patient are BS until I do my own interview and start to piece things together. If I had a dollar for everytime someone was diagnosed with bipolar...if these diagnosis were accurate then probably 25% of my city would have bipolar disorder...

But yea. Basically i just go from scratch as well, and have to start from a blank slate 9/10 times.

 

[FlowRate]

I, too, try to write an actual assessment on my new patients. If they're very straightforward it'll be short but if they're complicated I'll at least spend a couple of sentences explaining why. The next few follow-ups I'll often add what we've tried, why it did/didn't work. Every few follow-ups, if relevant, I'll more or less remove or condense the running history part of the assessment because that info will also live in the separate past med trials section of my treatment plan in a shorter form.

I'm working on revamping how our dept works with epic and I think we could start doing more problem based charting such that you can just comment on why you made the specific changes of the day in the A+P section and then you have a running log in the EMR of each visit's A+P.

 

[Stagg737]

I, too, try to write an actual assessment on my new patients. If they're very straightforward it'll be short but if they're complicated I'll at least spend a couple of sentences explaining why. The next few follow-ups I'll often add what we've tried, why it did/didn't work. Every few follow-ups, if relevant, I'll more or less remove or condense the running history part of the assessment because that info will also live in the separate past med trials section of my treatment plan in a shorter form.

I'm working on revamping how our dept works with epic and I think we could start doing more problem based charting such that you can just comment on why you made the specific changes of the day in the A+P section and then you have a running log in the EMR of each visit's A+P.

Is there no "overview" section in the problems list? It can just be updated there and then autopopulated into the notes if that's what you're referring to.

 

[FlowRate]

Is there no "overview" section in the problems list? It can just be updated there and then autopopulated into the notes if that's what you're referring to.

There is but I think the way most of us document is a unified assessment, not broken down by individual diagnosis. So you'd either be copy pasting into multiple problem entries or saying "refer to X." At least that's how our epic is currently set up. Apparently you can turn on system based grouping of problems and document in just the "mental health" section but that hasn't been fully clarified yet.