"Lets Show Patients Their Mental Health Records"

[WolverineDoc13]

I got this JAMA article in my mailbox this morning, and wondered your thoughts about the concept of sharing psych notes with patients. I'm all for clinician transparency, but the idea sounds both intriguing and scary at the same time. However, I'm just a 4th year med student, so hearing thoughts from residents/attendings/psychologists would be helpful.

The article is here: http://jama.jamanetwork.com/article.aspx?articleID=1853164 (you can PM me for a pdf if you don't have JAMA access)

One paragraph in particular addressed two fears I had about the subject.

"A clinician’s hesitation to reveal a note may largely reflect two questionable assumptions. The first—that the note will in some way be devastating rather than comforting—overlooks the fact that patients’ self-evaluations are often more negative than those of their clinicians. For example, an anxious patient may typically wonder whether he is “crazy,” but fears asking about it and getting an affirmative answer. In these cases, reading the note may actually reduce some worries that are fully operant but unwarranted.

"The second assumption—that the patient will be unable to say “I think you got something wrong … ” and in fact be right—discounts the potentially enormous benefit arising from patients’ opportunity to fact-check their own histories. Indeed, the clinician who actively solicits open and ongoing dialogue, including a patient’s opinion about a note’s accuracy, may enhance both clinical precision and the treatment relationship."

I'm also worried (according to the gist of the article), that this would affect how clinicians write their notes. Instead of focusing on the diagnosis and treatment plan for our patients, we would be focused more on how to word our notes accordingly to avoid pissing off our patients. (Perhaps I'm in the wrong on this. Again, I'm just a med student.)

Thoughts?

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[VMSmith]

You should always write your notes with the possibility in mind that someday the patient (or a lawyer) will someday request them.

 

[masterofmonkeys]

Sounds like it was written by someone who doesn't understand the concept of disordered personality structure.

 

[WolverineDoc13]

Sounds like it was written by someone who doesn't understand the concept of disordered personality structure.

Thanks for your thoughts on this. Mind elaborating?

 

[slappy]

I try to keep two sets of notes. An elaborate and detailed one that becomes a part of the official records, and one that is essentially my notepad (I use a different one for each of my patients which of course they do not know) where I jot down my impressions during the meetings and very sensitive data like how I think the transference relationship is going to play out over the next few months, etc. The latter never gets digitized.

 

[gibits]

I always write my notes with the expectation that the pt will read it. Why? Because it happens a lot, especially in the hospital setting. When I put someone on an extended hold or petition for a med competency hearing I have to read my notes out in front of the judge and patient. It often ends with the pt getting upset and acting out in front of the judge and I win my case. Not sure it that was the goal JAMA had in mind.

 

[Doctor Bagel]

If any of you work at the VA, you might not know that VA patients can already look at your notes. I have a patient there who routinely reads my notes and then talks to me about them in our visits. I'm not quite sure what I think about that, but at least it's good we're talking about it, instead of having a patient read your notes and not talk to you about it during an ongoing treatment process. I think this speaks to what slappy mentioned above -- separate the process stuff out from the official records.

 

[smalltownpsych]

The patient, so long as they are over the age of 18 and their parents if not, generally has access to their treatment record. However, a provider can withhold if they have sufficient reason. I am surprised that the VA has open access to medical records, I don't recall that being the policy when I had a practicum there in 2004. Although they were clear at that time that patients could access the records under HIPAA. Basically, HIPAA creates a provision for psychotherapy notes to be more protected than general health information, but each hospital that I have worked at interprets this differently. My general is to write or dictate my notes with the understanding that the patient will have access. I have also found that reviewing session notes to patients, especially adolescents can be beneficial for a variety of reasons.

 

[Elisabeth Kate]

I'm a student, like the OP, so I could be off base, but I think psychotherapy notes in particular might cause problems. When people engage in psychotherapy, they're open about their life, relationships, entanglements, etc. If your notes imply that the patient is responsible/complacent with certain situations, wouldn't that change how they present their problems to you in the future? For example, if someone is seeking psychotherapy to deal with a divorce and after reading your notes, the patient feels you're not adequately representing them as a victim of a vindictive spouse, won't they be motivated to change things up in your future sessions and isn't that counterproductive to the goal of psychotherapy?

 

[VMSmith]

I'm a student, like the OP, so I could be off base, but I think psychotherapy notes in particular might cause problems. When people engage in psychotherapy, they're open about their life, relationships, entanglements, etc. If your notes imply that the patient is responsible/complacent with certain situations, wouldn't that change how they present their problems to you in the future? For example, if someone is seeking psychotherapy to deal with a divorce and after reading your notes, the patient feels you're not adequately representing them as a victim of a vindictive spouse, won't they be motivated to change things up in your future sessions and isn't that counterproductive to the goal of psychotherapy?

This is why some psychotherapists keep two sets of notes - one set of blander notes for billing/medicolegal purposes and a set of process notes (kept completely separately) for things like transference/countertransference issues and your interpretations and such.

 

[smalltownpsych]

I'm a student, like the OP, so I could be off base, but I think psychotherapy notes in particular might cause problems. When people engage in psychotherapy, they're open about their life, relationships, entanglements, etc. If your notes imply that the patient is responsible/complacent with certain situations, wouldn't that change how they present their problems to you in the future? For example, if someone is seeking psychotherapy to deal with a divorce and after reading your notes, the patient feels you're not adequately representing them as a victim of a vindictive spouse, won't they be motivated to change things up in your future sessions and isn't that counterproductive to the goal of psychotherapy?

The best way to deal with that is to have my communication to the patient be consistent with the notes. Being able to deliver information that is counter to the patient's perspective in a way that they can accept is key to helping them improve.

 

[AcronymAllergy]

The patient, so long as they are over the age of 18 and their parents if not, generally has access to their treatment record. However, a provider can withhold if they have sufficient reason. I am surprised that the VA has open access to medical records, I don't recall that being the policy when I had a practicum there in 2004. Although they were clear at that time that patients could access the records under HIPAA. Basically, HIPAA creates a provision for psychotherapy notes to be more protected than general health information, but each hospital that I have worked at interprets this differently. My general is to write or dictate my notes with the understanding that the patient will have access. I have also found that reviewing session notes to patients, especially adolescents can be beneficial for a variety of reasons.

It's a more recent development at the VA; the policy went into effect within the past year or two. I believe there might be occasions where a patient needs to request a hard copy of the note rather than having it available online (other than to see it's been posted), but I could be wrong about that. And as far as I know, MH notes don't get a blanket increased-coverage clause or anything like that.

And yep, most folks I know who regularly conduct psychotherapy will typically keep two sets of notes: those that go into the chart and those the clinican holds for their own records and that may discuss/record information that could be potentially harmful for the patient to know, either in general or at that particular time.

 

[twright]

This is why some psychotherapists keep two sets of notes - one set of blander notes for billing/medicolegal purposes and a set of process notes (kept completely separately) for things like transference/countertransference issues and your interpretations and such.

This is exactly what we were taught during residency. My progress notes for therapy patients are exceedingly bland. Instead of "patient informed me that he cheated on his wife" it is "patient discussed ongoing relationships", etc.

 

[AcronymAllergy]

This is exactly what we were taught during residency. My progress notes for therapy patients are exceedingly bland. Instead of "patient informed me that he cheated on his wife" it is "patient discussed ongoing relationships", etc.

And in the VA for example, where technically just about any patient contact employee has access to medical records (regardless of whether or not they should be looking at various notes), the bland version can actually often be in the patient's best interests. More than once, I've had a veteran either turn down mental health services or be very hesitant to re-engage in them because, for example, a triage nurse in the ER told them (after mentioning having seen previous MH note headers) that the problem is probably just in their head.

 

[IndigoGirl1234]

I'd recommend writing to be objective about the situation focus on what the patient said/did in front of you, and leave your subjective feelings out of it. For example, you have a patient who self injures. During the session, the injury is revealed.... it looks like a mere scratch. Writing "the patient just scratched themselves" is shaming and subjective. The clinician could say a very, very superficial cut, or say the patient only scratched themselves while attempting to do x, y, z... the notes need to be presented in a context to not create additional harm (patient feeling not understood/judged/etc) and objective notes get the needed information recorded without shaming/judging the patient (of course you might be doing this privately but the patient doesn't have access to your private thoughts!).

 

[birchswing]

For Heaven's sake, don't write that the patient's hair is disheveled in every single encounter note. Bill Gates doesn't comb his hair either.

 

[smalltownpsych]

I'd recommend writing to be objective about the situation focus on what the patient said/did in front of you, and leave your subjective feelings out of it. For example, you have a patient who self injures. During the session, the injury is revealed.... it looks like a mere scratch. Writing "the patient just scratched themselves" is shaming and subjective. The clinician could say a very, very superficial cut, or say the patient only scratched themselves while attempting to do x, y, z... the notes need to be presented in a context to not create additional harm (patient feeling not understood/judged/etc) and objective notes get the needed information recorded without shaming/judging the patient (of course you might be doing this privately but the patient doesn't have access to your private thoughts!).

I agree with this and I really don't agree with the separate notes to protect patients from what we really think about them. I have had patients ask for their notes and we have read them together and if it is the facts then they don't have an issue. On the other hand I have seen patients become enraged at other providers interpretations in notes. I believe this whole secret note thing is a bad holdover from the analytic past that needs to be gotten rid of. Even an assaultive and psychotic intoxicated patient in the ED can read my note afterwards without argument because I just describe the objective facts in neutral manner and this has happened before.

 

[Psychotic]

So is this second set of secret notes only appropriate for psychotherapy patients as some of you seem to be indicating, or are some of you doing it for all of your patients? Where do you physically keep the notes? Is this a legally sensible thing to do? Is it more kosher in private practice? If you work for a hospital, or the VA, are you violating any workplace rules by doing this?

I wish whopper or anyone who deals with courts, lawyers, and testimony would chime in on this stuff - sounds like a huge "gotcha" if you are asked about your stash of secret notes in a legal proceeding.

 

[hamstergang]

I wish whopper or anyone who deals with courts, lawyers, and testimony would chime in on this stuff - sounds like a huge "gotcha" if you are asked about your stash of secret notes in a legal proceeding.

Don't take my word for it, but I was fairly certain that process notes are legally protected to be private. If there are good reasons, you can even not allow a patient to see their notes or at least you can black parts out first.

 

[MacDonaldTriad]

When a patient asks to read their chart, there are two responses: “yes”, and “federal law allows me to only provide a summary if I feel that you’re reading your chart might be detrimental to your mental health.”


The former usually entails about 12 minutes of reading followed by the realization that medical records are excessively boring, while the latter triples the intensity of the request and heightens curiosity to the point that nothing will stop the patient’s determination to see their notes.

 

[smalltownpsych]

Don't take my word for it, but I was fairly certain that process notes are legally protected to be private. If there are good reasons, you can even not allow a patient to see their notes or at least you can black parts out first.

True, but my understanding is that if a judge subpoenas them, then you would still have to provide them. I am actually more concerned, and so are my patients, about the other providers having access to their mental health records. Fortunately, we have been able to prevent access to our records at this facility. The one exception is when patient is hospitalized, we haven't been able to close that loop and that has led to some patients becoming angry, hurt, or feeling violated when their PCP drops a seemingly innocuous comment that came from that record.

 

[smalltownpsych]

When a patient asks to read their chart, there are two responses: “yes”, and “federal law allows me to only provide a summary if I feel that you’re reading your chart might be detrimental to your mental health.”


The former usually entails about 12 minutes of reading followed by the realization that medical records are excessively boring, while the latter triples the intensity of the request and heightens curiosity to the point that nothing will stop the patient’s determination to see their notes.

I have also found that the former approach can build trust when they see that what I put in the record is pretty objective and very little opinion or conjecture.

 

[Psychotic]

Don't take my word for it, but I was fairly certain that process notes are legally protected to be private. If there are good reasons, you can even not allow a patient to see their notes or at least you can black parts out first.

I just started 2nd year, and get my first psychotherapy patients next week, so trust me, I will be asking questions of my attendings and the program director on all of this.

Glad I came across this discussion today because I frankly had not heard of separate note keeping for any purpose.

Also - exercising the right to black out sections before showing a patient is one thing, but I am concerned about the legality and assumption of liability by having secret, separate notes apart from the official record. I am concerned less about what a patient might read in my notes and think about them than what my exposure is in legal matters, court proceedings, workplace rules, malpractice inquiries, state licensing authorities, etc.

 

[psych md jd]

Under HIPPA, psychotherapy notes are treated differently than a patient's medical record.

See: http://www.hhs.gov/ocr/privacy/hipaa/understanding/special/mhguidance.html

Generally, the Privacy Rule applies uniformly to all protected health information, without regard to the type of information. One exception to this general rule is for psychotherapy notes, which receive special protections. The Privacy Rule defines psychotherapy notes as notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session and that are separate from the rest of the patient’s medical record. Psychotherapy notes do not include any information about medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, or results of clinical tests; nor do they include summaries of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date. Psychotherapy notes also do not include any information that is maintained in a patient’s medical record. See 45 CFR 164.501.

Psychotherapy notes are treated differently from other mental health information both because they contain particularly sensitive information and because they are the personal notes of the therapist that typically are not required or useful for treatment, payment, or health care operations purposes, other than by the mental health professional who created the notes. Therefore, with few exceptions, the Privacy Rule requires a covered entity to obtain a patient’s authorization prior to a disclosure of psychotherapy notes for any reason, including a disclosure for treatment purposes to a health care provider other than the originator of the notes. See 45 CFR 164.508(a)(2). A notable exception exists for disclosures required by other law, such as for mandatory reporting of abuse, and mandatory “duty to warn” situations regarding threats of serious and imminent harm made by the patient (State laws vary as to whether such a warning is mandatory or permissible).
​

And under section 164.524 "... an individual has a right of access to inspect and obtain a copy of protected health information about the individual in a designated record set, for as long as the protected health information is maintained in the designated record set, except for: (i) Psychotherapy notes; and (ii) Information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding."


Also see: https://www.alaskabar.org/servlet/content/the_sticky_wicket_of_psychotherapy_notes.html

Are psychotherapy notes discoverable? Perhaps. The patient-litigant exception to the psychotherapist-patient privilege may come into play.

Redacting or "right" to black out sections? Sounds like a bad idea to me.

 

[Psychotic]

Are psychotherapy notes discoverable? Perhaps. The patient-litigant exception to the psychotherapist-patient privilege may come into play.

Redacting or "right" to black out sections? Sounds like a bad idea to me.

Thanks for the informative post. I agree, blacking out sections of a patient record before presenting it to the patient, if he is legally entitled to his record, sounds like a bad idea.

I still direct a question to some of the people who posted higher in the thread: I am satisfied that psychotherapy notes are protected, but some of you did not distinguish what you were putting in these "secret notes" outside of the patient record as only psychotherapy notes. From my reading of this so far, it sounds like having separate, secret files for any patient other than a psychotherapy patient could be a problem, right? Can anybody expand on this?

 

[splik]

I am satisfied that psychotherapy notes are protected, but some of you did not distinguish what you were putting in these "secret notes" outside of the patient record as only psychotherapy notes. From my reading of this so far, it sounds like having separate, secret files for any patient other than a psychotherapy patient could be a problem, right? Can anybody expand on this?

so what HIPAA calls "psychotherapy notes" are what psychiatrists would call "process notes". Psychotherapy/process notes are not part of the medical record. Personally I dont write psychotherapy notes but the main reason therapists to is so they remember what their patients told them, to make notes on the transference and countertransference, to make notes on their formulation of the patients, to transcribe pertinent material from the discussion. They may bring these notes to their supervision or peer discussion groups. Some analysts see the process notes as more informative of how the therapist has reconstructed the session and revealing their own phantasies about the patient and experience of the therapy.

These communications are privileged from the most part. The case I think was Jaffee v Redmond many therapists would absoutely refuse to disclose this information to the courts even risk being held in contempt.

Can this information be discoverable? well according to this: Plaintiff’s counsel can fairly expect records to be made discoverable when (1) the plaintiff discloses the treating physician or therapist as an expert, (2) their treatment is used to justify the damage claim and is a part of the medical damages, and (3) when the discovery responses indicate that the plaintiff is claiming the therapy/treatment was brought about by the defendant’s tortious conduct

Best to have them be so illegible no one can read them and destroy them and soon as is reasonably possible.

 

[smalltownpsych]

Basic records, often called progress notes, cover the who, what and when of treatment. These records, says Newman, should include such information as dates and types of services, assessments, intervention plans, consultations, testing reports, releases of information, consent forms and any supporting data.

and

In addition to these progress notes, psychologists can keep psychotherapy or process notes for their own use.

"These notes include a little bit more detail that some therapists like to include, perhaps information they consider relevant to hypotheses or analyses about behavior change," says Vasquez. As long as they're kept physically separate from progress records, the federal Health Insurance Portability and Accountability Act (HIPAA) gives such notes special protection. In most situations, psychologists can't release psycho-therapy notes unless the patient signs a detailed authorization form specifically authorizing their release. State practice laws regarding note-keeping requirements should also be considered, she says.

Obtained from APA website @ http://www.apa.org/gradpsych/2007/01/track.aspx

 

[Psychotic]

so what HIPAA calls "psychotherapy notes" are what psychiatrists would call "process notes". Psychotherapy/process notes are not part of the medical record. Personally I dont write psychotherapy notes but the main reason therapists to is so they remember what their patients told them, to make notes on the transference and countertransference, to make notes on their formulation of the patients, to transcribe pertinent material from the discussion. They may bring these notes to their supervision or peer discussion groups. Some analysts see the process notes as more informative of how the therapist has reconstructed the session and revealing their own phantasies about the patient and experience of the therapy.

These communications are privileged from the most part. The case I think was Jaffee v Redmond many therapists would absoutely refuse to disclose this information to the courts even risk being held in contempt.

Can this information be discoverable? well according to this: Plaintiff’s counsel can fairly expect records to be made discoverable when (1) the plaintiff discloses the treating physician or therapist as an expert, (2) their treatment is used to justify the damage claim and is a part of the medical damages, and (3) when the discovery responses indicate that the plaintiff is claiming the therapy/treatment was brought about by the defendant’s tortious conduct

Best to have them be so illegible no one can read them and destroy them and soon as is reasonably possible.

Should I be concerned that in my intern year just ended nobody at my program ever mentioned any of this to me, or to my cohort, not that i recall? I am going to check with peers on this - maybe I missed it.

But until reading it here, I had never heard a distinction about "process notes" to be logged and kept physically separate from the medical record - i.e., I have only ever dealt with the official medical record.

Again, I get my first psychotherapy patients next week, so I am loaded for bear (with questions for admin and attendings at least), but I have never had an attending comment on any notes I have written for the medical record, to say something like "this doesn't belong here" or "process notes should not be part of the medical record."

 

[splik]

Should I be concerned that in my intern year just ended nobody at my program ever mentioned any of this to me, or to my cohort, not that i recall? I am going to check with peers on this - maybe I missed it."

no why would they have mentioned this to you as an intern? it wasn't relevant. you haven't been seeing outpatients for therapy presumably. presumably no one has taught you how to write process notes anyway so it's unlikely you've written anything or put anything in the record that shouldn't be there. hopefully someone will talk about this with you when you begin seeing your psychotherapy patients.

But essentially the medical record would look like this:

ID/CC: 45 year old woman with depression

This was a 5o minute visit for psychodynamic psychotherapy

Pt described feelings of depression, aloneness, relationship difficulties and childhood. Reported having a difficult week. Significant stresses at work.

Provided: empathic validation, exploration of the transference affect, clarification, confrontation, praise

Assessment: This is a 45 year old woman with a history of depression in the context of interpersonal difficulties early in the course of psychodynamic psychotherapy. No SI, risk rated as low.

Diagnoses: Major depressive Disorder, recurrent, moderate

Plan: continue weekly psychodynamic psychotherapy

 

[splik]

I used to write far too detailed notes. But as mental health notes are available to everyone within the system and don't have a special level of security, it is much better to put the bear minimum information in the chart necessary for complete and accurate documentation and reimbursement. with EMRs people tend to overdocument anyway. Remember the medical record is not really confidential. Also there can be unintended consequences of your documentation - for instance one of my patient's, their spouse reads their notes and has said in the past if the patient has a psychiatric illness, they will leave the patient. So I have to balance being accurate and complete without putting anything that would adversely affect the pt.

 

[psych md jd]

... it is much better to put the bear minimum information in the chart ...

Good advice to prevent any charting forest fires.

​

 

[notdeadyet]

The former usually entails about 12 minutes of reading followed by the realization that medical records are excessively boring, while the latter triples the intensity of the request and heightens curiosity to the point that nothing will stop the patient’s determination to see their notes.

Amen to this.

If the prospect of showing your patient his/her progress notes makes you uncomfortable, you are charting in too much detail.

Splik's level of detail is right on. Even with a busy panel and a memory like a goldfish, a vague phrase is usually enough to trigger my memory sufficiently.


Sent from my iPhone using Tapatalk

 

[VMSmith]

rWhen I kept process notes during residency, I did not put any kind of identifying information in them, and wrote so rapidly that half the time I couldn't even read them and had to mostly guess what they patient had actually said based on the scribbles vaguely resembling words and my vague memory of a session that had happened days ago.

So if someone had subpoenaed those notes they would've been useless to them anyway.

Meanwhile, my progress notes for those sessions generally went something like:

Pt showed up 3 minutes late. Described frustrations regarding his job. Confronted pt regarding similar patterns at previous jobs.

MSE: well dressed, calm cooperative, with good eye contact, mood/affect euthymic and reactive, no perceptual abnormalities, blah blah blah

Assessment/Plan: adjustment disorder with anxious mood, continue psychodynamic psychotherapy

 

[digitlnoize]

I don't have a problem with showing patients their records. I think making it different than the rest of medicine on contributes to the stigma. Yes, personality disorders can be difficult, which brings me to the real problem...PR.

Psychiatry has a huge PR problem. We're already fighting an uphill battle, then we go and name diseases (that we could call ANYTHING) "personality disorders." Why not just drop the word "personality" from the nomenclature? Patients would have much less of a problem with being diagnosed with "Borderline Disorder" than "Borderline PERSONALITY Disorder. The latter sound like an insult, honestly.

I had a patient get upset about an "Adjustment Disorder" diagnosis once. They took it to mean that they had a hard time adjusting to things, and this was insulting to them. Why not "Depression due to Adversity" or something like that?

If we want the stigma to go away we need to stop trying to be "special" compared to the rest of medicine, and treat these illnesses like the medical conditions they are, while also not antagonizing patients with poorly worded nomenclature.

 

[whopper]

Agree with many of the comments above. In a legal sense patients are to have access to their records when they request it so anything you write into the medical record must be done with the expectation they will read it. Also agree with Smalltownpsych's comments that the communication to the patient should be consistent with the notes.

Now there is one exception-psychotherapy notes. That is allowed to be kept private from the patient.

I've found sometimes showing the patients their own records or telling them what I'll write meaningful.

I got a malingerer right now in jail up for murder who was fine up until a week ago. I saw him 3 months ago when he first went to jail and he had no signs of mental illness. His records state he showed no psychosis whatsoever in the jail until last week. Now he starts blowing kisses, pursing his lips as if he'll kiss you, and giving cutesy smiles and cutey blinks and won't talk thinking that this will pass for psychosis.

Me-"Mr. Patient, I just want you to know that I'm writing down into your medical record that I do not think you are mentally ill and you are putting up an act. Please talk to me about this because if you continue this behavior I will end this interview in the next minute." He's kept this up for a week (but only when I'm around, otherwise he he's fine).

I already requested he be removed from the psych infirmary but the COs told me they can't maintain him with his behavior so they're keeping him in the psych unit despite that I, the jail psychologist and none of the nurses think he's mentally ill.

Yesterday, he was standing naked in his cell and moving his left arm and leg in a rhythmic manner after I again attempted to talk to him and he just kept staring at the wall with his back towards me moving in the rhythmic manner. After a few beats I caught the beat and I out loud sang...."Dm Dm Dm, another one bites the dust! Dm Dm Dm, another one bites the dust! Oh and another one goes and another one goes, another one bites the dust! Something, something something, another one bites the dust!" in sync with his movements.

In general confrontation may not be a good way of dealing with malingering patients but I took the risk cause the guy was not responding to me. I was hoping I'd shake him out of his act.

 

[Ceke2002]

Agree with many of the comments above. In a legal sense patients are to have access to their records when they request it so anything you write into the medical record must be done with the expectation they will read it. Also agree with Smalltownpsych's comments that the communication to the patient should be consistent with the notes.

Now there is one exception-psychotherapy notes. That is allowed to be kept private from the patient.

I've found sometimes showing the patients their own records or telling them what I'll write meaningful.

I got a malingerer right now in jail up for murder who was fine up until a week ago. I saw him 3 months ago when he first went to jail and he had no signs of mental illness. His records state he showed no psychosis whatsoever in the jail until last week. Now he starts blowing kisses, pursing his lips as if he'll kiss you, and giving cutesy smiles and cutey blinks and won't talk thinking that this will pass for psychosis.

Me-"Mr. Patient, I just want you to know that I'm writing down into your medical record that I do not think you are mentally ill and you are putting up an act. Please talk to me about this because if you continue this behavior I will end this interview in the next minute." He's kept this up for a week (but only when I'm around, otherwise he he's fine).

I already requested he be removed from the psych infirmary but the COs told me they can't maintain him with his behavior so they're keeping him in the psych unit despite that I, the jail psychologist and none of the nurses think he's mentally ill.

Yesterday, he was standing naked in his cell and moving his left arm and leg in a rhythmic manner after I again attempted to talk to him and he just kept staring at the wall with his back towards me moving in the rhythmic manner. After a few beats I caught the beat and I out loud sang...."Dm Dm Dm, another one bites the dust! Dm Dm Dm, another one bites the dust! Oh and another one goes and another one goes, another one bites the dust! Something, something something, another one bites the dust!" in sync with his movements.

In general confrontation may not be a good way of dealing with malingering patients but I took the risk cause the guy was not responding to me. I was hoping I'd shake him out of his act.

Yeah just personally I tend to clap for Tinkerbell, and break into random renditions of the YMCA when I'm experiencing psychosis.