hebel

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I'm a relatively new psych intern, and I had a few questions about notes in general. I came across this article: http://thelastpsychiatrist.com/2006/09/how_to_write_a_suicide_note.html

...and it really had me thinking more about the notes I write. Now that I'm a resident, I have a totally different perspective on notes than as I did when I was a student even just a few months ago.

My biggest issue is sorting out the nuance of the Assessment and Plan portions of the note. What exactly is the assessment portion? I know it isn't where you just list diagnoses like I did as a student...is it where you come up why the patient is here and your rationale for diagnoses? Or is it more to explain your treatment rationale? Or is the plan the only place to explain the treatment rationale?

I would really appreciate the clarification of the assessment vs the plan section. Ive asked my co-residents and have kind of gotten answers that were more vague than expected or were conflicting sometimes. Thanks!
 

clausewitz2

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I'm a relatively new psych intern, and I had a few questions about notes in general. I came across this article: http://thelastpsychiatrist.com/2006/09/how_to_write_a_suicide_note.html

...and it really had me thinking more about the notes I write. Now that I'm a resident, I have a totally different perspective on notes than as I did when I was a student even just a few months ago.

My biggest issue is sorting out the nuance of the Assessment and Plan portions of the note. What exactly is the assessment portion? I know it isn't where you just list diagnoses like I did as a student...is it where you come up why the patient is here and your rationale for diagnoses? Or is it more to explain your treatment rationale? Or is the plan the only place to explain the treatment rationale?

I would really appreciate the clarification of the assessment vs the plan section. Ive asked my co-residents and have kind of gotten answers that were more vague than expected or were conflicting sometimes. Thanks!
Our notes don't break out assessment from plan but have a general "medical decision-making" section which I think is a better approach. Broadly speaking, though, assessment is where the reasoning behind your diagnosis and your take on the situation goes and should summarize what is important from the HPI and "objective" sections. The plan is how you intend to address the situation laid out explicitly as you see it in the assessment.

Obviously a somewhat artificial distinction. But I guess I see the desirability of a "do what it says here" section.
 
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masterofmonkeys

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In med school, I was taught that the 'Assessment' portion is where *I* come out. What I thought was important, what I thought the diagnosis was. What I was doing to further clarify. What I was doing for treatment. Limitations outside of my control. That was for ALL rotations. It explains why I'm doing what I'm doing and what I think is going on. Still what I teach the juniors to do. Makes it MUCH harder to argue against you down the line.
 
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Liquid8

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My biggest issue is sorting out the nuance of the Assessment and Plan portions of the note. What exactly is the assessment portion? I know it isn't where you just list diagnoses like I did as a student...is it where you come up why the patient is here and your rationale for diagnoses? Or is it more to explain your treatment rationale? Or is the plan the only place to explain the treatment rationale?
I use an "Assessment" or impression heading to include diagnosis, differentials, risk assessments or other issues and general impressions that I have about a patient that may not fit into a mental state examination. It can also be a place to write up a psychiatric formulation that explores possible aetiology (i.e. why is this particular patient presenting at this point in time?), although I think this practice depends on where you have trained - it was something quite prevalent in the Australian training system, although psychiatrist I worked with from the UK felt it had gone out of fashion.

Under a "Plan" heading, I would include all the management aspects that I want done. This will obviously differ depending on setting (inpatient vs outpatient, public vs private), but in any case it should address the issues identified in the "Assessment."
 

SeniorWrangler

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You should talk to attendings, they're co-signing what you write.
My take: Assessment is your impression of the patient's diagnosis and situation, including how they're responding to your interventions.
Plan is the specific next steps you are considering or implementing, ideally with brief explanation of why you're doing it. That way if you go on vacation or get hit by a bus, the next tern can read your note and understand what you were doing.
 

hamstergang

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Besides the many other things mentioned, I feel that there are 2 components that should be included in the assessment for billing purposes:

1) Status of problems, ie each problem is improved, stable, or worsening.

2) If not in straight outpatient, a justification for continuing at a more restrictive level of care.
 
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The longer I work in this field the less specific personal information I put in the chart. Way too often patients are requesting records for a variety of reasons and I want to protect what they told me. I was trained to put extensive and detailed information, but find that it is read less by another treating professional who will understand than it is by a wide variety of people who will misunderstand or misuse the information. Now I just put in what is minimally required with a bit more detail when outlining risk issues and the steps taken to address those.
 

HooahDOc

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The longer I work in this field the less specific personal information I put in the chart. Way too often patients are requesting records for a variety of reasons and I want to protect what they told me. I was trained to put extensive and detailed information, but find that it is read less by another treating professional who will understand than it is by a wide variety of people who will misunderstand or misuse the information. Now I just put in what is minimally required with a bit more detail when outlining risk issues and the steps taken to address those.
This.

Also, less detail increases efficiency. You will develop your own set of verbiage as you continue your training and eventually have standard phrases for things. I treat the assessment as a sort of, "discussion" about the patient to include rationale for diagnosis and treatment decisions. Honestly, though, I don't always do one, because some cases would be nothing more than, "he has ADHD, I'm prescribing this stimulant because he has ADHD". Since becoming an attending, my notes have become progressively shorter and succinct, but when I feel necessary will spend more time and provide more details in the documentation, particularly if my treatment regimen is unusual -- I want other providers to be able to understand why I chose what I did.

In the, "Plan" section, I found it to be infinitely helpful to also briefly mention my thoughts on what to do next if my recommendation doesn't work. This makes my f/u appts much easier and faster, and also really helps out covering providers.

Be wary of how much detail, as others have said. Patients can request their records at any time, and do with them whatever they want -- including handing them to a lawyer. I made the mistake of referencing in a note for my patient that a parent was in their own treatment, because I felt their issues had an effect on the child's presentation. I recognized this mistake when the other biological parent requested a copy of the child's records, and that I was about to get wrapped up in custody issues I wanted no part of.
 

Merovinge

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The longer I work in this field the less specific personal information I put in the chart. Way too often patients are requesting records for a variety of reasons and I want to protect what they told me. I was trained to put extensive and detailed information, but find that it is read less by another treating professional who will understand than it is by a wide variety of people who will misunderstand or misuse the information. Now I just put in what is minimally required with a bit more detail when outlining risk issues and the steps taken to address those.
This is fantastic advice for outpatient f/u or clear cut cases. I wish I would have learned it sooner and it is still a work in progress. Also completely agree with HooahDoc as well for outpatient.

As an intern, for inpatient cases, when there is not a clear diagnostic please make your assessment like any good doctor. You NEED a differential diagnosis, why you favor a specific diagnosis and what you are doing to r/o concerns on your differential (labs, eeg, mri, etc) along with what from your physical and mental status exam support your cause. Particularly with any new onset acute to sub acute cases your first job is to clarify the diagnosis and r/o any cause that can be reversed. Some programs do a great job teaching this but other inpatient docs I see do a terrible job and just automatically attribute sx to idiopathic DSMology. No one who's loved one gets hospitalized gives 2 ****s about you describing the narrative of their family member's life but they certainly care if you find out the person actually has epilepsy, a brain tumor, cushings, etc.
 

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The longer I work in this field the less specific personal information I put in the chart. Way too often patients are requesting records for a variety of reasons and I want to protect what they told me. I was trained to put extensive and detailed information, but find that it is read less by another treating professional who will understand than it is by a wide variety of people who will misunderstand or misuse the information. Now I just put in what is minimally required with a bit more detail when outlining risk issues and the steps taken to address those.
Yes, absolutely this. I put almost no specific psychosocial information beyond what is needed to support my diagnosis and plan. A typical assessment section could be like (these are all totally made up obviously and do not correspond to any real individuals):

"32F with hx 1 prior depressive episode, now returns with depressed mood, disturbed sleep, and passive thoughts of death x 3 weeks. She declines voluntary hospitalization, and given she denies active intent or plan, is forward-thinking and help seeking, and has no hx prior attempts at self harm, she does not currently meet criteria for hold and can be most appropriately managed on an outpatient basis at present."

Or,
"27M with no prior psych hx, now p/w onset of paranoia and auditory hallucinations X 1 week in context of recent heavy use of Adderall. Likely substance-induced psychosis, though will maintain watch for emerging indications of any primary psychotic disorder."

Or,
"46F with 3 prior episodes of MDD, poor response to antidepressants, and a single prior episode of hypomania in context of unopposed antidepressant, now p/w depressed mood, irritability, disrupted sleep and prominent anxiety x2 weeks. Given prior hypomania will avoid unopposed antidepressants, trial mood stabilizer."

Then I have a multiaxial list where I put my dx and any rule outs, and my plan is a bullet pointed list, often organized by problem and including, if appropriate, any intended Plan B in case of poor response or other such issue.

Like HooahDoc, I will be circumspect about social details. I avoid mentioning specific individuals and will just say something like "stressful home environment may be a contributor to the current presentation" if that is important to include.
 
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northernpsy

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Just wanted to add my support for the idea that learning to write a concise note that focuses on what is pertinent clinically (and, well, for billing) is important, especially if you leave academia. The culture at the place where I currently work is such that the other attendings write quite long notes. A lot of times when I cover for my colleagues I have all this detail to wade through and I can't find the plan for the patient or follow what med changes were made because they didn't mention it or such clinically relevant details were lost in a sea of pontification. The reality is that even if your notes are beautiful novels, other docs don't really want to spend the time reading lots of detail that ultimately doesn't matter. Focus on what actually explains what you did and why.
 
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This.

Also, less detail increases efficiency. You will develop your own set of verbiage as you continue your training and eventually have standard phrases for things. I treat the assessment as a sort of, "discussion" about the patient to include rationale for diagnosis and treatment decisions. Honestly, though, I don't always do one, because some cases would be nothing more than, "he has ADHD, I'm prescribing this stimulant because he has ADHD". Since becoming an attending, my notes have become progressively shorter and succinct, but when I feel necessary will spend more time and provide more details in the documentation, particularly if my treatment regimen is unusual -- I want other providers to be able to understand why I chose what I did.

In the, "Plan" section, I found it to be infinitely helpful to also briefly mention my thoughts on what to do next if my recommendation doesn't work. This makes my f/u appts much easier and faster, and also really helps out covering providers.

Be wary of how much detail, as others have said. Patients can request their records at any time, and do with them whatever they want -- including handing them to a lawyer. I made the mistake of referencing in a note for my patient that a parent was in their own treatment, because I felt their issues had an effect on the child's presentation. I recognized this mistake when the other biological parent requested a copy of the child's records, and that I was about to get wrapped up in custody issues I wanted no part of.
That reminded me of how we implemented an additional section for the treatment plan as part of our "new and improved" government mandated stuff. Not even sure what initials it's related to whether it is ACA, PCMH, or AHQA. Who knows?
My first one I put:
Goal: Decrease cutting
Intervention: DBT
To keep things interesting, next week I might put:
Goal: Reduce NSSI
Intervention: Teach adaptive coping skills​

I was at one place during my clinical rotations where they wanted numbers for the targets so we would put stuff like Goal: Reduce S/I by 50% as if that has any real meaning, but it kept the administrative/bureaucratic types off our backs. Nevertheless, I do try to keep this type of stuff matching to what we are actually working on and have some bearing on reality, but it is somewhat ridiculous to expect psychotherapy to be even close to that structured.
 
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HooahDOc

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That reminded me of how we implemented an additional section for the treatment plan as part of our "new and improved" government mandated stuff. Not even sure what initials it's related to whether it is ACA, PCMH, or AHQA. Who knows?
My first one I put:
Goal: Decrease cutting
Intervention: DBT
To keep things interesting, next week I might put:
Goal: Reduce NSSI
Intervention: Teach adaptive coping skills​

I was at one place during my clinical rotations where they wanted numbers for the targets so we would put stuff like Goal: Reduce S/I by 50% as if that has any real meaning, but it kept the administrative/bureaucratic types off our backs. Nevertheless, I do try to keep this type of stuff matching to what we are actually working on and have some bearing on reality, but it is somewhat ridiculous to expect psychotherapy to be even close to that structured.
Ah yes, the requirement for patient-specific treatment plans and outcome measures. I didn't realize we work for the same system.
 
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Ah yes, the requirement for patient-specific treatment plans and outcome measures. I didn't realize we work for the same system.
I think all of these systems have people with similar mindsets trying to run them. They think that they have to make sure that we aren't just throwing pills at the patients and telling them amusing anecdotes. Since I can't throw pills at them, they really have to make sure that we aren't just goofing off in treatment. They are like the parent of the kid that is at their wits end when they show up, then I try to explain how playing with the kid is part of the treatment and they just want me to double down on the ineffective parenting strategy that got us here in the first place.
 

hamstergang

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they just want me to double down on the ineffective parenting strategy that got us here in the first place.
This annoyed and confused me when I saw it in real life. Let me be the therapist and do therapy, and you be the parent and pretend to parent. It's such a sign of resistance to change.
 
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hebel

hebel

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Very helpful information posted, I really appreciate it. Your posts have made me realize I am probably agonizing over way too much detail in my notes in regards to psychosocial details (do you keep these vague and brief in the HPI section as well?)

Also, my only concern with brevity is that it seems to not allow you to adequately support yourself and your train of thought if your note was brought into court. Am I wrong in viewing the assessment and plan as a great place to "cover your ass?"
 

splik

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Also, my only concern with brevity is that it seems to not allow you to adequately support yourself and your train of thought if your note was brought into court. Am I wrong in viewing the assessment and plan as a great place to "cover your ass?"
I think CYA is a rather unfortunate turn of phrase, but yes from a risk management perspective you should document particular things. For example if you are not hospitalizing a suicidal patient you need to document why your plan is the least restrictive care setting, and why a higher level of care is not appropriate. This becomes key in the outpatient setting.
As Resnick says, "no one ever died because you didn't document a suicide risk assessment". you hear some people say stupid things like "if it isn't documented, it never happened". Well, docs fabricate things in notes all the time, usually minor things (for example documenting a normal neurological exam when one was not performed) so documentation doesn't mean it happened. Also if you tend not to document things (for example if seeing people for psychotherapy) then just because you didn't document the patient said her mother had died, doesn't mean it didn't happen. But, without documentation, your testimony in court relies much more heavily on your credibility as a witness and the plaintiff's counsel will do everything to discredit you. also as mentioned above writing too much can be a liability, particularly if your record is subpoenaed.

Good documentation is not to save you in court, but to save you from getting to court in the first place. an attorney will think twice if there is good documentation

as one of my attendings used to say "the more you write, the more rope you give for the lawyers to hang you with!"
 
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tr

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Very helpful information posted, I really appreciate it. Your posts have made me realize I am probably agonizing over way too much detail in my notes in regards to psychosocial details (do you keep these vague and brief in the HPI section as well?)

Also, my only concern with brevity is that it seems to not allow you to adequately support yourself and your train of thought if your note was brought into court. Am I wrong in viewing the assessment and plan as a great place to "cover your ass?"
Sure but what are you covering? My first example up above is mostly CYA (if in the unlikely/unfortunate scenario that the patient goes home and attempts suicide and the family sues, I've documented that she seemed low risk and didn't meet hold criteria at the time I saw her).

I don't see how excess irrelevant psychosocial detail offers any CYA advantage; as HooahDoc pointed out it is more likely to get you in trouble than anything else.

My HPI is very formulaic. 1-2 sentences describing the CC and the time/circumstances of onset, a paragraph of pertinent pos/neg ( like sigecaps or criteria for PTSD or whatever is relevant), and a targeted psych ROS section. All psychosocial detail is summarized as "family conflict" or "work stressors" or "legal battles" or "bereavement" or whatever.
 
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Well, docs fabricate things in notes all the time, usually minor things (for example documenting a normal neurological exam when one was not performed)
:O
This is an incredibly bad idea for many obvious reasons.
 

artorious22

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Assessment: major depression with SI
Plan: admit, monitor under SP's, monitor mood and behavior, adjust meds, individual counseling
That doesn't work anymore. You need to justify why they are in the hospital in your plan.
 

Merovinge

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That doesn't work anymore. You need to justify why they are in the hospital in your plan.
Not that I write notes like that but to answer your comment

"Assessment: major depression with active SI
Plan: admit, monitor under SP's, monitor mood and behavior, adjust meds, individual counseling"
 

michaelrack

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That doesn't work anymore. You need to justify why they are in the hospital in your plan.
I was kind of exaggerating, but actually a note like that probably would work as long as a reason for hospitalization was clear from the rest of the note (in other words, if the HPI/mental status exam justifies admission)..... insurance reviewers look at the whole note. But I agree that interns should be more explicit in their A/P than an experienced attending such as myself.

I should add, that one of the psych facilities where I work has a suicide assessment section of the eval that is separate from the plan
 
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artorious22

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Not that I write notes like that but to answer your comment

"Assessment: major depression with active SI
Plan: admit, monitor under SP's, monitor mood and behavior, adjust meds, individual counseling"
When they are on the unit, a good majority of people deny suicidal ideations. You need to do more than that. you need to paint a picture to make them look as bad as collateral is telling you in order to get reimbursed.
 
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michaelrack

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When they are on the unit, a good majority of people deny suicidal ideations. You need to do more than that. you need to paint a picture to make them look as bad as collateral is telling you in order to get reimbursed.
sorry, I should have been clearer that I was talking about the initial psych eval/H and P, not follow up progress notes.
 

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Great to read this thread. It helps to remind me that there's what me and a patient are doing together and the techno-bureaucratic language that must be part of all notes.

I laughed out loud at Splik pointing out the absurdity of if you don't document it didn't happen. With it's missed inverse that what is in the chart did happen.

I've also struggled with notion that cool technocratic language doesn't have an authorship point of view. And how ridiculously... it is mistaken has not having one. But then pivoted and released the irony when i thought about protecting the private information and intimate conversations I have with patients from gawkers, that smalltownpsych points out.

That helped make my note writing more efficient. Also i picked up some language that i like to use from a relationally oriented psychologist at a personality disorder clinic. Patient c/o of X, Dyad processed Y. Then i have smart phrases for certain groups of positives and negatives which is brilliant for people like me who type like drunken elephants.

It reminds me what is active and prominent in the patient's life and perspective for next time, so we can start again.

I try to take a Joe Friday Psycho/social hx for every new patient just so i have it. I propagate it forward and amend it. Epic is slick for this sort of thing.

And I'm finally sounding like an independent clinician in my assessments. Which is exactly as my seniors in this thread have pointed out so well. This the place where i think and describe and negotiate risk and discuss differential formulations. But also from a hardcore relational perspective. I spend a few minutes at the end of a session describing to a patient the things that i will include in my assessment and open the process to them and ask them to participate in their own formulation. This to me handles defensive practice much more elegantly than thinking about all the ways i can be stung by a law suit and populating my assessment with a lot of redundant useless language. I use the HPI for that.

Anyway... I'm journaling outloud. Thanks for this thread OP. It helped cement a lot of hard lessons that we're learning.

Inpatient notes are instruments in the war of attrition between insurance companies and inpatient admin. With the politics of liberal big brother organizations thrown in. Knowing the patient helps rapport. But you don't have to write novellas as I did. Everything subtracts from your time elsewhere. most poignantly face to face time with patients.
 
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