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- Nov 9, 2015
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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!
...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!