Medical-Legal Risks to Patients of Psychiatric Clinical Documentation

[Nasrudin]

Thinking about technology and information risks got me thinking about a recent journeyman shrink realization I got schooled on and wanted to ask my elders here how they avoid inadvertent documentation traps that early stage psychiatrist like me may unknowingly set for patients.

2 early stage private psychiatry ethical issues I walked into with my documentation: I documented suicidality and substance abuse thoroughly in a person who made a complete recovery from both of those, but whose life insurance wanted all the dirty laundry from all the visits, not just the recent 1-2 years of good well-being and functioning and consistent sobriety with no self-harming ideations. I felt like my documentation may have prevented this person from getting coverage for their family, although I'll never know because the person's residence had since changed to out of state. The second one was worse: I like to do extensive biographical work with psychotherapy patients and I had previously been keeping the longer social history obtained for no other intended audience but me, the patient, and possibly an interested collaborating clinician. Until a deposing attorney for in an employment dispute requested all of my records and I agree only because the patient instructed me to, and then the attorney proceeded to use my biographical history against my patient in a way that was intentionally hurtful to him. He won the case, but this was shocking to me, although, it occurs to me that was a naive premise to begin with.

So I want to refine my use of the official medical record to accomplish what it needs to as a clinical record and as an insurance billing instrument but I want advice on how to minimize any traps by unintended audiences and also to ask how you all design your psychotherapy notes to be protected and useful for reference but not viewable by anyone but you.

I appreciate any advice and helpful suggestions about how to improve this aspect of my care of paitents.

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[Celexa]

Aren't we allowed to keep separate psychotherapy notes which aren't discoverable? When I was seeing primary therapy pts in residency those chart notes were the blandest ones I ever wrote. Brief description of topic discussed (ie, 'patient discussed relationship with their family'), modality and/or specific interventions used, MSE, plan is to continue seeing weekly. The end.

Things like the presence of substance use and suicidal ideation though are so core to the clinical decision making I don't see how you could leave those out.

 

[splik]

Aren't we allowed to keep separate psychotherapy notes which aren't discoverable? When was seeing primary therapy pts in residency those chart notes were the blandest ones I ever wrote. Brief description of topic discussed (ie, 'patient discussed relationship with their family'), modality and/or specific interventions used, MSE, plan is to continue seeing weekly. The end.

Things like the presence of substance use and suicidal ideation though are so core to the clinical decision making I don't see how you could leave those out.

Psychotherapy notes are still discoverable and are often requested. They are just not part of the medical record per HIPAA. I’ll tell you that medical boards and PHPs often specifically request those therapy notes for physicians under investigation

 

[Sushirolls]

You are over thinking those 2 examples.

Document as you are trained. If an insurance company doesn't offer life insurance. That's not your problem. That's an issue between the patient and the insurance company they applied to. I've had 1 insurance company deny a patient in the past, and patient blamed me. I explained similar. I can just not document things. I had one patient once who was wanting to be a foster parent, temporary gigs, for babies. Patient had passive SI documented in my notes, and they denied the person on that. Patient stuck with me, was ticked at me for year or so, but eventually moved past that set back. More recently I had one insurance, not just deny, but actually request I fill out a form to describe. Patient paid extra for my time to fill out that form, and basically said they were great/stable/no issues for years. Don't know yet if they got the insurance.

As for a patient who voluntarily releases their records when they didn't need to... again, not your problem, that's theirs. I routinely caution patients to really think twice before they give records to XYZ if they don't have to do it.

 

[calvnandhobbs68]

Psychotherapy notes are still discoverable and are often requested. They are just not part of the medical record per HIPAA. I’ll tell you that medical boards and PHPs often specifically request those therapy notes for physicians under investigation

Just to throw this out there though, how would anyone ever know if you kept separate “process notes”? So if, for instance, you submitted/saved notes for official documentation/billing purposes but kept process notes in a paper notebook?

 

[michaelrack]

Just to throw this out there though, how would anyone ever know if you kept separate “process notes”? So if, for instance, you submitted/saved notes for official documentation/billing purposes but kept process notes in a paper notebook?

They won't know for sure. Are you going to lie and say you don't have any, or just not submit them if a court orders you to submit "any and all notes" for a patient?

 

[aim-agm]

They won't know for sure. Are you going to lie and say you don't have any, or just not submit them if a court orders you to submit "any and all notes" for a patient?

The real pro move is to write the paper notes in "doctor scratch", so you can submit them but no one else will be able to read them.

 

[tr]

Thinking about technology and information risks got me thinking about a recent journeyman shrink realization I got schooled on and wanted to ask my elders here how they avoid inadvertent documentation traps that early stage psychiatrist like me may unknowingly set for patients.

2 early stage private psychiatry ethical issues I walked into with my documentation: I documented suicidality and substance abuse thoroughly in a person who made a complete recovery from both of those, but whose life insurance wanted all the dirty laundry from all the visits, not just the recent 1-2 years of good well-being and functioning and consistent sobriety with no self-harming ideations. I felt like my documentation may have prevented this person from getting coverage for their family, although I'll never know because the person's residence had since changed to out of state.

Life insurance companies are looking for any reason to reject people. I don't release my actual notes to insurance companies. Instead I provide a summary of past treatment and specifically note their current euthymia/stability/good functioning (assuming that's true).

The second one was worse: I like to do extensive biographical work with psychotherapy patients and I had previously been keeping the longer social history obtained for no other intended audience but me, the patient, and possibly an interested collaborating clinician. Until a deposing attorney for in an employment dispute requested all of my records and I agree only because the patient instructed me to, and then the attorney proceeded to use my biographical history against my patient in a way that was intentionally hurtful to him. He won the case, but this was shocking to me, although, it occurs to me that was a naive premise to begin with.

Right so that's why it's not a good idea to put extensive psychosocial information in the medical record.

So I want to refine my use of the official medical record to accomplish what it needs to as a clinical record and as an insurance billing instrument but I want advice on how to minimize any traps by unintended audiences and also to ask how you all design your psychotherapy notes to be protected and useful for reference but not viewable by anyone but you.

I appreciate any advice and helpful suggestions about how to improve this aspect of my care of paitents.

My psychotherapy notes are usually like 3 lines:

Treatment goals: reduce anxiety (copied forward from last note)
Techniques used: Reviewed HW of exposure to social situation. Started a Mood Log for anxious feelings related to the exposure
HW for next time: Complete remaining columns of Mood Log begun in session

What are 'process notes' for? I've never felt like I would have needed a more extensive written detailing of the patient's psychosocial situation. For someone I'm seeing regularly, I usually remember enough details of their story to be able to discuss coherently, and if there's some specific detail I don't remember that's germane to whatever we are talking about, the patient will remind me.

 

[whopper]

You're not allowed to lie on your notes. When third parties want notes and use those notes against your patient, if the patient signed a release that's not on you unless you wrote something outside of professional guidelines. That said there's some diplomacy you need to employ, but getting into this issue is very nuanced and is more like discussing a book than something I want to cover in 1 post.

 

[ObsequiousAplomb]

I agree with everything already said here.

I would like to take a step back though and address the OP.
The insurance policy has rules for who can and cannot qualify for it. Based on the truth that is in the medical record this person no longer qualified for the insurance policy. They weren't denied for arbitrary reasons, they were denied for actuarial reasons. I don't see any harms done here. The system worked as it is supposed to.
If they want another policy that doesn't require these rules, then they need to do that on their own time. What were they expecting you to do, commit insurance fraud for them? Are you upset because you were prevented from being party to insurance fraud?

 

[calvnandhobbs68]

I agree with everything already said here.

I would like to take a step back though and address the OP.
The insurance policy has rules for who can and cannot qualify for it. Based on the truth that is in the medical record this person no longer qualified for the insurance policy. They weren't denied for arbitrary reasons, they were denied for actuarial reasons. I don't see any harms done here. The system worked as it is supposed to.
If they want another policy that doesn't require these rules, then they need to do that on their own time. What were they expecting you to do, commit insurance fraud for them? Are you upset because you were prevented from being party to insurance fraud?

Agree I don't really see a problem with the first one. It'd be like a patient being mad their gastro's office has documentation they were hospitalized for an ulcerative colitis flare up years ago even if it's well controlled now.

That's why the advice generally is get life insurance as soon as possible as young as possible when you have fewer medical problems.

 

[whopper]

I've had patients with top government security clearance, or other high sensitivity positions where their employer wanted their medical records. I cannot lie or intentionally not put stuff into their records that had to be put in.

I always tell patients in such situations if a 3rd party wants their records, and they sign a release it's on them if the records contain anything they don't want their employer to hear. Otherwise don't sign a release. If they are forced to or face unemployment that's on them too.

 

[aim-agm]

I've had patients with top government security clearance, or other high sensitivity positions where their employer wanted their medical records. I cannot lie or intentionally not put stuff into their records that had to be put in.

I always tell patients in such situations if a 3rd party wants their records, and they sign a release it's on them if the records contain anything they don't want their employer to hear. Otherwise don't sign a release. If they are forced to or face unemployment that's on them too.

As others have mentioned, one challenge is when the patient may not have a choice because records are subpoenaed by a court. I'm most concerned about adversarial proceedings such as divorce or child custody, where a lawyer could twist the medical record to devastating effect on the patient.

 

[whopper]

I'm most concerned about adversarial proceedings such as divorce or child custody, where a lawyer could twist the medical record to devastating effect on the patient.

This is something that legally has been a WTF zone for me. HIPAA says you don't have to give records unless the patient agrees, the exception being an emergency, yet when courts order records doctors are supposed to provide them despite the conflict with HIPAA.

The job requiring the records or the patient loses the job, I get it. The bottom line if you can't do a job cause of medical reasons you can't do a job, and some jobs there's no room for patients hiding medical problems. The current issue with the Secretary of Department of Defense is a great example of this.



Now subpoenaed records are different cause it's often times not in areas that are emergencies or something that could become emergencies. In forensic training I brought this up, and was told by very good legal minds that while this does violate HIPAA because it's not our job to interpret the law, someone whose job it is to interpret the law gave the order, and while they could be wrong, it's in their lap to determine not ours. The patient's lawyer could always argue the judge's order was in violation of HIPAA and shouldn't have been done, but by then it's out of our hands.

Unfortunately from my own experience, even judges often times don't know the law. As one of my law professors brought up, judges are often times the bad to mediocre lawyer that couldn't make in private practice and usually only only good on upper state and federal levels. So whenever I get a court order to give the records (and it's very rare but has happened), I often times get the feeling the judge doesn't know WTF they're doing, but by then it's out of my hands.

 

[clausewitz2]

This is something that legally has been a WTF zone for me. HIPAA says you don't have to give records unless the patient agrees, the exception being an emergency, yet when courts order records doctors are supposed to provide them despite the conflict with HIPAA.

The job requiring the records or the patient loses the job, I get it. The bottom line if you can't do a job cause of medical reasons you can't do a job, and some jobs there's no room for patients hiding medical problems. The current issue with the Secretary of Department of Defense is a great example of this.



Now subpoenaed records are different cause it's often times not in areas that are emergencies or something that could become emergencies. In forensic training I brought this up, and was told by very good legal minds that while this does violate HIPAA because it's not our job to interpret the law, someone whose job it is to interpret the law gave the order, and while they could be wrong, it's in their lap to determine not ours. The patient's lawyer could always argue the judge's order was in violation of HIPAA and shouldn't have been done, but by then it's out of our hands.

Unfortunately from my own experience, even judges often times don't know the law. As one of my law professors brought up, judges are often times the bad to mediocre lawyer that couldn't make in private practice and usually only only good on upper state and federal levels. So whenever I get a court order to give the records (and it's very rare but has happened), I often times get the feeling the judge doesn't know WTF they're doing, but by then it's out of my hands.

You may want to take a look at the actual text of HIPAA or any of the many summaries HHS has available. Judicial proceedings are specifically and explicitly exempted from the need for authorization for disclosure of protected health information provided there is a subpoena requesting them. It really could not be simpler.

There are a lot of non-emergency exceptions to the privacy provisions of HIPAA, worth taking a look at before making sweeping statements about what it requires or doesn't require.

 

[hamstergang]

In forensic training I brought this up, and was told by very good legal minds that while this does violate HIPAA because it's not our job to interpret the law, someone whose job it is to interpret the law gave the order, and while they could be wrong, it's in their lap to determine not ours.

Perhaps those were very good legal minds who advised you, but they're completely ignorant of HIPAA and I probably wouldn't actually trust any of what they say.

Summary of the HIPAA Privacy Rule

Summary of the HIPAA Privacy Rule

www.hhs.gov

"Covered entities may disclose protected health information in a judicial or administrative proceeding if the request for the information is through an order from a court or administrative tribunal. Such information may also be disclosed in response to a subpoena or other lawful process if certain assurances regarding notice to the individual or a protective order are provided."

(I realize the same point was made just a post before mine, but I wanted to provide a direct link and quote to demonstrate just how bad these very good legal minds really were.)

 

[whopper]

Agree based on the quotes above!

 

[Crayola227]

So in no way am I advocating dishonesty because of what insurance might see.

I will say, that some patients are however saavy to these issues, or should they have their psych treatment or notes shoved in their faces somehow by the world and negative consequences, that this alone can have a drastic effect on their care. One being, this kind of stuff often leads people to either not seek care at all, not be fully honest with their provider, or cease treatment altogether.

Most of the time the harms of this occuring because of something you would like to put in your note, vastly outweighs the benefit to your patient.

The notes are there to help the patient. Not the insurance, not a judge, not anyone that might like to read them beyond delivering care, even if said parties have the right to them. It might seem like they are there to help you, but what are they there to help you do? Help the patient.

This is why the axiom, don't put more than is absolutely necessary.

Essays and essays have been written about the ethics of this. The patient is only revealing things that can even be written down by you, for one purpose they are trusting you for. To help them. It's not so you can create a novel of their life that maybe one day 15 years later someone reads it and they don't meet an actuarial standard. Your documentation of things told to you in confidence did this, not the "truth."

Because arguably if they knew you were writing down more than necessary that could be used in court against them, who in the world would say anything that could be.

We see this all the time with health professionals seeking care.

And the notion that it's the patient's fault confidentiality is breached - there are 1,000 things that could lead to those records being used against them, and many of those possibilities are beyond their control, and no one can really foresee.

This is why, without being dishonest or compromising care, I will do my best to leave things out or describe as benignly as I can, things that might be damaging to the patient and used against them outside the medical sphere. My notes should never do this, it's literally contrary to the very reason they exist at all. It's not about making the patient look good. It's about my job to help them, and my job is never to record things that could be used against them unless necessary for treatment.

So I really object to this notion, "the patient got what they deserved because they were honest with their psychiatrist and all I did was document the truth." You're not lying by omission. You can argue your ethical duty is actually omission, unless what you write down advances care. This is basically the definition of confidentiality.

Tldr
Don't write stuff that might hurt the patient outside the exam room unless you really, really, really need to.

 

[ObsequiousAplomb]

So in no way am I advocating dishonesty because of what insurance might see.

I will say, that some patients are however saavy to these issues, or should they have their psych treatment or notes shoved in their faces somehow by the world and negative consequences, that this alone can have a drastic effect on their care. One being, this kind of stuff often leads people to either not seek care at all, not be fully honest with their provider, or cease treatment altogether.

Most of the time the harms of this occuring because of something you would like to put in your note, vastly outweighs the benefit to your patient.

The notes are there to help the patient. Not the insurance, not a judge, not anyone that might like to read them beyond delivering care, even if said parties have the right to them. It might seem like they are there to help you, but what are they there to help you do? Help the patient.

This is why the axiom, don't put more than is absolutely necessary.

Essays and essays have been written about the ethics of this. The patient is only revealing things that can even be written down by you, for one purpose they are trusting you for. To help them. It's not so you can create a novel of their life that maybe one day 15 years later someone reads it and they don't meet an actuarial standard. Your documentation of things told to you in confidence did this, not the "truth."

Because arguably if they knew you were writing down more than necessary that could be used in court against them, who in the world would say anything that could be.

We see this all the time with health professionals seeking care.

And the notion that it's the patient's fault confidentiality is breached - there are 1,000 things that could lead to those records being used against them, and many of those possibilities are beyond their control, and no one can really foresee.

This is why, without being dishonest or compromising care, I will do my best to leave things out or describe as benignly as I can, things that might be damaging to the patient and used against them outside the medical sphere. My notes should never do this, it's literally contrary to the very reason they exist at all. It's not about making the patient look good. It's about my job to help them, and my job is never to record things that could be used against them unless necessary for treatment.

So I really object to this notion, "the patient got what they deserved because they were honest with their psychiatrist and all I did was document the truth." You're not lying by omission. You can argue your ethical duty is actually omission, unless what you write down advances care. This is basically the definition of confidentiality.

Tldr
Don't write stuff that might hurt the patient outside the exam room unless you really, really, really need to.

I hear you. In the OP it was that the patient had been suicidal and using illicit substances. The first one always needs to be documented honestly and accurately. The second, there's a little leeway (for example, I ask if people have ever tried LSD or psilocybin, but I never actually write the answer down unless they sound like they have an SUD) but it's not like we can leave out "continuous IV fentanyl use" from a note just because we're trying to protect the patient.

 

[comp1]

The comment above about the notes being there for the benefit of the patient primarily really struck me. I wonder if that really is actually the primary purpose of medical documentation in today's world.

 

[ObsequiousAplomb]

The comment above about the notes being there for the benefit of the patient primarily really struck me. I wonder if that really is actually the primary purpose of medical documentation in today's world.

some might say that the entire purpose of medical care is to benefit the patients. The ancillary things like notes are supposed to be in service of that end. I think we like to keep the notes benefiting us as well, because why write anything that could hurt you?

 

[Stagg737]

some might say that the entire purpose of medical care is to benefit the patients. The ancillary things like notes are supposed to be in service of that end. I think we like to keep the notes benefiting us as well, because why write anything that could hurt you?

Indirectly, yes. Historically, notes were a means to communicate a medical opinion to other healthcare professionals so that they could understand other doctor's evaluations and treatment plans and third parties weren't meant to be privy to that information. Imo modern medical notes are a bas****ized version of what a medical record was meant to be and are just as much, if not more, for communication with third parties not directly involved in clinical aspects of patient care. Kind of a sad commentary on modern medicine, but thus is the evolution of the system.

 

[Crayola227]

I hear you. In the OP it was that the patient had been suicidal and using illicit substances. The first one always needs to be documented honestly and accurately. The second, there's a little leeway (for example, I ask if people have ever tried LSD or psilocybin, but I never actually write the answer down unless they sound like they have an SUD) but it's not like we can leave out "continuous IV fentanyl use" from a note just because we're trying to protect the patient.

Absolutely.

I sorta went off because the talk about keeping more detailed notes. It's a rock and a hard place. Because understandably keeping track of the specifics can really help you better understand the context of the patient and their struggles and engage. Especially with deeper psychotherapy, bigger panels, or shorter visits. But then the issue that anything except a verbal conversation with no witnesses or recording can always lead to a breach of confidence and unintended consequences. There were some really good creative ideas about this.

So I know a provider who did this. For some of the history, he would have the patient write down a whole history, without a name, and then he would read it. I'm not sure if he kept it in a file or not. I think he didn't. His rationale was that anything legally requested would be requesting notes he had written or was pertaining to the patient, and that he couldn't submit anything he hadn't written that had no authorship noted or even names of who was being discussed. May as well be a flyer on a car windshield for all that. Obviously if he were asked specifically if he had knowledge the patient had written such a thing or what it might have said, that's different. Although, if he doesn't discuss any of the details specifically with the patient, again, there is less to discuss if he's asked about it. If you don't even confirm with the patient it's their life story, it may as well be the plot of a movie they wrote up that you read. It's splitting a hair though.

One might argue that you might even toss this in the bin as not belonging in the medical record before giving it over.

This was a guy who worked with healthcare professionals and the board, and it was obviously a tactic he did to try to facilitate communication and honesty without creating the kind of paper trail he knew always got pulled in.

I've seen other physicians do something similiar, read what a patient writes, and then hand it back.

Of course this still relies on memory, and as noted, some of it you need to document no matter what.

 

[Crayola227]

So one example given, passive SI. I have seen plenty of physicians leave it out if they don’t think it's clinically significant or a risk. You can debate this. Just saying.

 

[clausewitz2]

So one example given, passive SI. I have seen plenty of physicians leave it out if they don’t think it's clinically significant or a risk. You can debate this. Just saying.

Some specialties might get away with this but we are the ones people come after (if they are going to come after anyone) after a suicide, so probably not a great option.

 

[Merovinge]

So one example given, passive SI. I have seen plenty of physicians leave it out if they don’t think it's clinically significant or a risk. You can debate this. Just saying.

Which is a terrible idea, given that this is a core symptom of illnesses we treat. Pretending someone didn't discuss passive SI is like a neurologist pretending someone didn't describe a sudden loss of consciousness. I don't think there is much debate. If you can't be bothered to discuss passive SI, the treatment for the condition causing that, and what the safety plan is/why the person does not meet criteria for inpatient hospitalization, psychiatry is not the field for you.

 

[ObsequiousAplomb]

I mean, passive SI never meets inpatient criteria, so it's not like you need to document your way around that...
Passive SI is also an incredibly broad topic that covers "I had a single thought one time last week for 2 seconds about death that wasn't repugnant for the first second" to "I'm constantly fantasizing about death, how it would go, what it would be like and all the beautiful details. No actual plans of course, I'd never do that *wink*"

Somewhere along that line is the need to actually document something and its treatment. I don't think the first point really does warrant documentation in a therapy patient I see 4 days a week, for example, when they bring it up on Tuesday and we see each other two or three more times that week.

 

[allantois]

I have thoughts about SI daily contemplating patients' SI.. lol

 

[Sushirolls]

IMO, we don't joke about SI/HI or using the word "crazy" in psych.
Most everything else is fair game.

For instance, I really wish Crayola had a crayon for an avatar.

 

[clausewitz2]

IMO, we don't joke about SI/HI or using the word "crazy" in psych.
Most everything else is fair game.

For instance, I really wish Crayola had a crayon for an avatar.

Bob Spitzer apparently used to tell his trainers that the first diagnostic question in psych was always 'crazy or not', so ymmv in terms of the word being taboo.

 

[Sushirolls]

Bob Spitzer means nothing to me. Never heard the name until now and had to Google him.

 

[Bartelby]

I agree with Sushi's early post. A lot of what we document could be harmful if reviewed by an insurance company, court, etc. but we still need to document appropriately. Things like assessing for SI are absolutely standard to include as part of a risk assessment. We should not include inaccurate information, and leaving a record that makes it look like we didn't bother to ask is (in my opinion) inviting trouble when unexpected bad outcomes occur.

That said, Crayola's point has validity too. I always ask myself if something is directly relevant and keep documentation as telegraphic as I reasonably can. For example, if the patient admits to some petty crime that isn't directly relevant to their management I'm likely to leave that out. I will also summarize 40 minutes of psychotherapy into a couple of vague sentences that are good enough for the insurance reviewers.

Unfortunately the stuff most relevant to us is often the stuff most relevant to a life insurance company or court. The system isn't perfect, but my stance has been to document honestly and with discretion where I can and then accept the rest as our of my hands. I have also had requests from patients not to document relevant information and I have always told them that I cannot proceed with treatment under those restrictions. So far each time that has come up the patient has accepted that and treatment has proceeded without issue (though of course they might be lying to me about some sensitive information from then on, which is their choice).

 

[clausewitz2]

Bob Spitzer means nothing to me. Never heard the name until now and had to Google him.

Really? I am kind of surprised, he was an incredibly prominent and influential psychiatrist from not long ago who bears a significant portion of the blame and credit for the modern DSM.

 

[comp1]

Spitzer might actually be THE most influential psychiatrist of the last 50 years, if not 100. He wasn't super into the limelight though, so I'm not surprised his name isn't sung from the rooftops like some others. Quite honestly, he could almost be listed the author of the DSM-III. The whole concept of checklists and numbers of diagnostic criteria, that's him. It wasn't handed down from on high. Psychiatry was a more pure branch of philosophy before him. He also got homosexuality removed (on a technical level, I know there were activists who deserve credit). The guy WAS our field.

 

[splik]

Spitzer might actually be THE most influential psychiatrist of the last 50 years, if not 100. He wasn't super into the limelight though, so I'm not surprised his name isn't sung from the rooftops like some others. Quite honestly, he could almost be listed the author of the DSM-III. The whole concept of checklists and numbers of diagnostic criteria, that's him. It wasn't handed down from on high. Psychiatry was a more pure branch of philosophy before him. He also got homosexuality removed (on a technical level, I know there were activists who deserve credit). The guy WAS our field.

He presaged psychiatry being influenced or taken over by AI. As early as the 1960s, he predicted that computerized diagnoses were the future of psychiatry. And he reimagined the DSM with that in mind. Having strict operational criteria for psychiatric diagnoses would allow for the computerization of such diagnoses.

A word on homosexuality. It is often incorrectly claimed that Spitzer removed homosexuality from DSM-II in the 1970s. At that time, they actually just put homosexuality into parentheses, and the position statement accompanying the change (authored by Spitzer) noted ‘hardly anyone can disagree’ that ‘Modern methods of treatment enable a significant proportion of homosexuals who wish to change their sexual orientation to do so.’ It goes on to say “no doubt, homosexual activists will claim that psychiatry has at last recognized that homosexuality is as “normal” as heterosexuality. They will be wrong.”

I mention this only because this pinkwashing of history ignores that these changes are incremental. It wouldn't but until almost 25 years later in 1987 that homosexuality was removed from DSM-III-R. He was a political animal and the whole DSM-III project was a political one requiring a lot of horsetrading and backroom deals. Spitzer also caught some flack for co-authoring a paper suggesting that gay men could change their sexual orientation. The paper wasn't offensive but it certainly put him in the crosshairs of activists (and it wasn't a very good paper as it just showed that gay men who were religiously tortured could become celibate rather than straight).

But yes, he was a very important figure in American psychiatry.

 

[comp1]

Perhaps I gave him too much credit regarding sexual orientation, but for his time and his age, even considering the 2001 paper, darn impressive.

 

[whopper]

On a related topic over 8 out of 10 times, if I message a a doctor either by call, fax, or snail mail I do not get a response. Sometimes this is highly relevant such as the patient has a BP >180/110, or they want to be on a stimulant despite having a cardiac pathology.

When this happens, in neutral, matter of fact documentation, I write down I attempted to communicate with the other doctor, but "as of this writing," haven't heard anything back yet.

Just a few weeks ago, a physician, after 8 attempts, finally got in contact with me, and it was likely because I gave my patient a copy of the note and told her to give it to the other doctor with documentation showing the other doctor didn't communicate with me despite my attempts. In my defense, it also had a caveat written that I didn't know the doctor's circumstances, and the documentation was there not to criticize the other doctor, but to simply state I was making attempts.

The other doctor pointed out that he didn't like the documentation. I replied that I'm not trying to criticize or harm him, but I need to document this, especially because (at least in my area) I hardly ever get responses, and this did lead to bad outcomes. I asked him, "doesn't the same thing happen to you and don't you find it frustrating?" He agreed, and I told him I would document he did get in contact with me and we were able to resolve the needed issue. After I told him I would update the record it diffused his frustration.

I now make it a habit to document all communication attempts. This problem wasn't anywhere near as bad when I worked in other areas, but in my current area? I've made records requests over 10x and still haven't gotten them-most of the time.

 

[aim-agm]

I mean, passive SI never meets inpatient criteria, so it's not like you need to document your way around that...
Passive SI is also an incredibly broad topic that covers "I had a single thought one time last week for 2 seconds about death that wasn't repugnant for the first second" to "I'm constantly fantasizing about death, how it would go, what it would be like and all the beautiful details. No actual plans of course, I'd never do that *wink*"

Somewhere along that line is the need to actually document something and its treatment. I don't think the first point really does warrant documentation in a therapy patient I see 4 days a week, for example, when they bring it up on Tuesday and we see each other two or three more times that week.

Passive SI is actually a very narrow topic, and would only cover "I have thoughts of killing myself if it would be by inaction." That could meet inpatient criteria if you suspect patient will act on it, although it will rarely qualify for emergent commitment - exceptions would be if certain actions would be urgently necessary to maintain life that you reasonably believe patient will not engage in.

Death not repugnant - Could describe as ambivalence about living if there is reduced desire to live as well. If not, would be thoughts about death with reduced ego dystnocity.

Fascinated by death - morbid preoccupation. Not SI, although with that presentation you would probably characterize as being significant probability of dissumulation of SI

 

[comp1]

Eh...passive SI means you have thoughts of suicide without an intent or plan to complete suicide. I'd argue it's pretty broad and it's also extremely common. It could have been going on for years or it could have just come on after a stressor last night. It could be totally incapacitating. It could be something that flits in and then quickly out of your head. I think it can be a normal human experience. I'd also argue in some cases it could warrant inpatient hospitalization, although arguably less often than active SI would.

 

[aim-agm]

Eh...passive SI means you have thoughts of suicide without an intent or plan to complete suicide.

That is "SI"...or "SI without intent or plan" if you want to be exact.

 

[Stagg737]

That is "SI"...or "SI without intent or plan" if you want to be exact.

Disagree. When I read "SI without intent or plan" I assume it is "active SI", meaning they are having thoughts of wanting to kill or themselves without a specific plan or intent. "Passive SI" can entail anything from wishing they didn't have to exist to wanting to fall asleep and never wake up to wishing something or someone else would kill them. Imo and how I was trained at multiple sites, SI implies that the patients wants to be dead/not exist.

I typically phrase your definition of "death not repugnant" as "apathy towards life" when it's necessary to include that, typically with more severe cases of depression or abulia without true SI.

 

[Celexa]

Disagree. When I read "SI without intent or plan" I assume it is "active SI", meaning they are having thoughts of wanting to kill or themselves without a specific plan or intent. "Passive SI" can entail anything from wishing they didn't have to exist to wanting to fall asleep and never wake up to wishing something or someone else would kill them. Imo and how I was trained at multiple sites, SI implies that the patients wants to be dead/not exist.

I typically phrase your definition of "death not repugnant" as "apathy towards life" when it's necessary to include that, typically with more severe cases of depression or abulia without true SI.

This ambiguity is exactly why I don't use either term. If the pt has SI without intent or plan I say that. If they say sometimes they feel it would be easier to be dead I say that. Plain straightforward language reflecting what they actually told me.

Even worse than passive or active SI is 'safety concerns'. I have to train my residents out of writing 'no safety concerns' for pts that don't have SI or HI and actually write something useful. We are on the CL service. Like OK the demented grandma in bed 9 isn't suicidal or homicidal, but she just tried to run out into traffic bc she thinks it's 1970 and wants to hitchhike to warmer climes, so we're gonna look damn stupid writing 'no safety concerns' if something bad happens.

And don't get me started on the number of times I see the risk of non-suicidal mania drastically under appreciated.... but hey, there were 'no safety concerns!'

 

[Stagg737]

This ambiguity is exactly why I don't use either term. If the pt has SI without intent or plan I say that. If they say sometimes they feel it would be easier to be dead I say that. Plain straightforward language reflecting what they actually told me.

Even worse than passive or active SI is 'safety concerns'. I have to train my residents out of writing 'no safety concerns' for pts that don't have SI or HI and actually write something useful. We are on the CL service. Like OK the demented grandma in bed 9 isn't suicidal or homicidal, but she just tried to run out into traffic bc she thinks it's 1970 and wants to hitchhike to warmer climes, so we're gonna look damn stupid writing 'no safety concerns' if something bad happens.

And don't get me started on the number of times I see the risk of non-suicidal mania drastically under appreciated.... but hey, there were 'no safety concerns!'

I don't put just "passive SI" in the chart, I'll clarify what that means as above. But when talking with residents and staff the term has a specific meaning that I expect others to understand, that being that the patient wants to die/be dead but doesn't want to act to kill themselves. It's just relevant to keep med student and resident presentations concise.

For patients with chronic and well-documented SI that has been severe or with past attempts, sometimes I'll say something like "reports some transient, passive SI since last appointment which is easily managed with coping skills and report it is not distressing." Especially if they're coming out of an episode where they had significant SI or there were legit safety concerns. I'll use "active SI without intent or plan" meaning thoughts of killing themselves without intent or plan, but always clarify those points.

The "no safety concerns" part I get, that looks awful if anything happens. We'll say something like "no psychiatric concerns" if stable or "no psychiatric barriers to discharge" if the issue is social or medical, but I agree the broader the blanket the more you're setting yourself up to look really dumb if something goes wrong. Relevant to the other ER psych job thread, explanation of all of this is why ER documentation can take so long.

 

[clausewitz2]

This ambiguity is exactly why I don't use either term. If the pt has SI without intent or plan I say that. If they say sometimes they feel it would be easier to be dead I say that. Plain straightforward language reflecting what they actually told me.

Even worse than passive or active SI is 'safety concerns'. I have to train my residents out of writing 'no safety concerns' for pts that don't have SI or HI and actually write something useful. We are on the CL service. Like OK the demented grandma in bed 9 isn't suicidal or homicidal, but she just tried to run out into traffic bc she thinks it's 1970 and wants to hitchhike to warmer climes, so we're gonna look damn stupid writing 'no safety concerns' if something bad happens.

And don't get me started on the number of times I see the risk of non-suicidal mania drastically under appreciated.... but hey, there were 'no safety concerns!'

I will use the phrase 'safety concerns' strictly in the context of 'such-and-such family was present and denied any safety concerns' but that's pretty much it.