Need help regarding documentation

[PsyMD]

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I am new psych intern. I am struggling with the documentation. Heavily confused as what to include in documentation. Is there any resources or book to help with that.

Also need a good suggestion about book for emergency psychiatry. Can’t figure out whom to admit and whom to discharge. Would help if someone could suggest me a good material to read about psychiatry disposition??

 

[splik]

For a primer on emergency psychiatry the clinical manual of emergency psychiatry by Riba and Ravindranath is what I recommend to trainees for our emergency psychiatry curriculum. The key textbook in the field is behavioral emergencies for the emergency physician by Leslie Zun.

Frankly, what you are asking for is not going to be found in a book (though I dont want to discourage reading!) You will need to talk with senior residents and your attending supervisors because it is very institution dependent what kind of documentation is expected and admit v dispo (which has more to do with what resources are available and your attending supervisor, than the clinical status of the patient). You will find that some attendings are risk averse and will admit everyone, while others will be comfortable discharging patients feigning SI. In addition the available of non-hospital crisis alternatives, PHP, IOP, the number of available inpatient beds etc which varies from geographical location and even hospital significantly influences decisions regarding admissions and discharge. You will quickly learn what is expected.

The Unfortunately titled "How to write a suicide note" is a popular blog post on documenting suicide risk assessment, particularly with regards to discharging patients who are claiming suicidal ideation. I also like "The therapeutic discharge" articles which goes through documentation for patients who are deceptive (e.g. malingering). This article is also popular with residents. Reading notes from your co-residents will give you a sense of what is expected in terms of format.

 

[NickNaylor]

Documentation serves three main goals:

1) Justify billing - as a resident I doubt you will need to worry yourself with this, but obviously it's something you'll worry about in the future
2) Describing services rendered
3) Outlining the clinical rationale for #2

Some might argue that documentation also serves as a medicolegal safeguard for you as a physician, but I would argue that if you successfully do the above things well the medicolegal issue will be less of an overt concern.

Assuming you work in a large healthcare system, #1 is likely going to most prominently shape what is included in your documentation and the templates you have for notes. There is likely to be no flexibility in this regard... the guidelines for what must be included for billing are fairly rigid and are either met or not. At least at my institution, all of the templates used in our service lines are reviewed by our billing staff to ensure that documentation won't be what limits billing.

Beyond that, you should provide enough documentation so that anyone who reads your note but has not seen the patient understands 1) what you think is going on with the patient, 2) what you did in terms of your management, and 3) why you did what you did. Other concepts like risk assessment are invariably rolled up in #3. For any one patient, think about your options and, in your documentation, explain why you chose the option that you did. If you're discharging a patient, why did you not pursue a more intensive level of care? If you're admitting a patient, why? If you're providing outpatient referrals, what are you hoping to achieve here? If you're starting a patient on lithium, why? If you're starting a patient on a particular antidepressant, why? Why escitalopram instead of sertraline? Why are you starting divalproex instead of lithium or an antipsychotic for manic patients? These explanations can be extremely brief but, nevertheless, I think are important to include for those that come after you and read your notes, wondering why the patient is on the medications he/she is on.

I agree with what @splik said in terms of there being no concise resource that you can simply read and understand how to document and why disposition decisions are made. You will become more familiar with these things as you progress through your training. As a mid-year PGY-1, my hope has a supervising attending would be that you can accurately document the information that you obtain in the interview (and complete your interview accordingly), you can come up with a reasonable assessment with a differential diagnosis, and you can come up with an initial plan for management and explain to me why you did what you did. Your assessment and plan may not be perfect, but my hope would be that you at least have a rational train of thought for your proposed plan. The information you obtain in the interview should support your working and differential diagnosis, and your plan should make sense based on what you think is going on. If you think someone is acutely psychotic and likely has an underlying psychotic disorder, I hope to see in your plan that you are starting an antipsychotic, not an antidepressant or a mood stabilizer, for example.

 

[Stagg737]

Can’t figure out whom to admit and whom to discharge.

I like the old adage "If they want to be admitted, they probably don't need it. If they don't want admission, they probably need it."

On a more serious note, keep it basic. When it comes down to it, there's only a few reasons to admit 95% of patients.

1) They're a direct risk to themselves d/t a (treatable) mental illness
2) They're a direct risk to others d/t a (treatable) mental illness
3) They're an indirect risk to themselves because they lack the ability to keep themselves alive d/t a (treatable) mental illness

The first two are pretty self-explanatory. Are they altered enough to be a threat and you can do something about it? Admit them. Are the a threat simply because they're antisocial? Don't admit them (but make sure you're documenting why they can't be treated). The tricky parts are knowing the local laws or facility policies that can effect this. Whisper the word suicide at my VA and you're getting admitted (oftentimes even when you're not suicidal). Substance detox will muddy the waters (though it shouldn't), so ask your attendings about this.

The third one is when things can get tricky. How do you gauge whether they can adequately care for themselves and if it is d/t treatable mental illness? Get collateral if possible. Hasn't bathed in 3 weeks and is only eating/drinking olive oil (actual patient)? Admit them. Only bathing once a week, but still able to feed themselves and not has housing, probably not going to admit unless one of the first two is true. Are they so disorganized you can't even get an appropriate answer out of them and can't get collateral? Admit them.

It's also important to get good at assessing capacity for those patients who would benefit from admission but refuse. If the olive oil guy can hold a completely appropriate conversation, explain why he is doing what he is doing, and can tell you the risks of doing this, it's going to be a lot harder to involuntarily admit them than the guy who can't even string a coherent sentence together.

The other 5% of patients are either administrative/social admits or the very rare "wtf is going on?" patient when they're fine with admission. These include patients going to a substance or other specialized program in 3-4 days who you want to keep safe until then/detox, patients who have MH problems and don't feel safe at home (sometimes d/t their own mood, sometimes d/t someone else threatening them) until you can get them somewhere safe, or "the rocks" aka patients with significant MH waiting placement. In terms of the last one, these patients often tie your hands because you just can't safely d/c them but the resources they need aren't readily available, I see these more at the VA than anywhere else.

There's always caveats and exceptions to the above, but if you stick to the 3 rules above, you'll do fine with most patients. These can also vary depending on what other resources your area has available for patients (having good IOP/PHP programs around is helpful for keeping chronic self-harm patients out of the inpatient unit).