Non-Clinical Documentation

[AbnormalPsych]

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Throughout my training and early career I have overheard conversations and have had on occasion had peers and supervisors tell me to document various things. These things are not usually directly related to cases or to clinical care and thus would not be appropriate in a medical record or psychotherapy notes. More professional related things (e.g., critical verbal feedback, being asked by a superior to complete a task in a manner inconsistent with norms or policy, basically things where you want to cover your a**).

How have others gone about documenting non-clinical things? I have heard of people sending an email to themselves, as that includes a time stamp.

 

[Therapist4Chnge]

Email can be a great paper trail. If there is a meeting or conversation you want to capture, it’s helpful to send an email as a summary of the meeting/conversation...particularly if there are deliverables or decisions that you find concerning. You can also state your concerns and/or clarify what is being asked.

This is a good approach in general, not just for things that concern you. I prefer for someone to summarize a meeting and list takeaways and next steps, as it helps keep projects on track and clarified duties/roles/etc.

 

[smalltownpsych]

Email can be a great paper trail. If there is a meeting or conversation you want to capture, it’s helpful to send an email as a summary of the meeting/conversation...particularly if there are deliverables or decisions that you find concerning. You can also state your concerns and/or clarify what is being asked.

This is a good approach in general, not just for things that concern you. I prefer for someone to summarize a meeting and list takeaways and next steps, as it helps keep projects on track and clarified duties/roles/etc.

I have done this for some things, but also need to keep in mind potential for hipaa violations if email system is not secure so make sure to leave out any“individually identifiable health information”.
Along the lines of this, I have seen colleagues use patient initials in potentially less secure communications such as text messages or email. I wonder if that is really appropriate or legal.