VA Mental Health Provider Venting / Problem-solving / Peer Support Thread

[WisNeuro]

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I'm curious. For folks in the PP world, do you document risk assessment in each clinical note for every interaction with every client? I feel like I've been in VA long enough now I don't even remember what's normal anymore. E.g., it seems excessive to document risk assessment for a 2min scheduling phone call with a low acute/chronic risk patient, but c'est la vie.

If there is a known history of severe depression, especially with any suicidal or para-suicidal behavior, yes, it is screened and documented. It's documented in my neuropsych evals, but that's a given as you should be screening psychiatric symptoms along with cognitive complaints in every neuro eval. Complete risk assessment is only necessary if they endorse suicidal thoughts.

I do not screen for it in initial phone messages, as I have not yet established a clinical relationship with that patient.

 

[beginner2011]

If there is a known history of severe depression, especially with any suicidal or para-suicidal behavior, yes, it is screened and documented. It's documented in my neuropsych evals, but that's a given as you should be screening psychiatric symptoms along with cognitive complaints in every neuro eval. Complete risk assessment is only necessary if they endorse suicidal thoughts.

I do not screen for it in initial phone messages, as I have not yet established a clinical relationship with that patient.

And for instances with no history of depression or suicidal/parasuicidal behavior? My experience is that it's pretty standard in VA for any and all clinical encounters (momentary phone contacts or otherwise) to include at minimum a boilerplate statement (e.g., "veteran provided no evidence of acute high risk for self-harm or violence") just to document that risk factors were considered by the provider and determined to be negative. Is this typical outside of the VA?

I don't recall it being standard in our departmental clinic during graduate school, although there were a few cases I had where, as you mentioned, there was a history so I documented for each encounter.

 

[WisNeuro]

And for instances with no history of depression or suicidal/parasuicidal behavior? My experience is that it's pretty standard in VA for any and all clinical encounters (momentary phone contacts or otherwise) to include at minimum a boilerplate statement (e.g., "veteran provided no evidence of acute high risk for self-harm or violence") just to document that risk factors were considered by the provider and determined to be negative. Is this typical outside of the VA?

I don't recall it being standard in our departmental clinic during graduate school, although there were a few cases I had where, as you mentioned, there was a history so I documented for each encounter.

If no history, they are still asked about depression and suicidal ideation in clinical interview, but if they say no, there is no reason to assess further.

 

[AbnormalPsych]

My favorite is being told I have to process a clinical reminder to screen for depression in a patient whom I've already diagnosed with major depressive disorder and already given the PHQ-9 to today.

WHUT.

And for instances with no history of depression or suicidal/parasuicidal behavior? My experience is that it's pretty standard in VA for any and all clinical encounters (momentary phone contacts or otherwise) to include at minimum a boilerplate statement (e.g., "veteran provided no evidence of acute high risk for self-harm or violence") just to document that risk factors were considered by the provider and determined to be negative. Is this typical outside of the VA?

I don't recall it being standard in our departmental clinic during graduate school, although there were a few cases I had where, as you mentioned, there was a history so I documented for each encounter.

I do this in all my interactions with patients. I just have a similar one sentence boilerplate template. Copy and paste. Documents that it was considered, for the higher ups that will be reviewing records if there are complaints, negative outcomes, whatever.

 

[Fan_of_Meehl]

WHUT.



I do this in all my interactions with patients. I just have a similar one sentence boilerplate template. Copy and paste. Documents that it was considered, for the higher ups that will be reviewing records if there are complaints, negative outcomes, whatever.

Yup.

 

[beginner2011]

To clarify, what I'm wondering is if folks outside the VA who are seeing a clients with no risk factors for suicide continue to explicitly and routinely document SI/HI in all notes.

For example, @AbnormalPsych:

If you were in private practice, working with someone who had adjustment disorder and had denied SI or any related risk factors at intake, would you continue to include that documentation of risk in every note?

I guess I'm wondering if this boilerplate acknowledgment of risk is a routine part of clinical practice for all folks that I should be glad I gained through VA, or if this is something that is considered an excessive practice due to VA culture.

 

[cara susanna]

Sadly, that one is actually already true...well annually not at every interaction, yet

It's getting close to that IMO.

 

[AbnormalPsych]

To clarify, what I'm wondering is if folks outside the VA who are seeing a clients with no risk factors for suicide continue to explicitly and routinely document SI/HI in all notes.

For example, @AbnormalPsych:

If you were in private practice, working with someone who had adjustment disorder and had denied SI or any related risk factors at intake, would you continue to include that documentation of risk in every note?

I guess I'm wondering if this boilerplate acknowledgment of risk is a routine part of clinical practice for all folks that I should be glad I gained through VA, or if this is something that is considered an excessive practice due to VA culture.

Yes. The way things are going in the field and in my state, I will always do this if I talk to a patient I am responsible for. Period. Although if it is not a topic of conversation or there is legit no risk I don't say denied. I say no evidence of x, y, z, or no report of SI, or yada yada yada. Figure out what sentence works best for you. Never hurts to spend 3 seconds to copy and paste a sentence that could save your butt in a board hearing or something.

Pro tip:
Generate a list of multiple of these sentences for common scenarios and presentations to pick and choose from to paste in. Include sentences about safety plans (e.g. patient agreed to call 911 or go to the ED if....), etc that you routinely cover.

 

[IWillSurvive]

What actually is the consequence if you don't do the three phone calls for a NS?

My facility has a 'workgroup' for no shows but I don't know what they actually do. I was pleased that leadership recently told us that providers are only responsible for making the first call and that the MSA's should do the 2 follow-ups. Mind you, I don't think the 2 follow-up calls ever actually happen, but we are only personally required to do all 3 calls when it's a high risk no show.

 

[Therapist4Chnge]

Yes, exactly. I also read somewhere on this forum that RVUs are a measure of efficiency, not productivity, and using them for the latter purpose is inherently flawed.

I think it's annoying that I essentially get punished for having an efficient, focused session. If I did 60 min of supportive therapy my RVUs would be better, do they really want that though? Not to mention that due to our system, I have trouble discharging patients who aren't actually doing work.

Someone remembers my posts lamenting about RVUs....

 

[Therapist4Chnge]

To clarify, what I'm wondering is if folks outside the VA who are seeing a clients with no risk factors for suicide continue to explicitly and routinely document SI/HI in all notes.

For example, @AbnormalPsych:

If you were in private practice, working with someone who had adjustment disorder and had denied SI or any related risk factors at intake, would you continue to include that documentation of risk in every note?

I guess I'm wondering if this boilerplate acknowledgment of risk is a routine part of clinical practice for all folks that I should be glad I gained through VA, or if this is something that is considered an excessive practice due to VA culture.

I don't mention it past my intake and assessment reports for patients w/o a history or w/o a related psych dx. That said, if SI/HI were at all mentioned, I'll make a point to ask every or nearly every note and document as such.

 

[cara susanna]

Someone remembers my posts lamenting about RVUs....

Thank you for the validation 😉

 

[beginner2011]

Thank you for the validation 😉

Is the distinction between productivity/efficiency -VS- effectiveness? I think of productivity and efficiency as two sides of the same coin, but effectiveness is about outcomes. It seems like effectiveness is really where RVUs fail.

 

[cara susanna]

Is the distinction between productivity/efficiency -VS- effectiveness? I think of productivity and efficiency as two sides of the same coin, but effectiveness is about outcomes. It seems like effectiveness is really where RVUs fail.

Even then, could we really say that RVUs are a measure of productivity? Like is a 60 min session where I'm listening to someone talk about their week really more productive than a 30 min session where you actually teach CBT skills etc?

Edit: Oh, I guess if you think more productivity in terms of generating money, yeah then it is.

 

[Sanman]

Even then, could we really say that RVUs are a measure of productivity? Like is a 60 min session where I'm listening to someone talk about their week really more productive than a 30 min session where you actually teach CBT skills etc?

This gets to a larger issue than just the VA. The healthcare system is being structured on billable work. In healthcare as a whole, there is a poor measure of quality of care. Accountability orgs try to get at quality of care, but it mostly seems like they are just creating quality based paperwork instead. This has been a general criticism of mine for a long time and a reason for the mid-level explosion. There is literally no financial benefit for doing your job better.

 

[R. Matey]

This gets to a larger issue than just the VA. The healthcare system is being structured on billable work. In healthcare as a whole, there is a poor measure of quality of care. Accountability orgs try to get at quality of care, but it mostly seems like they are just creating quality based paperwork instead. This has been a general criticism of mine for a long time and a reason for the mid-level explosion. There is literally no financial benefit for doing your job better.

Almost the opposite really, if patients get better quickly after a few sessions of CT vs. unstructured supportive therapy plus ACT-lite offered by mid-levels, it's seen as a problem

 

[cara susanna]

Me to the Problems tab after taking over 10 min to figure out how to add other specified trauma or stressor-related d/o.

WHY CAN'T YOU SEARCH BY ICD CODE? WHY IS THIS SO HARD?

 

[PsyDr]

Me to the Problems tab after taking over 10 min to figure out how to add other specified trauma or stressor-related d/o.

WHY CAN'T YOU SEARCH BY ICD CODE? WHY IS THIS SO HARD?

if you know how the ICD10 is organized, it gets real simple.

It is an F43 something. Guessing .89.

Because if it were an F10s it would be about substance abuse, F20s it would be about psychosis, if it were about F30s it would be about depression. If it were about F40s it would be some form of anxiety disorder which includes PTSD, if it were F50s it would involve some body system dysfunction, if it were F60.something it would be about sex, if it were F70s it would be about intellectual disability, F80s would be about developmental delay, and F90 is about disorders in childhood.

 

[AcronymAllergy]

if you know how the ICD10 is organized, it gets real simple.

It is an F43 something. Guessing .89.

Because if it were an F10s it would be about substance abuse, F20s it would be about psychosis, if it were about F30s it would be about depression. If it were about F40s it would be some form of anxiety disorder which includes PTSD, if it were F50s it would involve some body system dysfunction, if it were F60.something it would be about sex, if it were F70s it would be about intellectual disability, F80s would be about developmental delay, and F90 is about disorders in childhood.

If only it were this logical. The problem list actually uses ICD-9 instead of 10, but even then, I don't know that you can search by code; I believe it's only searchable by name. And this is of course unique to only the problem list. The encounter information is all ICD-10 and searchable by code.

 

[cara susanna]

Yup, you can't search by code for the problems list.

 

[beginner2011]

I came across some marketing materials for recruiting psychologists. It looks like the estimated annual compensation for a licensed psychologist is about $167,236-$172,865 for FTE GS-13 with 36-49 leave days (~13 sick, 13-26 annual) and holidays (10 federal) per year.

All things considered, that's much better than I expected.

https://www.vacareers.va.gov/Content/Documents/Print/VHAmarketing_TotalRewardsBrochure_external_11.9_508c.pdf

 

[AcronymAllergy]

There are worse jobs and employers out there, and VA's benefits are not horrible. The pension's not bad, you do get a good amount of leave, and the health insurance into retirement is solid if you can stick around that long (there are some stipulations). There's also something to be said for job security and, as they point out, the absence of any non-compete. The only issue I'd have with the above image is the $114k salary number, as I don't know how representative that is of VA psychologists. I suspect it may be skewed upward somewhat by a small number of long-term psychologists in high-COL areas. For a frame of reference, using the "rest of US" pay scales, that'd equate to a GS13 step 8, give or take, which (if my math is correct) takes 12 years of service to achieve without any other bumps.

 

[Sanman]

I came across some marketing materials for recruiting psychologists. It looks like the estimated annual compensation for a licensed psychologist is about $167,236-$172,865 for FTE GS-13 with 36-49 leave days (~13 sick, 13-26 annual) and holidays (10 federal) per year.

All things considered, that's much better than I expected.

https://www.vacareers.va.gov/Content/Documents/Print/VHAmarketing_TotalRewardsBrochure_external_11.9_508c.pdf

View attachment 330469

For those interested in PP, this is what you have to net to be even with a VA salary. Really, you should be netting minus expenses a bit more to make up for the retirement package.

@AcronymAllergy - I make more than this and I am not a step 8. It will depend on locality adjustments.

 

[AcronymAllergy]

For those interested in PP, this is what you have to net to be even with a VA salary. Really, you should be netting minus expenses a bit more to make up for the retirement package.

@AcronymAllergy - I make more than this and I am not a step 8. It will depend on locality adjustments.

Hmm, my post somehow got lost.

But yes, it definitely depends on locality. I just don't know how representative the number provided is of VA psychologists as a whole, which probably depends on the intended purpose of the infographic--if it's to recruit new/early-career psychologists, it may be an overstatement; if it's geared toward folks coming up on mid-career, it could be very representative.

It does provide a good figure to shoot for in PP or negotiations with other employers as far as matching total compensation. Then again, some of the math relative to PP can get a bit tricky (e.g., although you lose FERS, you can back your forced contribution to it; tax breaks and other benefits of PP; etc.).

 

[cara susanna]

Yeah, I'm ECP (my fellowship was about 5 years ago) and I am not making anywhere close to that. Granted, I don't live in an area with a high CoL adjustment.

 

[flerfmcgerf]

I've got a question about folks' experience with their "tours of duty". On internship I worked in outpatient specialty mental health and residential SMI, and granted my internship was pretty lax as far as I could tell, but I almost never had to work outside of my 8-430 schedule for clinical related stuff (dissertation writing was a different story).

On the other hand, in my current PCBH fellowship work, I am getting slammed. It feels like it is all due to documentation - and we aren't even seeing a high volume of people because appointments are taking longer due to only using VVC (late start due to tech difficulties, PHQ-9/GAD/PCL have to be done in session rather than before, etc.). So I'll see someone in 40 mins, then I have to write the note, enter the encounter, write the return to clinic order(s), sometimes write consults, send a message to the clerk about the order I wrote, put in the VVC appointment in virtual care manager, add information about the appointment to an end-of-day disposition email, and sometimes communicate directly with the PCP. My supervisor is more meticulous than any I've ever had before, and extremely detailed oriented, which may be a major contributor to the length of the note-writing time. But I was talking to the social worker who said that even though their days are longer now due to VVC, they have traditionally stayed until 530 - 630 every day on their 800-430 shift. My supervisor seems similar. The PCP's seem to even have it worse.

Is this a PCBH thing? Does anyone successfully keep things within their "tour of duty" in any VA clinic? When I've considered a VA job in the past, having the set schedule always seemed like one of the best perks.

 

[Fan_of_Meehl]

I've got a question about folks' experience with their "tours of duty". On internship I worked in outpatient specialty mental health and residential SMI, and granted my internship was pretty lax as far as I could tell, but I almost never had to work outside of my 8-430 schedule for clinical related stuff (dissertation writing was a different story).

On the other hand, in my current PCBH fellowship work, I am getting slammed. It feels like it is all due to documentation - and we aren't even seeing a high volume of people because appointments are taking longer due to only using VVC (late start due to tech difficulties, PHQ-9/GAD/PCL have to be done in session rather than before, etc.). So I'll see someone in 40 mins, then I have to write the note, enter the encounter, write the return to clinic order(s), sometimes write consults, send a message to the clerk about the order I wrote, put in the VVC appointment in virtual care manager, add information about the appointment to an end-of-day disposition email, and sometimes communicate directly with the PCP. My supervisor is more meticulous than any I've ever had before, and extremely detailed oriented, which may be a major contributor to the length of the note-writing time. But I was talking to the social worker who said that even though their days are longer now due to VVC, they have traditionally stayed until 530 - 630 every day on their 800-430 shift. My supervisor seems similar. The PCP's seem to even have it worse.

Is this a PCBH thing? Does anyone successfully keep things within their "tour of duty" in any VA clinic? When I've considered a VA job in the past, having the set schedule always seemed like one of the best perks.

Hate to say this (but it's the truth)...I rely on no-shows and cancellations to allow time for paperwork these days and get out by the end of my shift. I don't think it's a PCBH thing but more of an outpatient psychotherapy thing (at the VA) these days. And the paperwork/computer-work overload is getting cumulatively worse with every passing year. It's also based on an algorithmic model of patient care that often doesn't match real world parameters (and need for fluid decision-making in context) and that also makes unwarranted assumptions regarding the validity/importance and ultimate probative value of symptom self-report checklists in a system wherein the size of a patient's monthly check is directly related to symptom self-report. The medical metaphor and associated 'protocol-for-syndrome' approach has been oversold and overstretched for decades.

 

[PsychPhDone]

I've got a question about folks' experience with their "tours of duty". On internship I worked in outpatient specialty mental health and residential SMI, and granted my internship was pretty lax as far as I could tell, but I almost never had to work outside of my 8-430 schedule for clinical related stuff (dissertation writing was a different story).

On the other hand, in my current PCBH fellowship work, I am getting slammed. It feels like it is all due to documentation - and we aren't even seeing a high volume of people because appointments are taking longer due to only using VVC (late start due to tech difficulties, PHQ-9/GAD/PCL have to be done in session rather than before, etc.). So I'll see someone in 40 mins, then I have to write the note, enter the encounter, write the return to clinic order(s), sometimes write consults, send a message to the clerk about the order I wrote, put in the VVC appointment in virtual care manager, add information about the appointment to an end-of-day disposition email, and sometimes communicate directly with the PCP. My supervisor is more meticulous than any I've ever had before, and extremely detailed oriented, which may be a major contributor to the length of the note-writing time. But I was talking to the social worker who said that even though their days are longer now due to VVC, they have traditionally stayed until 530 - 630 every day on their 800-430 shift. My supervisor seems similar. The PCP's seem to even have it worse.

Is this a PCBH thing? Does anyone successfully keep things within their "tour of duty" in any VA clinic? When I've considered a VA job in the past, having the set schedule always seemed like one of the best perks.

I think it depends heavily on local culture and leadership (service/area/section).

 

[AcronymAllergy]

I think it depends heavily on local culture and leadership (service/area/section).

I would agree with this. There can also often be individual provider characteristics involved (e.g., some providers I work with regularly stay late finishing notes, but most everyone else leaves on/near their regular end time, which I suspect relates to the types of notes written, the efficiency in writing those notes, and the length of sessions held), although here it sounds like it's affecting multiple folks in PC. Understaffing can be another common contributing factor.

Our primary care providers used to regularly need to stay late, but I think that's calmed down since they've actually hired the number of docs they're supposed to have.

 

[erg923]

My, my how things can change. Everyone was lined up at the door at 4:28 when i worked there.

1. Ft. Knox will be there tomorrow. I don't understand why there is a need to get every single thing done that day. I would ask you supervisor genuinely if this is just his/her work preference, or if they think there is some ethical need to work an hour/day for free?

2. Notes should be short, short, short. Communications with PCP should be short. They dont want to know all that much detail, I assure you

3. I think sessions in primary care in the VA are suppose to be 30 minutes, max?

add information about the appointment to an end-of-day disposition email

What the hell is this? That's what your notes in the medical record are for.

write the return to clinic order(s), sometimes write consults, send a message to the clerk about the order I wrote

RTC notes used to be a few clicks and some drop downs. And why do you have to send a message to the clerk RTCs? Dont they get alerts on CPRS?

 

[cara susanna]

I keep appts to 45 min max so I have 15 min for admin work. Helps a lot, although I'm also really just fast with notes and documentation in general (and I'm not gonna pretend like my documentation is the absolute best that it could be, either). But a few of my coworkers, especially the ones who do intakes, have to come in on their days off or stay late to catch up.

In terms of PCMHI, there are tricks of the trade to help. Starting the note while they're filling out MBC, having templates or specific language that you can copy and paste, keeping appts to 20-30 min (ideally 20 or 25), etc. That last one is crucial: if you are consistently seeing people for 40 min, you're not gonna have enough time.

 

[cara susanna]

My, my how things can change. Everyone was lined up at the door at 4:28 when i worked there.

1. Ft. Knox will be there tomorrow. I don't understand why there is a need to get every single thing done that day. I would ask you supervisor genuinely if this is just his/her work preference, or if they think there is some ethical need to work an hour/day for free?

2. Notes should be short, short, short. Communications with PCP should be short. They dont want to know all that much detail, I assure you

3. I think sessions in primary care in the VA are suppose to be 30 minutes, max?



What the hell is this? That's what your notes in the medical record are for.



RTC notes used to be a few clicks and some drop downs. And why do you have to send a message to the clerk RTCs? Dont they get alerts on CPRS?

I think that the issue is, within PCMHI, you often have open access so the appt is scheduled essentially on the fly. I used to just start a note within the PCP's clinic encounter and then copy and paste it into a new note within my clinic encounter once my appt had been created.

 

[Sanman]

Agreed with the others that it depends on individual writing style, efficiency, etc as well as local culture. At my VA, plenty of people walking out the door between 4 and 4:30 with a few staying late. The one person that routinely stays late has the most detailed and best documentation of anyone I know. Plenty with briefer notes packing up at 4:05. No one has given those people a hard time. This can be person and dept specific if you have a nitpicky boss that wants lots of redundancy.

 

[AcronymAllergy]

My, my how things can change. Everyone was lined up at the door at 4:28 when i worked there.

1. Ft. Knox will be there tomorrow. I don't understand why there is a need to get every single thing done that day. I would ask you supervisor genuinely if this is just his/her work preference, or if they think there is some ethical need to work an hour/day for free?

2. Notes should be short, short, short. Communications with PCP should be short. They dont want to know all that much detail, I assure you

3. I think sessions in primary care in the VA are suppose to be 30 minutes, max?



What the hell is this? That's what your notes in the medical record are for.



RTC notes used to be a few clicks and some drop downs. And why do you have to send a message to the clerk RTCs? Dont they get alerts on CPRS?

They're still mostly a few clicks, but in the era of COVID, at least at our VA, a LOT of scheduling orders have gotten lost in the shuffle. I suspect the follow-up message to the clerk is to increase the likelihood that the orders get processed.

I agree about the end-of-day log. That definitely seems inefficient/unnecessary.

 

[summerbabe]

Is this a PCBH thing? Does anyone successfully keep things within their "tour of duty" in any VA clinic? When I've considered a VA job in the past, having the set schedule always seemed like one of the best perks.

I agree that this seems more a product of your supervisor/clinic or local work culture.

Redundant CPRS and Virtual Care Manager orders, senseless clinical reminders, MAS staff not doing their jobs and other VA quirks will likely continue if you're interested in a VA career. But I'm guessing your documentation/consultation process from internship was generally fine and once you're licensed (or operating under another supervisor as a graduate psychologist), you will regain your flexibility to document and do your job differently. Hold onto any positives that you've learned from this supervisor/experience and be confident that you can provide the same quality with more efficiency and better work/life balance.

 

[flerfmcgerf]

And the paperwork/computer-work overload is getting cumulatively worse with every passing year.

This is getting at what I was worried about. I couldn't tell if I had just been very sheltered as an intern (i.e. I didn't have "permissions" to do consults) or if things had randomly gotten a lot more complicated.

the size of a patient's monthly check is directly related to symptom self-report.

On internship, I had to do a brief literature review paper. This was the topic. So much of the evidence for/against PTSD treatments in the VA is involving this population with these motivations...

I don't understand why there is a need to get every single thing done that day.

I think the supervisor is afraid that if it doesn't get done today, that it will just be more overwhelming tomorrow.

Notes should be short, short, short.

Ok, this is how things used to be in the other clinics, unless it was an intake. And to me, it felt fine. My notes in PCBH are longer than my notes in specialty mental health. My current supervisor seems to have this intense fear of the - and excuse me for forgetting the right acronym - people who inspect notes. There was a rumor going around that they are going to start monitoring how much of the note is copied and pasted. There's actually a setting somewhere in CPRS where you can turn on a visualization of how much of the note is "fresh" as opposed to copied.

I think sessions in primary care in the VA are suppose to be 30 minutes, max?

So I do need to be quicker. although they haven't been as strict during COVID. It is weird transitioning from specialty mental health into PCBH during the pandemic and maybe I'm just not getting the model down very well. Reading out those measures to folks who cannot, for the life of them, just give you a number or "more than half the days" does take a good 5-7 mins.

once you're licensed (or operating under another supervisor as a graduate psychologist), you will regain your flexibility to document and do your job differently.

Ok, that makes sense. I was more worried when I heard about the other provider also staying later, but I honestly think I could probably run things through without so much documentation. I did however learn that my default note writing is not detail oriented enough, so that's one thing I'll take with me.

There seems to be an intense amount of redundancy in the process here. There's also an intense fear of open encounters, which is why we have all the messages to the clerk.

Lastly, I do think this clinic is understaffed. I don't think a lot of providers find this area very desirable - so that might be why the PCPs are so intensely overloaded and regularly staying past 6.

 

[AcronymAllergy]

Ok, this is how things used to be in the other clinics, unless it was an intake. And to me, it felt fine. My notes in PCBH are longer than my notes in specialty mental health. My current supervisor seems to have this intense fear of the - and excuse me for forgetting the right acronym - people who inspect notes. There was a rumor going around that they are going to start monitoring how much of the note is copied and pasted. There's actually a setting somewhere in CPRS where you can turn on a visualization of how much of the note is "fresh" as opposed to copied.

I've begun seeing this in my system. It shows you which parts are copied/pasted, and there's a separate window that tells you where the information was copied from (e.g., MS Word, another chart, etc.). No clue if it's formally being monitored, for what, or by whom.

There are certain parts of notes that are required, but I wonder if your supervisor's list of required information is accurate. A good bit of it can also be templated so that minimal work on your part results in customizing the information to each individual patient. And you can also look into dictation software; even if you're a fast typist, it can save you time.

 

[Fan_of_Meehl]

I've begun seeing this in my system. It shows you which parts are copied/pasted, and there's a separate window that tells you where the information was copied from (e.g., MS Word, another chart, etc.). No clue if it's formally being monitored, for what, or by whom.

There are certain parts of notes that are required, but I wonder if your supervisor's list of required information is accurate. A good bit of it can also be templated so that minimal work on your part results in customizing the information to each individual patient. And you can also look into dictation software; even if you're a fast typist, it can save you time.

Being monitored by a crack team of Commodores of the Copypasta (GS-13)...most likely. Compliance reports and nasty-grams to follow shortly, cc'ed to your service chief, of course.

 

[erg923]

This is getting at what I was worried about. I couldn't tell if I had just been very sheltered as an intern (i.e. I didn't have "permissions" to do consults) or if things had randomly gotten a lot more complicated.


On internship, I had to do a brief literature review paper. This was the topic. So much of the evidence for/against PTSD treatments in the VA is involving this population with these motivations...


I think the supervisor is afraid that if it doesn't get done today, that it will just be more overwhelming tomorrow.


Ok, this is how things used to be in the other clinics, unless it was an intake. And to me, it felt fine. My notes in PCBH are longer than my notes in specialty mental health. My current supervisor seems to have this intense fear of the - and excuse me for forgetting the right acronym - people who inspect notes. There was a rumor going around that they are going to start monitoring how much of the note is copied and pasted. There's actually a setting somewhere in CPRS where you can turn on a visualization of how much of the note is "fresh" as opposed to copied.


So I do need to be quicker. although they haven't been as strict during COVID. It is weird transitioning from specialty mental health into PCBH during the pandemic and maybe I'm just not getting the model down very well. Reading out those measures to folks who cannot, for the life of them, just give you a number or "more than half the days" does take a good 5-7 mins.


Ok, that makes sense. I was more worried when I heard about the other provider also staying later, but I honestly think I could probably run things through without so much documentation. I did however learn that my default note writing is not detail oriented enough, so that's one thing I'll take with me.

There seems to be an intense amount of redundancy in the process here. There's also an intense fear of open encounters, which is why we have all the messages to the clerk.

Lastly, I do think this clinic is understaffed. I don't think a lot of providers find this area very desirable - so that might be why the PCPs are so intensely overloaded and regularly staying past 6.

I didn't know there was such a thing, I worked in the VA for 5 years and no one ever randomly "inspected" my notes. Basing ones practice patterns in a fear model (of some note boogey man?) is not sustainable and should not be how a supervisor mentors a fellow. And it does not make for an appealing or rewarding work environment.

What you are essentially saying is that your supervisor is anal and inefficient. You are in primary care. You should document like primary care. This is not creative writing. Speaking their language and operating more like them than a "traditional psychologist" is what makes for a good (and efficient) primary care clinician.... and this is suppose to be what a PCBH fellowship is training you to do/be.

 

[cara susanna]

They can take away my C&Ped note templates from my cold, dead hands.

 

[WisNeuro]

I didn't know there was such a thing, I worked in the VA for 5 years and no one ever randomly "inspected" my notes. Basing ones practice patterns in a fear model (of some note boogey man?) is not sustainable and should not be how a supervisor mentors a fellow. And it does not make for an appealing or rewarding work environment.

What you are essentially saying is that your supervisor is anal and inefficient. You are in primary care. You should document like primary care. This is not creative writing. Speaking their language and operating more like them than a "traditional psychologist" is what makes for a good (and efficient) primary care clinician.... and this is suppose to be what a PCBH fellowship is training you to do/be.

Did you ever have an annual peer review? This is supposed to happen in some capacity on a yearly basis. And, if done the right way, is actually beneficial.

 

[WisNeuro]

They can take away my C&Ped note templates from my cold, dead hands.

Yeah, I mean neuropsych reports are heavily templated. Also, I never wrote in CPRS, so technically everything I did was copy and pasted from word.

 

[erg923]

Did you ever have an annual peer review? This is supposed to happen in some capacity on a yearly basis. And, if done the right way, is actually beneficial.

No, never

 

[AcronymAllergy]

No, never

Were you (psychologists) members of the medical staff? If not, that might be why, although even our non-medical staff members (e.g., chaplains, social workers) have peer review of notes that're due in monthly or quarterly and are part of each provider's annual review. Heck, even our interns are required to do it.

 

[WisNeuro]

Were you (psychologists) members of the medical staff? If not, that might be why, although even our non-medical staff members (e.g., chaplains, social workers) have peer review of notes that're due in monthly or quarterly and are part of each provider's annual review. Heck, even our interns are required to do it.

After doing peer review, I am a firm believer that it should be part of every clinical job.

 

[erg923]

Were you (psychologists) members of the medical staff? If not, that might be why, although even our non-medical staff members (e.g., chaplains, social workers) have peer review of notes that're due in monthly or quarterly and are part of each provider's annual review. Heck, even our interns are required to do it.

I wasn’t under the mental health service line, if that’s what you’re asking. I never did any peer review of notes when i was there. And I dont think anyone ever peer reviewed me either. I'm sure someone looked at my notes when prepping the performance eval and productivity report. But I never got any direct feedback from any kind of audit or anything.

 

[cara susanna]

We do peer review but it doesn't involve reviewing notes (although it did at the previous facility I was at). People present a case at a meeting and we all rate them.

 

[Fan_of_Meehl]

We do peer review but it doesn't involve reviewing notes (although it did at the previous facility I was at). People present a case at a meeting and we all rate them.

Wow. This sounds actually meaningful. At our facility it has always been a cross-sectional review of a handful of progress notes reviewed by two peers.

 

[AcronymAllergy]

We do peer review but it doesn't involve reviewing notes (although it did at the previous facility I was at). People present a case at a meeting and we all rate them.

Yeah, I've heard of that version of peer review as well.

Reviewing notes/having notes reviewed is less work, but a case presentation could be a great way to actually actively demonstrate competence.

 

[thebalmofhurtminds]

I didn't know there was such a thing, I worked in the VA for 5 years and no one ever randomly "inspected" my notes. Basing ones practice patterns in a fear model (of some note boogey man?) is not sustainable and should not be how a supervisor mentors a fellow. And it does not make for an appealing or rewarding work environment.

What you are essentially saying is that your supervisor is anal and inefficient. You are in primary care. You should document like primary care. This is not creative writing. Speaking their language and operating more like them than a "traditional psychologist" is what makes for a good (and efficient) primary care clinician.... and this is suppose to be what a PCBH fellowship is training you to do/be.

This was one of the (many) main reasons I left. The level of attention paid to specific aspects of the notes, the overburden of additional notes/templates/art projects mandatory for each - sometimes 20 minute! - patient destroyed any appeal for the actual work environment. Each patient was just a tedious check list of bureaucratic nonsense.