Weird chart notes

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
WisNeuro

WisNeuro

Board Certified in Clinical Neuropsychology
Verified Member
Psychologist
Verified Expert
15+ Year Member
Bronze Donor
Joined
Feb 15, 2009
Messages
19,133
Reaction score
26,557
Members don't see this ad.
Every now and then I run across some weird phrasing or just unnecessary charting. For example, in the chart I am currently reviewing, it ends with

"Appropriate pleasantries exchanged."

If you don't document this, am I to assume you exchanged inappropriate pleasantries? Anyone else have some good ones?

*please remember not to include any PHI*
 
Oh... I have a multipage document saved just for this. These are real. I promise. My favorites from the mental status section of an assessment.

1. This is a pleasant male who appears documented age. He has a walking stick and a brown briefcase, which is an older style briefcase from perhaps the
60’s and 70’s that is faux leather. The leather is torn and you can see sponge peaking out from the areas that are torn.

2. This is a short, balding dark skinned male who has dark hair with flecks of white strands. He is wearing shorts and his zipper is open. He later on recognizes it and corrects that.

3. This recently separated male is recently separated from his wife and is in the process of getting a divorce.

4. His eyes well up during the initial part of the evaluation. Then tears start flowing and stain his blue shirt.

I could go on and on... saving bad writing is somewhat of a professional hobby.
 
WisNeuro said:
Every now and then I run across some weird phrasing or just unnecessary charting. For example, in the chart I am currently reviewing, it ends with

"Appropriate pleasantries exchanged."

If you don't document this, am I to assume you exchanged inappropriate pleasantries? Anyone else have some good ones?

*please remember not to include any PHI*
Click to expand...
I once reviewed a patient's prior report where, in the medical history section, it said: "it is unclear if he is allergic to bees."

There were no other allergies and no previous or subsequent references to bees.... just came totally out of left field. I still wonder what else he may or may not be allergic to.

Sent from my SCH-I545 using SDN mobile
 
Justanothergrad said:
Oh... I have a multipage document saved just for this. These are real. I promise. My favorites from the mental status section of an assessment.

1. This is a pleasant male who appears documented age. He has a walking stick and a brown briefcase, which is an older style briefcase from perhaps the
60’s and 70’s that is faux leather. The leather is torn and you can see sponge peaking out from the areas that are torn.

2. This is a short, balding dark skinned male who has dark hair with flecks of white strands. He is wearing shorts and his zipper is open. He later on recognizes it and corrects that.

3. This recently separated male is recently separated from his wife and is in the process of getting a divorce.

4. His eyes well up during the initial part of the evaluation. Then tears start flowing and stain his blue shirt.

I could go on and on... saving bad writing is somewhat of a professional hobby.
Click to expand...

It's like bad middle school prose

LETSGONYR said:
I once reviewed a patient's prior report where, in the medical history section, it said: "it is unclear if he is allergic to bees."

There were no other allergies and no previous or subsequent references to bees.... just came totally out of left field. I still wonder what else he may or may not be allergic to.

Sent from my SCH-I545 using SDN mobile
Click to expand...

upload_2016-6-2_14-15-11.jpeg
 
"Client does not appear to enjoy trout."

Still makes me chuckle.
 
Not exactly, but similar:

I just reviewed a psych testing report, the sole rationale for which was to stated as "what underlying reasons have caused the patient to drink excessively." Interesting already, right?

The 2nd recommendation to come from this length evaluation was that the patient should engage in a course of psychotherapy to gain better insight into why he feels the need to use alcohol and cannabis to deal with life problems.

Time and resources well spent, Doc.

Hashbrown#PHDFAIL
 
Last edited:
It's always a bit cringe-worthy when providers basically call each other out and talk to one another via medical records.

Things akin to (approximately): "Patient asked for a letter supporting their illness. I told the patient that the chief of XXX (added as co-signer to note) told us not to write any letters for patients, and that Dr. XXX (misspelled) would handle them instead. I will talk with my supervisor (added as co-signer to note) to see if it's ok to write a note for the patient."
 
AcronymAllergy said:
It's always a bit cringe-worthy when providers basically call each other out and talk to one another via medical records.

Things akin to (approximately): "Patient asked for a letter supporting their illness. I told the patient that the chief of XXX (added as co-signer to note) told us not to write any letters for patients, and that Dr. XXX (misspelled) would handle them instead. I will talk with my supervisor (added as co-signer to note) to see if it's ok to write a note for the patient."
Click to expand...

Using CPRS as an IM service (essentially) is a terrible problem in primary care at our VA.
 
AcronymAllergy said:
It's always a bit cringe-worthy when providers basically call each other out and talk to one another via medical records.
Click to expand...

I admittedly do this on a regular basis. Started when an attending wrote np testing order 2hrs prior to discharge, and I had to talk at the med exec meeting about why I was missing consults.
 
AcronymAllergy said:
It's always a bit cringe-worthy when providers basically call each other out and talk to one another via medical records.
Click to expand...

I had a provider call out (totally unrelated to my final summary) a point in my chart of a premorbid intellectual functioning estimate of average functioning. Her contention was that the patient had to have been at least high average to superior given that she completed an MBA through Phoenix, online. But did it in a 2 paragraph rant. This was in a mTBI patient who failed 4/5 of my PVT's and had an invalid MMPI-RF.
 
WisNeuro said:
I had a provider call out (totally unrelated to my final summary) a point in my chart of a premorbid intellectual functioning estimate of average functioning. Her contention was that the patient had to have been at least high average to superior given that she completed an MBA through Phoenix, online. But did it in a 2 paragraph rant. This was in a mTBI patient who failed 4/5 of my PVT's and had an invalid MMPI-RF.
Click to expand...

"As I am sure Dr. X is professionally, legally, and ethically bound to not deviate from the community standard of care by resorting to pure speculation, I would welcome the opportunity to discuss the technique he/she used to estimate premorbid abilities. "
 
This isn't a chart note, but I want to share it anyway, and us academics need an in on this thread.

Email from someone I don't know:
Hi,
I am writing because I am going to be taking a custody evaluation--a Parent Test. Can you let me know what that would consist of?
Click to expand...

Actual reply:

Sorry, I don't know anything about that. My last name is not related to my area of study.
Click to expand...
 
PSYDR said:
I admittedly do this on a regular basis. Started when an attending wrote np testing order 2hrs prior to discharge, and I had to talk at the med exec meeting about why I was missing consults.
Click to expand...

In that case, and when it comes to things like responding to consults, I could understand it. Heck, we have a template for the sole purpose of showing that we've reviewed a chart and accepted or rejected said consult. And I can certainly also appreciate it when folks use it to send along treatment-related requests and concerns (e.g., "patient's B12 and potassium are low, please have them follow-up with primary care for supplement"). We just had one MH provider in particular who would use the chart to say...less than appropriate things.

And RE: typos, some of the ones that show up from Dragon are pretty hilarious.
 
Justanothergrad said:
Oh... I have a multipage document saved just for this. These are real. I promise. My favorites from the mental status section of an assessment.

1. This is a pleasant male who appears documented age. He has a walking stick and a brown briefcase, which is an older style briefcase from perhaps the
60’s and 70’s that is faux leather. The leather is torn and you can see sponge peaking out from the areas that are torn.

2. This is a short, balding dark skinned male who has dark hair with flecks of white strands. He is wearing shorts and his zipper is open. He later on recognizes it and corrects that.

3. This recently separated male is recently separated from his wife and is in the process of getting a divorce.

4. His eyes well up during the initial part of the evaluation. Then tears start flowing and stain his blue shirt.

I could go on and on... saving bad writing is somewhat of a professional hobby.
Click to expand...
I have often wondered at some of the degree of descriptiveness about things like appearance. I usually will just say appropriately dressed which means I didn't really notice anything that was relevant.
"Adolescent wearing slightly faded black jeans with rips around the knees, high top basketball shoes with loose laces, and band T-shirt for the Black Veil Brides." I mean really, who cares? Is it really just a holdover from when psychology over-interpreted everything? When I would review testing to see if kids were appropriate for my program, I could care less about those irrelevant and non-predictive observations. Some assessor a would write up 20 page reports that I had to wade through to find useful information. Something like actual assessment results and actual significant events that occurred. Now that actually means something.
 
smalltownpsych said:
I have often wondered at some of the degree of descriptiveness about things like appearance. I usually will just say appropriately dressed which means I didn't really notice anything that was relevant.
"Adolescent wearing slightly faded black jeans with rips around the knees, high top basketball shoes with loose laces, and band T-shirt for the Black Veil Brides." I mean really, who cares? Is it really just a holdover from when psychology over-interpreted everything? When I would review testing to see if kids were appropriate for my program, I could care less about those irrelevant and non-predictive observations. Some assessor a would write up 20 page reports that I had to wade through to find useful information. Something like actual assessment results and actual significant events that occurred. Now that actually means something.
Click to expand...
I've always been skeptical of it as well. It's a long standing tradition without any evidence of usefulness. It could make for an interesting study to see how it impacts interpretation of results as clinicians view a report. I'm always curious about how we use language in reports though. I mean, we don't receive training (because there is a lack of consensus on what objectively defines a lot of the terms we use regularly (e.g., probabilistic language), even when writing up reports on objective and actuarial measures.

Some more gems:
1. As mentioned earlier, after rubbing his nose with the back of his hand he states, “She even said that Ihad picked my nose. I have nasal congestion. Maybe
this is the reason why.” However, having said that, he goes on and removes the particle that was attached and matted to his left nare and throws it to the
side during the interview.

2. This is a female with tan skin and wearing make-up, and wearing her exercise tights and running shoes (which is florescent pink with other
florescent colors mixed into it).

3. She’s wearing hiking boots, cargo pants and top which is gender-inconsistent.

4. He has a prominent nose.
 
smalltownpsych said:
I have often wondered at some of the degree of descriptiveness about things like appearance. I usually will just say appropriately dressed which means I didn't really notice anything that was relevant.
Click to expand...

In the medicolegal context there is some utility in this. For example: Litigants will come in with a day or twos stubble. Especially in small lawsuits or workers comp. it's super useful to say something like, "grooming was adequate. While X had a days stubble, he has obviously shown care in maintaining the shape of his goatee/mustache/beard despite this minimal lapse."
 
I'm as long-winded as they come in terms of writing, but my take RE: behavioral observations (or just about anything else in the report) is that if it doesn't relate to the referral question, contribute to your conceptualization of the case, and/or pertain to results from testing, don't include it.
 
AcronymAllergy said:
I'm as long-winded as they come in terms of writing, but my take RE: behavioral observations (or just about anything else in the report) is that if it doesn't relate to the referral question, contribute to your conceptualization of the case, and/or pertain to results from testing, don't include it.
Click to expand...

Exactly, that's where my Socratic questioning comes in with trainees. If they can't defend the inclusion of something, it must go. I have a 3-4 page report reputation to keep up.
 
Agreed with all of the above. It is all about utility. If there is a reason to comment, then you say it, and if you say it, then provide evidence to substantiate it. On a side note, I was actually glancing through some records to see if I could find some good bad examples of this and at first glance it actually appears as though the psychologists here at this hospital have done a pretty good job of reporting succinct and relevant information.
 
WisNeuro said:
Exactly, that's where my Socratic questioning comes in with trainees. If they can't defend the inclusion of something, it must go. I have a 3-4 page report reputation to keep up.
Click to expand...

Damn, Tolstoy. This is neuropsych, not the phone book.
 
PSYDR said:
In the medicolegal context there is some utility in this. For example: Litigants will come in with a day or twos stubble. Especially in small lawsuits or workers comp. it's super useful to say something like, "grooming was adequate. While X had a days stubble, he has obviously shown care in maintaining the shape of his goatee/mustache/beard despite this minimal lapse."
Click to expand...
I take it you aren't in the demographic that accepts all forms of manscaping, including purposefully maintained stubble.

http://www.menshealth.com/grooming/shaving-stubble

Lapse? The litigant shows premeditated style!
 
I'm at about 4 or 5 pages for an assessment report including tables. I am becoming exceptionally brief with my intake reports and progress notes as I am seeing more and more that everyone gets access to whatever we put in the chart. I think we might have discussed that in another thread already.
WisNeuro said:
Came across this one today

"Is future oriented, one day wants a home with a view."
Click to expand...
Hey, they did a good job making a relevant statement and then backing it up. Sort of. 😉
 
smalltownpsych said:
I'm at about 4 or 5 pages for an assessment report including tables. I am becoming exceptionally brief with my intake reports and progress notes as I am seeing more and more that everyone gets access to whatever we put in the chart. I think we might have discussed that in another thread already.

Hey, they did a good job making a relevant statement and then backing it up. Sort of. 😉
Click to expand...

Yeah, I try to minimize any information that could be easily misinterpreted, and never include anything I wouldn't be comfortable with the patient seeing.

It's also why my recommendations are so long. I actually hope the patients get a copy and print them out. Apparently some of the psychiatrists pull mine up and review them with patients as well.
 
I do non-neuro comprehensive assessments, but very rarely do they go over 2 pages single spaced. They're a little longer depending on the type of report and how much needs to be tabled versus included in paragraph body. Brevity is beautiful.
 
My report length varies by what the reversal source wants. Some are 1 page. Some are 3-5 pages.

Forensic reports tend to be between 50-150 pages. But that includes a review of each page of evidence, test scores, and a reference section.
 
I just finished a placement at an interdisciplinary diagnostic assessment clinic and our reports were typically 20-25 pages, sometimes longer. It wasn't trainees (self included) being non-succinct, either, as we were frequently told to add additional information/behavioral observations to reports. Recommendations alone were typically 4 pages.
 
I hope this fits in here. I'm a psychiatry resident, and I'm pretty sure this part of the chart was entered by a social worker. It's something the EMR forces them to enter on all patients.

Consumer's response to "The most distressing event you experienced was..."
"9/11/01"

"...and it happened on..."
Date: 2001 ? Exact date is unknown
 
Verbosity is vomitous.

I'm often verbose, and I like it :/
 
futureapppsy2 said:
I just finished a placement at an interdisciplinary diagnostic assessment clinic and our reports were typically 20-25 pages, sometimes longer. It wasn't trainees (self included) being non-succinct, either, as we were frequently told to add additional information/behavioral observations to reports. Recommendations alone were typically 4 pages.
Click to expand...

A lot depends on the reason for the reports, I'd wager most have been talking about standard neuro evals. I've seen some forensic reports that were far longer than 25 pages. The standards also seem to be very different for psychoeducational testing. When I did it our reports were more like 15-20 pages (usually 5-6 of tables alone). That was supervised by a neuropsychologist who encouraged < 5 page reports when I did neuro cases with her, so obviously she doesn't just like ridiculously long reports.
 
futureapppsy2 said:
I just finished a placement at an interdisciplinary diagnostic assessment clinic and our reports were typically 20-25 pages, sometimes longer. It wasn't trainees (self included) being non-succinct, either, as we were frequently told to add additional information/behavioral observations to reports. Recommendations alone were typically 4 pages.
Click to expand...

It depends on the case, type of referral, and audience. I work in peds, and our reports are often used to get accommodations in school (as well as outside services, etc.). So we are required to include a more extensive background, explanation of testing results, and more detailed summary of each diagnosis. For a kid with a complex medical history, maybe ASD, ADHD, LD, executive dysfunction, language weaknesses, other diagnoses, etc... yeah, our reports get long (though rarely as long as you mentioned). I've regularly had recommendations sections alone (and score summaries, too) that are more than four pages. Though it pains me sometimes... they take forever to write and I know that no one reads them thoroughly. But I'm still a fellow so my ability to write a report in my own style is limited.
 
LETSGONYR said:
Though it pains me sometimes... they take forever to write and I know that no one reads them thoroughly.
Click to expand...

So why is this so common? Psychology seems to lack an ability to change based on common sense demands.
 
erg923 said:
So why is this so common? Psychology seems to lack an ability to change based on common sense demands.
Click to expand...

Good question. I'd say that for many clinicians, it's a combination of... "that's what I was taught, so it's easier for me to do it that way than to start learning a new method," "this is what schools/parents/consumers expect, so I have to produce this or I'll have several phone calls after every case explaining why what I gave them is just as good," "I want to be thorough, since that's what being a good practitioner entails," and "I never got good training in how to be concise yet still effective at conveying the essential information (or even identifying what information is essential vs. superfluous)."

It can interfere with patient care, too, since it extends the turnaround time for reports (particularly when there are trainees involved, since the writing/editing/revision time for a 12-page report is often much longer than for a 4-page report, though I admit that's not always the case).
 
In a practicum I did at a private psychoeducational testing clinic run by my school we wrote 40+ page psychoeducational evalutions, complete with detailed descriptions of every single subtest we gave. I learned a lot there, but it was also by far my least pleasant training experience, the fact that my supervisor was an incredibly harsh editor with a ridiculously short temper did not help. After that I decided I was not going into testing, and did all my remaining field placements in counseling heavy sites. It wasn't until I graduated and started working in the real world that I got back into serious testing, very happily writing 4-5 page reports. I joke that I still have a little PTSD from my practicum experience every time I submit a report to someone for review.
 
You must log in or register to reply here.

Similar threads

P
Deleting notes
Replies
10
Views
1K
psychma
P
P
Taking good notes why interviewing/evaluating patients
Replies
5
Views
902
AcronymAllergy
AcronymAllergy
Dre42
Psych Careers MEGA CHART
Replies
30
Views
4K
WisNeuro
WisNeuro
P
Possible Ethical Violation--Writing Another Therapists' Notes
Replies
30
Views
2K
singasongofjoy
singasongofjoy
PikminOC
Progress notes
Replies
27
Views
2K
PikminOC
PikminOC
Top