FOR COMPLETE PSYCHIATRIC MEDICAL RECORDS ...

Take a good initial history. Document ...

• A baseline medical history and exam to rule out pathology;

• The names of other physicians a patient sees;

• A drug and sexual history (Even if a patient misrepresents facts, the quality and quantity of your documentation are evidence that you asked the questions.).

Obtain and document pertinent information. 
Ensure that progress notes include ...

• A synopsis of the patient’s subjective complaints, using quotes when it is important to distinguish between the patient’s narrative and your own observations or opinions;

• Your objective observations of the patient’s affect;

• Documentation of objective data relevant to the patient’s care (e.g., medications taken, other doctors seen, family and social history, lab test results, etc.);

• A treatment plan and rationale for your recommendations and treatment. For potentially suicidal or homicidal patients, document actions you have taken—or those you have considered but rejected or deferred—and the reasons for your decisions;

• Sufficient detail—to justify treatment recommended and drugs prescribed; to justify payment; and to distinguish between the patients’ statements, behaviors and responsibilities, and your own.

• The substance of significant phone conversations (with patients, other doctors, mid-level therapists, managed care plans, etc.)

• Evidence of the patient education you provide (both oral and written).

• Precise documentation of referrals to other physicians.

• Documentation of patients’ failure to follow your advice.

• Thorough documentation of informed consent discussions.

• Documentation of patients’ “informed refusal” of your advice.

• Evidence of the timeliness with which you review, correct and sign transcription of hospital and office reports.

• Properly corrected errors (no write-overs or cross-outs).

Prevent medication-related problems. Be sure to ...

• Ask patients about allergies and medication use (including OTC, alternative and complementary remedies, and street drugs);

• Use a Medication Control Record to track prescriptions, samples given, changes in medication regimen, and all refills (see Figure 6 for a prototype of an MCR).

• Limit refills in accordance with accepted medical standards.

• Monitor and document each drug’s effectiveness to justify continued prescribing.

• If lab tests are required, or are recommended by manufacturer, don’t forego them without documentation of your reasons.

• Be wary of “lost drug” excuses and other ploys to obtain additional medications.

• Have an agreement with your call group colleagues about prescribing refills for one another’s patients.

Ask patients ...

• To authorize release of a copy of other physicians’ medical records, if needed;

• For written permission to share drug and diagnostic information with his or her other physicians and/or mid-level therapist; or ask the patient to inform other physicians about medications you prescribe, and document that you have done so. Document subsequent communication with those individuals.
  
  

Figure 4