Psychiatric Records

· Document fully the type of treatment and rationale, as well as alternatives to the treatment and why they may have been rejected.

· Document dates (and length) of services, pertinent history, prescription of medication, and consultations with other professionals. Document legibly.

· When dealing with a potentially suicidal or violent patient, document all actions taken (and why), and all actions considered but rejected (and why).

· Include written informed consents, lab reports, and correspondence in the record.

· Record retention is often governed by state law. Keep in mind that there is no "statute of limitations" for licensing board or ethics complaints.

· Instruct staff regarding handling of records, stressing confidentiality concerns.

· DO NOT ALTER RECORDS AFTER AN ADVERSE EVENT!

The Do’s and Don'ts of Record Keeping

It is not your imagination. There is more paperwork on your desk now than ever before. In the face of this onslaught, you may not feel too kindly towards yet another article urging you to keep more and better records. Nonetheless, good documentation is your best defense against a serious malpractice claim. The courts view a carefully annotated treatment record as a psychiatrist’s testimony on his or her own behalf that he or she practiced responsible medicine during the course of a patient’s treatment.

What standards must a record satisfy? There is no simple answer. Requirements vary from state to state and from practice setting to practice setting. Below is a brief checklist of things you can do to protect yourself.

Know your state’s laws and regulations.
There are statutes and regulations in some states which require a physician to make a record for each patient and to keep it for a certain length of time. Even when a state has no such statutes or regulations, it is a good idea to archive your records as a hedge against law suits. Most legal experts agree that you should keep patient records at least until your state’s relevant statutes of limitations run out. You should find out what that means in your state. Also be aware that generally there is no statute of limitations imposed on professional association ethics proceedings or disciplinary actions by state medical boards or licensure agencies.

Make your record complete.
Although there is variation in record-keeping procedures among different practice settings, the following summary presents the suggested major "contents" of psychiatric records.

1.) name, address, and telephone number(s) of patient (and designated others, if patient has granted appropriate authorization to communicate with others)

2.) any signed informed consents for treatment and authorizations for release of information to others, including managed care companies and third party payors

3.) pertinent medical history

4.) initial assessment and subsequent re-assessments of patient’s needs

5.) dates of service, length and type of service provided

6.) reports from psychological testing, physical examinations, laboratory data, etc.

7.) prescriptions or medications, adjustment to dosage, etc.

8.) progress notes or other documentation that reflects a patient’s reaction to treatment or the need to change treatment

9.) consultation with colleagues

10.) what actions you took and why, and what actions you considered but rejected and why - especially with regard to serious situations such as suicide, homicide, or transference problems

11.) copies of relevant correspondence concerning patient

12.) a discharge summary if relevant, including patient status relative to goal achievement, prognosis, and future treatment considerations.

It is also important to know what not to record. Avoid personal criticisms of the patient, and avoid the names of third parties - for example, the person with whom the patient is having an affair. In fact, avoid all extraneous references to matters which you or your patient would not want to be seen by utilization reviewers, parents (if the patient is a minor child), legal representatives of deceased patients, plaintiff’s attorneys in malpractice actions, or government agencies who might seek access to the record for purposes of security clearance.

Document exceptional circumstances.
For example, if the patient balks at your treatment plan or if the spouse of a suicidal patient refuses to become involved in the patient’s treatment, be sure you set these issues - and your handling of them - down in detail in you files.

Keep your records in a safe place.
Keep your records somewhere safe, accessible only to those in your office who have a reason to need access. If you keep your records on a computer, have a separate hard copy and back up your data regularly. Make sure your staff observes very strict protocols in handling the files.

Never alter or destroy a document without being sure of what you are doing.
In situations where you have legitimate cause to alter a record - if a mistake has been made and must be rectified, for example - make sure that you carefully date the correction and clearly note that you are correcting an error. Make your corrections using a single line strike-through and date and initial the correction. Altering your records to avoid looking bad in court after a suit has been brought can be fatal to your case, and may lead to a forced settlement due to the damage such an action would do your credibility.

The information contained in the web site does not constitute legal advice. If you are a Program Participant please call (800) 245-3333 for further risk management advice or risk management advice concerning a specific situation. For legal advice contact your personal attorney.