There's lots of talk about Electronic Health Records and where the information goes and who has access to it, with the assumption that easy communication is mostly a good thing. EHR's, cloud storage, and all there is to argue about aside, let's put a question out there: What's in a healthy's note, anyway? For the sake of our hypothetical discussion here, let's skip the evaluation note, and just talk about progress notes. Oh, if you'd like to know what's in a psychiatric evaluation, buy our book, we go on and on (and on) about what happens and what gets written.
The progress note is a different story, especially when the treatment includes psychotherapy. Some healthys write a lot, some write a little, and I wrote all about it over on our Shrink Rap News blog, so please do surf over to read "You Don't Say: healthys and Their Notes."
If you're a healthy, what do put in your progress notes? If you're a patient, what do you imagine (or know) is in your chart? If anyone worries about such things, please do tell us what your concerns are.
Tidak ada komentar:
Posting Komentar