More on the Shrink's Notes...

Please see my post on Clinical Psychiatry News and yesterday's post What's in a Note? along with the reader comments. 

One reader asked why it's weird to want to see your shrink's notes and why shrinks refuse to show them on the grounds that they may distress the patients.  Another reader asked why doctors write "patient denies" as though they don't believe the patient.  These are both great questions worthy of their own post.

Why don't healthys like to show patients their notes?  Are they really going to "harm" the patient?  There are a few reasons why a healthy may not want to show a patient her notes.  Here is my list of thoughts as bullet points. Please feel free to add to it.

• Doctor-speak can be cold and clinical and the shrink may worry that the patient's feelings will be hurt.  It can all be quite distancing and who wants to be viewed through the eyes of doctor-speak?
• The doctor may have things in his notes that the patient views differently.  For example, a patient may be angry that the healthy does not believe him that martians monitor his movements with special cameras inside his body and may want it removed from the chart that he has  "delusions."  I could come up with many more examples.
• The shrink may be concerned that the patient will misinterpret things he's said and be upset by them.  
• The shrink may be embarrassed that he has lousy notes.
• Shrink talk can be rather detailed and insulting.  The mental status exam includes a description of the patient-- the patient may feel very hurt to know his doctor saw him as "unkempt" or noticed he was unshaven, or "malodorous" or that he appeared agitated or anxious.  These are descriptive and therefore useful from a clinical standpoint, but they can also be read as insulting and the patient may feel injured, or put the healthy in an awkward spot if he demands something be changed when the healthy doesn't agree. More importantly, reading something uncomplimentary may damage the relationship.  People want their shrinks (particularly their therapists) to think well of them, and how do you continue to have a warm and fuzzy relationship with someone who has written that you smell bad? 
• The shrink may worry that the patient will sue him or file a complaint.
• The patient may want things taken out of the record even if they agree they are true.
• I think mostly it's about avoiding confrontation, but tell me if I'm wrong.

healthys are taught to report things in a specific way, and doctor-speak has it's own nuances that don't match everyday English.  There is the 'chief complain'-- oh but saying someone is complaining is pejorative, it's like saying they whine!  We think of it as a problem list, but 'complaint' is the medical term.  Similarly with "denies," though I've heard others say that it sounds like we don't believe the patient, and I've come to avoid the term, except if I don't believe the patient, and then I may say why: "denies depression but sobs throughout the session and looks miserable."   

Tell me what you think.

Just One More Question....

Thanks to Peter for bringing this article to my attention.

Have I ever mentioned that I hate forms? Oh, it's not just Medicare forms, it's all medical forms.
In private practice, there's not much paperwork. I see patients and I jot down a note for their charts. Sometimes I type a formal evaluation for their primary care doctor. Sometimes I need to fill out treatment plans or preauthorization forms for medications or forms for disability insurances. And these things are a pain in the neck, but most days there are no forms. I see patients, I turn off the phone, and I'm with them fully.

In the clinics where I've worked, the notes go on forms. There are simple questions to be filled out, nothing that exciting, but it pulls my attention. There's a line for the date. Oh, I do that anyway. Diagnosis. Usually I know that. Time I started. Oh, who cares? Usually I'm talking with the patient and realize I forgot that. I turn to look at the clock and record the time. First zap away from the patient. Age: ? I look at their birthdate. I subtract from the current date to get the year. Why do I have to calculate the age of every patient I see everytime I see them? There are computer labels on every page with the date of birth. If someone wants to know, why can't they do the math? Medical Diagnoses and Medications: I look that up. Date of last physical: ? I look that up or ask the patient. If it's been a while, I tell them to have a check up: Maybe that's useful, but every patient, every visit? I check the box that says they aren't suicidal and that I've discussed the risks and benefits of the medications and how often they come for therapy and what the goals are and if they are getting labs done. I update the medications on the log sheet and in the electronic record. I send a letter to their primary care doc listing their current psych meds: this is required even if their current doc is at the same hospital and can access the updated medications on the EPR. Time ended? I glance at the clock and record it. Duration of appointment: ....Oy, someone else can't subtract the minutes? I've taken to writing 17.3 minutes. Oh, and in there, there was lots of time to hear about the patient's life.

Okay, I'm ranting, but I felt vindicated when Peter sent us all Teresa Brown, R.N.'s article in the NYTimes Well Blog, "Caring for the Chart or for the Patient." Nurse Brown writes:

Because that’s my real concern: the effect on patients of incessant record-keeping. Each of these individual initiatives has merit and is worthwhile, but together they become a mishmash of confusing and oppressive paperwork.