Documentation on the PRMS Blog

It’s that time again, when you may be thinking about resolutions for the new year. While termination has always been a popular topic on our Risk Management Helpline, during the past year we have addressed more termination issues than ever before. It’s an important topic because once a treatment relationship has been established, the psychiatrist remains responsible for the pat ...

Just recently, the Illinois legislature set aside a psychologist prescribing bill after initially supporting it.  (The Illinois Psychiatric Society’s president, Eldon Trame, MD, gives a nice summary of the whole process here.) What led me to explore what happened in Illinois was an article in the most recent issue of Psychiatric Times, “Why Psychiatrists Are Physicians First,” ...

A Guest Blog by Donna Vanderpool, MBA, JD, Vice-President of Risk Management It’s the start of a new year, so I just cannot resist offering one resolution to consider for 2012. Here it is: try to document your patients’ treatment records so that someone else can read the record and understand what happened in your treatment and why. The “someone else” could be another clinicia ...

Try this as a way of assessing the adequacy of your own patient records. Pull an “inactive” record from your files (i.e., someone you haven’t seen in 3 years or more). Look through it. – Do your notes bring to mind the patient? – Do you understand what you were doing with that patient, in terms of general medical history, your diagnosis, your treatment plan at the time, and  th ...