![]() The biggest mistake in medical note writing is spending too much time or using too many words in the "objective" section and not enough in the "assessment" section. Write so the reader does not have to guess what you were thinking See the Table for key points addressed here. Should two thirds of the H&P be devoted to symptomatology-assessing for depression and the like-and one third to the assessment and plan? In addition, within any section, what needs to be written explicitly and what can be left out? In this article I offer 9 maxims to help focus the writing, using the model of an emergency department (ED) setting to illustrate. This article is about documentation and prioritizing the information contained in the report.ĭuring the patient interview, the clinician will learn far more than he or she can include in the report how do you decide what is important for posterity? It is unreasonable and disingenuous to assume that every H&P will be a thorough and rigorous journalistic recording of the facts, events, and thought processes that occurred during the interview. This article is not about how to perform a suicide assessment it is assumed the clinician is already able to do this, or knows where to go for assistance. The result is an adverse judgment, settlement, or the immense frustration of a lawsuit that could have been avoided with different (and more focused) documentation. As a forensic psychiatrist, I have seen reports that fail to convey the rigor, time, and thoughtfulness that went into the work because, although lengthy, the content was not prioritized. Unfortunately, psychiatrists receive comparatively little practical guidance in documenting the history and physical examination (H&P) of a suicidal patient. Proper suicide assessment is probably the most important part of a clinician's job appropriately, heavy emphasis is placed on this in our education.
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