If your patient makes accusations toward another patient, describe the alleged encounter this way:
“Charlene was upset over an interaction she described with another patient. Staff allowed her time to ventilate, and (name/dose of sedative) was given. The incident was addressed with the other patient’s treatment team and staff … ”
7. Do not include complaints about other staff members, whether from the patient, staff, or a doctor.
Let’s say a resident pages his backup attending but receives no answer. Entering in the patient’s chart that “Dr. Smith was paged but did not answer” gives the impression that Dr. Smith is ignoring calls, when in fact any of the following may be true:
- the resident does not realize Dr. Smith traded on-call duty with another doctor
- the batteries in Dr. Smith’s pager died
- or Dr. Smith was home, available by telephone, with his pager tucked away in his briefcase.
If the doctor on call cannot be reached, call another doctor—a supervisor or department head—and document your conversation with him or her. Do not identify the doctor who was not available.
Supervisors should address doctor availability issues the following day. Such issues do not belong in a patient’s chart.
8. Document responses to and from other providers. When consulting another doctor for advice, describe the encounter and identify the doctor by name. For example:
“Dr. Mark Jones advised me to accommodate the patient’s request for discharge, because he has known the patient for many years and feels it is safe for the patient to come to see him at the clinic in the morning.”
9. When disregarding a consultant’s advice, clearly explain why. For example:
“Neurology consultant recommended stopping patient’s antipsychotic due to risk of tardive dyskinesia. This patient, however, has been on numerous antipsychotics over the years, and this is the only one that controls his schizophrenia. Patient is aware of the risk of tardive dyskinesia and does not find it problematic. Patient is competent and understands the need to weigh potential side effects against the medication’s benefits, and he prefers to continue the medication.”
10. Never enter derogatory or pejorative statements about a patient. As psychiatrists, we must convey a sense of concern and respect for the patient, regardless of diagnosis and presentation.
Rather than entering, “This patient is obviously lying about his history,” instead write, “This patient’s version of his history is at odds with that in previous hospital records.”
Related resources
- Selden BS, Schnitzer PG, Nolan FX. Medicolegal documentation of prehospital triage. Ann Emerg Med 1990;19:547-51.
- Bjorck JP, Brown J, Goodman M. Casebook for managing managed care: a self-study guide for treatment planning, documentation, and communication (1st ed). Washington, DC: American Psychiatric Association, 2000.
- Wiger DE. The clinical documentation sourcebook: a comprehensive collection of mental health practice forms, handouts, and records (2nd ed). New York: John Wiley &Sons, 1999.
Drug brand names
- Amitriptyline • Elavil
- Chlorpromazine • Thorazine
- Lithium • Eskalith, others