The Clinical Note: What Does Your Psychiatrist Write About You?

This blog post was reviewed and approved for publication by Chenhang Zou M.D., a Board-certified psychiatrist at Apraku Psychiatry.

You're with your psychiatrist, discussing your thoughts, fears and experiences. Suddenly, you notice them scribbling away, and a wave of vulnerability washes over you. What are they writing? Could it be a judgment or analysis to which you’re not privy? These moments can evoke a mix of curiosity and uncertainty, leaving you to wonder about the content of those clinical notes.

The goal of this article is to unravel the mystery behind your psychiatrist's notes. We aim to put your mind at ease by breaking down the essential elements typically found in these clinical records. Understanding the ‘what’ and ‘why’ behind these notes can help demystify the process, creating a more transparent and trusting therapeutic relationship. In a field that relies heavily on patient history and evolving context, these notes are a pivotal aspect of effective psychiatric treatment.

The Role of Clinical Notes in Psychiatry

Clinical notes serve multiple crucial functions in the realm of psychiatry. At the most basic level, they act as a written record of your psychiatric sessions, documenting what was discussed, observed and planned for future treatment. These notes provide an ongoing narrative of your mental health journey, facilitating a continuity of care that is essential in psychiatric treatment.

Psychiatrists use these notes as an indispensable tool to better understand, diagnose and treat mental health conditions. The information recorded can include everything from your reported symptoms and moods to medical history and medication regimens. By revisiting these notes, psychiatrists can gain a holistic understanding of your condition, allowing for more accurate diagnoses and targeted treatment plans. It provides a way to track the effectiveness of medications, therapeutic interventions and lifestyle changes over time.

Beyond patient care, clinical notes also have legal and ethical implications. They constitute an official medical record, which can be necessary for insurance purposes or in the event of legal proceedings. Ethically, maintaining detailed and accurate notes is a cornerstone of professional responsibility. They safeguard against memory lapses and provide an objective account of clinical decisions, ensuring that psychiatrists can justify their treatment choices based on documented observations and patient reports.

Top Highlights

• Clinical notes are essential for documenting mental health treatment, guiding therapy, and ensuring continuity of care.
• Notes are protected by law, ensuring confidentiality, with secure storage and limited, consent-based access.
• They contribute to treatment by providing baseline assessments, tracking progress, and facilitating adjustments in therapy.
• Understanding the role and content of clinical notes can help to empower patients in their mental health journey.

Typical Components of Clinical Notes

There are two main types of clinical notes: The initial psychiatric evaluation (or “H&P” note) and the follow-up note (or “SOAP” note) for subsequent appointments.

Clinical notes can vary from practice to practice and even from psychiatrist to psychiatrist within the same practice. However, there are common elements that you'll likely find in any set of psychiatric clinical notes.

Initial Psychiatric Evaluation (‘H&P’ Note)

As you may have guessed, the initial psychiatric evaluation is made by your psychiatrist at the start of your treatment. Formally called the “History and Physical” (or “H&P”), this largely follows the standard evaluation note used across different medical fields, with a few adjustments made to make it relevant specifically for psychiatry.

The H&P is a comprehensive note that compiles essential information about your medical, psychological, and social background, which is crucial for forming an accurate diagnosis and treatment plan. This might encompass:

• Symptoms Presentation: Detailed documentation of the symptoms you are experiencing, including their onset, duration, and severity.
• Psychiatric History: Information about any previous mental health diagnoses, treatments, and responses to those treatments.
• Medical History: A detailed record of past and present illnesses, surgeries, and chronic conditions.
• Social and Family History: An exploration of your social environment, including family dynamics, work stressors, and support systems. This also includes a history of mental health issues in the family, which can be relevant for understanding genetic predispositions.
• Lifestyle Factors: Notes on your lifestyle that could affect mental health, such as sleep patterns, dietary habits, exercise, substance use, and stress levels.

This note also includes medication lists, which track both current and past prescriptions to monitor ongoing treatments and prevent potential drug interactions. And information from third-party consultations, such as notes from other healthcare providers or specialists, to offer a more comprehensive understanding of your health history and any concurrent treatments.

Follow-up Note (‘SOAP’ Note)

Following your initial appointment, a follow-up note is used. Again, the format can vary slightly, but one of the most common frameworks used is “SOAP”, which stands for Subjective, Objective, Assessment and Plan.

• Subjective:
  • What you tell the psychiatrist about how you're feeling.
  • Symptoms you're experiencing and personal insights, including emotions, perceptions, and concerns.
• Objective:
  • Observable facts collected during the session.
  • Includes behavioral observations, appearance, and sometimes even vital signs.
• Assessment:
  • Synthesizing both Subjective and Objective components to form or refine a diagnosis.
  • Identifying patterns, triggers, or contributing factors to your mental health condition.
• Plan:
  • Outlines the next steps in your treatment.
  • Could involve medication adjustments, further tests, or scheduling follow-up appointments.

Confidentiality and Access

One of the foremost concerns patients have regarding clinical notes is the issue of confidentiality and access. Let's delve into these matters to clarify how your information is both protected and made available to you.

Confidentiality

• Legal Compliance:
  • Clinical notes are private. Various laws - including the Health Insurance Portability and Accountability Act (HIPAA) - ensure the confidentiality of health information.
  • Psychiatrists must take the utmost care in protecting your information. Violations are subject to legal consequences.
• Limited Access:
  • In principle, access to your clinical notes is restricted to the author - your psychiatrist!
  • You may decide to grant access to other parties, such as your primary care or other healthcare provider.
  • At Apraku Psychiatry, we take your personal privacy extremely seriously, going beyond legal requirements. We will always ask for your explicit consent before releasing any information about you to others.
• Secure Storage:
  • Notes are securely stored in encrypted electronic medical records.
  • Regular audits ensure the integrity and security of the stored information.

Access

• Patient Rights:
  • You have the right to request your own clinical notes, and your psychiatrist will grant access unless they consider that it may be harmful to your well-being to do so.
• Process for Access:
  • To request access, you'll likely need to submit a written request to your psychiatrist.
  • There might be some wait time, but your psychiatry practice should aim to make this process as straightforward as possible.
• Shared Decision-making:
  • Your notes are primarily written for a potential clinician readership, meaning that they can contains lots of jargon. Nevertheless, in some circumstances, having access to your notes can facilitate an open dialogue between you and your psychiatrist.

Understanding your rights and the measures in place to protect your information can empower you in your mental health journey. Confidentiality and access to clinical notes are not just legal requirements but are essential components of a trust-based patient-doctor relationship, especially in the context of psychiatric care.

How Notes Impact Treatment

Clinical notes serve as more than just a record-keeping tool; they actively contribute to the trajectory of your treatment in a variety of ways.

Guiding Treatment Plans

• Baseline Assessments:
  • Initial notes provide a snapshot of your mental health at the beginning of treatment, allowing for a comprehensive treatment plan tailored to your needs.
• Adjusting Approaches:
  • As your psychiatrist reviews your notes over time, they can adjust medications or therapeutic approaches based on the patterns and insights gleaned from them.
• Setting Goals:
  • Notes often include short-term and long-term goals which guide the focus and expectations of ongoing treatment.

Continuity of Care

• Reference for Future Consultations:
  • Accurate and detailed notes ensure that the high standard of care is maintained even if there's a long gap between appointments.
• Collaborative Care:
  • Notes may be shared with other healthcare providers involved in your treatment, like your primary care physician, for a holistic approach to your well-being.

Measuring Progress

• Monitoring Symptoms:
  • Regular entries allow your psychiatrist to track the severity and frequency of symptoms, which is crucial for understanding the effectiveness of treatment.
• Identifying Triggers and Coping Mechanisms:
  • Clinical notes can reveal situational triggers or effective coping strategies that may not be apparent without such a record.

By enhancing understanding, guiding the course of treatment, and facilitating collaborative care, clinical notes are invaluable tools in providing you with the most effective and personalized mental health care.

Conclusion: The Integral Role of Clinical Notes in Mental Health Care

Understanding what goes into your psychiatrist's clinical notes can be empowering. Far from being a mere bureaucratic requirement, these notes serve a multifaceted role that is crucial to both the psychiatrist and you as the patient. They guide treatment plans, ensure continuity of care, and are vital for the legal and ethical integrity of a psychiatry practice.

Recognizing the contents and purpose of these notes can alleviate some of the vulnerability and uncertainty you may feel during your mental health journey. It's important to know that these records are designed to benefit you — they are a tool to optimize your treatment and ensure you are receiving the best care possible.

So rather than being a cause for concern or nervousness, next time you see your psychiatrist scribbling away, remember that they are just helping to ensure you are receiving the best possible support.

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This blog post is brought to you by Apraku Psychiatry.

Apraku Psychiatry is a private practice offering video appointments with Board-certified psychiatrists licensed in multiple states. More blog articles can be found here. To schedule an appointment with one of our psychiatrists, patients can complete the online booking form.