Psychiatry Clerkship

Case notes vary from hospital to hospital so be sure to check for any policies and procedures to insure you are in compliance.

These instructions and handout is a roadmap for what should be included in case notes during a patient in-take.

Identifying Data – 1-2 sentences

TIP: set the stage for the rest of the note, not to provide a comprehensive history, so err toward brevity on this one. Avoid writing paragraphs of dialogue from patient.

•   patient’s age
•   gender
•   diagnosis
•   circumstances leading to this admission
•   Brief patient quotes can be used as needed

Chief Complaint - pick one

• primary reason (e.g., evaluate for suicidal ideation)
• quote succinctly illustrating the current level of pathology

History of Present Illness

TIP: More distant aspects of the patient’s history such as previous episodes of mental illness, while highly relevant to the current circumstances, should be reserved for Psychiatric History

•   circumstances leading up to admission
•   report of the patient’s initial interview
•   include sufficient information to suggest a diagnosis

Collateral Information should be sought for every patient you evaluate.

•   Documentation should include not only the contact information for your sources (e.g., telephone numbers) but also a brief summary of their report

(Other possible sources include roommates, other family members, friends, or witnesses to recent events

•   report from emergency services (if they were brought in by police or an ambulance).
•   presence or absence of consent to contact collateral should be clearly documented, as a patient’s right to privacy must be maintained.

Psychiatric History is one of the most crucial aspects of a complete evaluation, as it helps to assess severity of symptoms as well as guide treatment. For this reason, spending a little extra time on this section is well worth the effort.

•   Any contact that the patient has had with psychiatric care, both inpatient and outpatient, should be clearly documented, with diagnoses and treatments described.
•   Medication trials in particular can help to guide current treatment.
•   Document:
  • history of suicide attempts
  • history of violent acts

TIP: Stylistically, it can be helpful to include a brief summary of the most salient parts.

Substances minimum to include

•   Tobacco
•   Alcohol
•   Marijuana
•   Prescription medications with abuse potential
•   illicit substances
•   consider caffeine use in patients with insomnia, depression, restlessness, or anxiety
•   If use of any of these substances is present, assessing duration, frequency, and amount of use
•   determining last use of substances (alcohol in particular) is crucial for evaluating the risk for withdrawal
•   complicated substance history - inclusion of treatment history (e.g., 12-step groups, medication treatments, inpatient rehabilitation programs, etc.

Paint a concise picture of the patient’s life trajectory

•   family structure
•   educational history
•   employment history

•   Current circumstances
  • living situation
  • source of income
  • social supports

TIP: The goal of taking a good social history is twofold.

•   helps to humanize the patient by detailing their life course
•   it can provide useful information on the nature and severity of their mental illness.

Knowing the overall course of the patient’s functional status can help to distinguish between different diagnoses when the symptoms overlap or are unclear (e.g., differentiating between schizophrenia with depressed mood versus major depressive disorder with psychotic features).

This is not necessarily required for all patients. (It is unlikely to change management for an elderly patient with Alzheimer’s dementia, for example.) It should be assessed in younger patients, including all child and adolescent patients.

Psychiatric diagnoses and outcomes for all first-degree relatives

TIP: A particular focus on suicide and suicide attempts is recommended, as suicidal acts can run in families.

TIP: Use the metric of “Would this change management?” when deciding how much to include. Notes from other providers should not be excessively copied and pasted.

As an example, a diagnosis of an active urinary tract infection requiring antibiotics should be included, whereas a remote history of a urinary tract infection that resolved several years ago is unlikely to impact current treatment. For relevant diagnoses, describe current treatments.

TIP: especially important in acute situations where emergent medications may be needed.

Detailed Medication Reconciliation – is one of the most important parts  of the note and is never optional.

TIP: Remember to record that you have discussed the risks and benefits of proposed treatments with the patient. Write down rationale for medications.

Medications for both psychiatric and medical indications should be documented to facilitate decision making regarding which medications should be continued, held, or discontinued upon admission. Indications for medications should be included as well.

Cover all organ systems, with a particular focus on ruling out life-threatening or other serious illnesses that would require admission to a medical or surgical unit.

Positive responses should include follow-up information to guide medical decision making (e.g., specifying the amount of weight loss). Use clinical judgment to determine the level of severity required for inclusion. For example, a 3 lb weight loss is probably not relevant, whereas a 20 lb weight loss is.

• vital signs
• rule out major medical comorbidities or assess the status of existing comorbidities
• neurologic examination, including cranial nerves

TIP: Write about what is required by standard care

Many psychiatric hospitals request

• Basic “screening labs” such as a BMP and CBC prior to admission
• Other labs with relevance to psychiatric management could include a
  • CBC with differential (for patients on Clozapine or Valproic acid)
    • thyroid stimulating hormone
    • RPR
    • vitamin B12
    • folate
  • obtain a urine drug screen for all patients regardless of their self-reported substance use

If available, should be reviewed.

While most guidelines do not suggest routine head imaging for all patients with a psychiatric illness, some cases where the etiology is not quite as clear (e.g., new onset of psychotic symptoms in a 78 year-old patient) or where symptoms or physical examination may suggest an alternate etiology (e.g., presence of focal neurologic signs or symptoms) may raise the utility of imaging in determining a final diagnosis.

-  the psychiatric version of a physical exam.

• should be based only on what is directly observed by you.
• consider using concrete examples (noted by the phrase “as evidenced by”) to support the parts of the exam (such as insight) requiring more judgment on the interviewer’s part.
• Suicide Risk Assessment - should be performed and documented for all patients. An evidence-based approach is best. However, even with careful assessment of suicide risk, there is no validated method of accurately predicting which patients will attempt suicide in the near future, and it is helpful to document this in your assessment as well. If prediction is not a possibility, the goal then becomes foreseeability, which relies upon the clinician’s judgment and the general standard of practice to decide which patients are in need of a higher level of care. In this case, the foreseeability of the patient attempting suicide is high enough to warrant inpatient hospitalization

Diagnostic Impression is where you begin to put everything together into a coherent whole.

TIP: Be sure to use specifics when documenting diagnoses.

• List the diagnoses that you believe to be most likely
  • do not hesitate to include “rule out” diagnoses. These diagnoses will help to inform future providers about aspects of the history which may need to be clarified further.
• Substance-induced disorders can nearly always be included as a rule out diagnosis until there is sufficient evidence that substances are not contributing to the clinical picture (usually after a urine drug screen is performed)
• Consideration of a comorbid personality disorder is important as personality disorders can often contribute to and/or present as mood or psychotic disorders
• Including significant psychological, social, and environmental factors can also help to guide future providers towards aspects of the history that require attention, either by contributing to the severity of pathology or by interfering with recovery.

Put the majority of your effort, as it is certain to be the most frequently read and referenced part of your note.

TIP: Take this opportunity to explain the thought process regarding diagnosis, disposition, and treatment.

Goal (approximately one paragraph)

• Succinctly summarize all of the most salient aspects of the history, including the History of Present Illness and any aspects of the overall history that most contribute to your clinical decision making.

For the plan

Goal

• translate the history into a reasonable plan of care.
  • Phrases such as “Given that,” “Considering these factors,” or “With this in mind” will be helpful in allowing future readers to trace the process of your clinical decision making.

Psychiatric Part

List

• all relevant psychiatric diagnoses as well as the plan of care for each
• primary diagnosis should contain the core aspects of the plan (e.g., admit to inpatient hospitalization)
• If multiple psychiatric diagnoses are present, make sure to pair medications with their appropriate diagnosis
• suggest directions for treatment that cannot be accomplished immediately (e.g., personality testing).

Medical Part -  follow the same rules as above

• pair treatments to their appropriate diagnosis

PRN/FEN/PPx – consider including

• for as-needed medications; fluids, electrolytes, and nutrition; and prophylaxis) for all patients
• doses of basic over-the-counter medications such as Acetaminophen or Magnesium hydroxide to deal with the normal aches and discomforts of everyday life, can prevent unnecessary delays in patient care, provide nursing staff with additional options for patient care

Includes:

• patient’s current admission status (i.e., voluntary versus involuntary)
• presence of a durable power of attorney

Finally, for the purposes of helping your colleagues on call, include contingency planning (e.g., what to do if this voluntary patient requests to leave), as it can communicate your wishes for this patient and prevent unfavorable outcomes (e.g., the patient being allowed to leave since they are on voluntary status despite being at a high risk for suicide).

obtain for all patients, regardless of age or medical comorbidity

Consider what the most likely plan for discharge is.

TIP: you can revise as more information becomes available 

Includes the contributions of medical students or other sources of information)

TIP: this is necessary for purposes of clarity, and most likely reimbursement.