how to do documentations in medical file in psychiatry and to avoid legal claims , while you provide proper care for the patient .

1. Dr. Ahmed Albehairy, M.D
Psychiatry Consultant, AFCPC, Taif

2.  Understand the importance of formal policies
and procedures for medical records.
 How to deal with and establish the security of
health information in the files.
 To avoid liability claims.

3.  Considered to be an accurate reflection of
care provided.
 Files have a legal specifications, shown
standards of care, continuity of care and any
malpractice issues.
 Also they are used to reconstruct the care
provided and shows professional creditability.

4.  Unpermitted.
 Unethical.
 Inability to defend malpractice case.
 Can lead to license revocation. !!!!!

5.  Elementary of the claim:
- duty.
- Breach.
- Causation.
- Damage.
 Standards of care .

6.  Improper diagnosis .
 Improper treatment.
 Suicide .
 Violent behavior.
 Vicarious liability.
 Others ( informed consent, pt rights, civil
committee issues, & abandonment).

7.  Informed consent .
 Out /in patient follow up.
 After discharge from hospital.
 Prescriptions.
 Restriction and seclusion.
 Electronic medical recording.
 Issues of communications other than file
( phone calls and e-mails).

8.  Document objectively.
 Use direct patient quotes.
 Document patient’s actual behavior.
 Avoid using opinions/personal comments.

9.  Relevant information: diagnosis and
treatment.
 Assessment of risk of suicide and violence .
 Medication should be charted.
 Use objective language , explaining the
psychiatric terms.
 Compliance.
 Informed consent issues.
 Boundary issues.
 Thorough documentation of termination.

10.  Detailed sexual behavior.
 Interpersonal conflicts.
 issues the may be embarrassing to the
patient if disclosed.
 Third party names.
 But in some cases, specially military services ,
sexual behavior and criminal , child abuse
reports would be documented.

11.  Who is signing the document? capacity, after
18/21years.
 Diagnosis.
 Medication being recommended.
 Prognosis.
 Discussion of risks vs. benefits of treatment
or facility.
 Alternatives.
 Risks of foregoing treatment should the
patient refuse.

12.  Legible.
 Copy kept in medical records.
 Effective communication with other providers
regarding the medications .
 Monitoring blood levels or other lab testing
for medications.
 Follow up testing.
 Avoid “cut and paste” when using electro
medical record.

13.  Appropriate medical officials.
 Time limited.
 Patient condition might be reviewed.
 if there is extension, must be reviewed and
reauthorized.

14.  Document the phone session or interaction.
 Assessment upon the available tone ,
complains and family information .
 Reaction and decision after the phone call e.g
next appointment .

15.  Private , but not confidential.
 Encryption.
 Should be a part of medical report.
 Informed consent issues.

17. ‫المادة‬ ‫في‬25
‫نفسي‬ ‫مريض‬ ‫أسرار‬ ‫إفشاء‬----‫سجن‬3‫شهور‬‫و‬‫غرامة‬
50000‫لاير‬.
‫االخالل‬‫بيئة‬ ‫من‬ ‫المرضي‬ ‫بحقوق‬‫امنه‬‫اورعاية‬‫طبية‬‫او‬‫عدم‬‫اعالمه‬
‫العالجية‬ ‫بالخطة‬‫او‬‫من‬ ‫رغم‬ ‫علي‬ ‫دخوله‬‫ارادته‬‫اتخاذ‬ ‫دون‬‫االجراءات‬
.......‫سجن‬ ‫بين‬ ‫تتراوح‬6‫شهور‬‫و‬3‫سنوات‬/‫خمسون‬ ‫من‬ ‫وغرامة‬
‫الي‬200‫الف‬‫لاير‬.

18.  Care for the patient needs and demands .
 Care for the legal perspectives of the file.