Psychiatrists in any clinical setting have to take notes in order to properly care for patients. Locum psychiatrists encounter a special challenge here, given that they don’t see patients for years on end or even work at the same facility for an entire career. It can be hard for locum psychiatrists to know what to include in notes they know will be passed on to permanent placement doctors at the end of the assignment.
Writing for the Psychiatric Times, doctors Awais Aftab, Samantha Latorre, and Sarah Nagle-Yang put together a ‘Primer for Psychiatry Residents’ that was published on January 12 (2017). It is an excellent post that offers a lot of valuable content that residents and locum psychiatrists alike can benefit from.
Based on that post, here are five things that locum psychiatrists should know about notes:
1. The Purpose of Taking Notes
The purpose of taking notes as a psychiatrist runs far deeper than just keeping track of what you talked about with the patient. Notes serve four very important purposes:
- they are records containing clinical information necessary for future treatment;
- they are tools of communication with colleagues;
- they provide important data for billing purposes; and
- they serve as a record in the event of litigation.
These four purposes provide a basic outline of what kinds of information psychiatry notes should contain.
2. There Is No Specific Format
The psychiatric profession has never established a specific format for note-taking. Locum psychiatrists should not get hung up on format to any degree, and they need only pay attention to format if the facility they are currently working at requires uniformity. Otherwise, notes can be a combination of narrative, bullet points, and even references to external sources.
3. Brevity Is a Valuable Commodity
As with any other form of medicine, psychiatry is a time-consuming practice. Furthermore, time is limited. Locum psychiatrists should understand that their colleagues and employers have neither the time nor interest in reading long-winded reports that contain a lot of words without saying anything valuable. Locums should learn to love brevity. Brevity is a valuable commodity in the world of medicine, and one that a lot of doctors could use more of.
4. Medical Rationale Is Necessary
When a locum makes changes in patient medication, it is important for that doctor to explain the rationale behind his or her decision. Changes in medication could lead to unintended consequences, so documentation must be clear and concise in this regard. Where black box medications are recommended, doctors should engage patients in detailed and frank discussions while documenting those discussions by way of notes.
5. Stick with Standard of Care
Lastly, locum psychiatrists should stick with the standard of care when writing notes. In other words, colleagues and employers will have no interest in information outside of the scope of standard care unless that information is especially pertinent to the case. There is no point in getting into speculation or unproven methods of care as a locum. If such discussions are appropriate for a particular case, they are better left to those doctors who will eventually be providing long-term care.
Note-taking is a regular part psychiatry that cannot be avoided. Taking good notes is something every locum psychiatrist can learn with a little bit of practice and the tips listed above. Moreover, employers and colleagues will come to appreciate the locum who masters note-taking skills. Good notes can mean the difference between a positive reputation as a locum tenens Psychiatrist and a reputation of being merely adequate or completely ineffective.