“Although a number of forms of medical record documentation may simulate valid recordkeeping, in reality these are hollow shells of verbiage rather than appropriate chart content."
So say Drs Thomas Gutheil and Robert Simon in their article published in the December 2011 issue of Psychiatric Times, entitled "Empty Words in Psychiatric Records: Where Has Clinical Narrative Gone?" In that article, the authors address problems of “meaningless phrasings, empty shells, and template-distorted records.”
Dr Gutheil has chosen that article—and the issues it addresses—as a top paper of the year and a key challenge facing psychiatrists. Here, he offers tips that may help you manage your medical records to optimize patient care, to manage risks, and to prevent liability.
Dr Gutheil is professor of psychiatry at Beth Israel Deaconess Medical Center of Harvard Medical School in Boston, and a new member of the editorial board of Psychiatric Times.
[Editor’s note: Dr. Gutheil mentions the MMPI-III in his podcast: he meant to cite the MMPI—II.]
Click here for the article.