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

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

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Clinical documentations,

  1. 1. Dr. Ahmed Albehairy, M.D Psychiatry Consultant, AFCPC, Taif
  2. 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. 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. 4.  Unpermitted.  Unethical.  Inability to defend malpractice case.  Can lead to license revocation. !!!!!
  5. 5.  Elementary of the claim: - duty. - Breach. - Causation. - Damage.  Standards of care .
  6. 6.  Improper diagnosis .  Improper treatment.  Suicide .  Violent behavior.  Vicarious liability.  Others ( informed consent, pt rights, civil committee issues, & abandonment).
  7. 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. 8.  Document objectively.  Use direct patient quotes.  Document patient’s actual behavior.  Avoid using opinions/personal comments.
  9. 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. 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. 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. 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. 13.  Appropriate medical officials.  Time limited.  Patient condition might be reviewed.  if there is extension, must be reviewed and reauthorized.
  14. 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. 15.  Private , but not confidential.  Encryption.  Should be a part of medical report.  Informed consent issues.
  16. 16. ‫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.
  17. 17.  Care for the patient needs and demands .  Care for the legal perspectives of the file.

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