Writing Progress Notes: 10 Dos and Don’ts. What to Include in – and Exclude From – Patients’ Medical Records
Roth L S
This article provides a summary of what information psychiatrists should include in a patients’ progress notes. Psychiatrists are advised to be concise but to include details that explain treatment decisions such as discontinuing suicide precautions or not hospitalizing the outpatient who expresses suicide ideation. Psychiatrists should also provide sufficient detail for other caregivers who will view the chart. They should write legibly & respect patient privacy. Notes should not include complaints about other staff or pejorative statements about the patient. They should document responses to & from other caregivers & reasons for disregarding a consultant’s advice.