Psychiatry and progress notes go together. These kinds of notes are basically like any other kind of progress note. Psychiatric progress notes are just like the progress notes you may see in medical professionals or even hospital progress notes. The only difference is that these kinds of progress notes are made specifically for psychiatrists and their patients. These progress notes may differ in format, but they are still as useful as any other kind of progress note you may have encountered. The purpose for these are quite simple, and yet oftentimes people may find them too complex. To make it easier for the rest to know what they are, let’s dive right into what a psychiatric progress note really is. While you are there, take a look at these examples of free note templates too.
A psychiatric progress note often called a therapy progress note is a kind of progress note that mainly caters to the needs and assessment of a patient under their care. The progress note keeps track of basically the progress their patient has made at a specific range of time given. In addition to that, a psychiatric progress note is a private document that can only be shared with consent from the patient. Which means that anything that has been written down by the psychiatrist cannot be shared within the members of the patient’s family. However, it can be shared to the medical staff to help out with what kind of medications may help for the patient.
What is in a psychiatric progress note? How is it any different from any kind of medical progress note? Have you ever asked yourself these kinds of questions, as you begin making your psychiatric progress note? Don’t panic, there are steps below to help you answer these questions.
Just as you will notice with any kind of progress note, you will need the correct details about your patient. Their complete name, address, contact details and of course the assessment you have made about them. The details are important when you are making a psychiatric progress note. As these details will also be of use to the medical staff for medicinal purposes.
It is quite understandable that a lot of people may complain over the fact that the progress note may not make any sense. This is also why you must avoid making your progress note too difficult to decipher. Rather, make sure and as much as possible to make your work cleaner, clearer and more concise. That way, it would be easier for the medical staff to understand your handwriting.
Another thing to take notice of when you are making your progress notes. You are allowed to share the information with specific doctors for the medication. Which is why it is important to keep your writing clear and concise. But it does not necessarily mean you can share the information to their family members. Avoid doing that.
Lastly, while you write down the daily notes or the current notes about your patient, be attentive to how they are also feeling. It is not basically only about the general or the specific information your patient may be telling you, but it is also about how they are feeling.
A psychiatric progress note or a therapy progress note is a kind of progress note. They can also be called case notes, and they are used by psychiatrists to write as a summary of how their patient is currently feeling. They are going to be comparing their previous notes to see any progress that the patient may have at the moment.
The only time they are private is when the psychiatrist and the patient will refuse to show it to anyone but the medical staff. What is being written in the progress note is a private matter as it is only between the therapist or the psychiatrist and the patient. Anything can be written there, but it does not necessarily mean that the note can be read by just about anyone. It is considered a breach in privacy.
Avoid writing your personal opinion over a professional assessment and opinion. Your patient is not asking for a personal opinion, they need your professional opinion on their matter.
Psychiatrists or therapists are not rookies or strangers to writing down their progress notes. However, there are times when they may forget that their progress notes are also going to be used by doctors to determine the kind of medication their patients need. With the amount of information and writing, it is also best to remember to keep your writing clear in order for others to understand without problems.