Paranoia and progress notes: a guide to forensically informed psychiatric recordkeeping.
Trainees in the mental health professions, and their teachers, might well use paranoia as a motivating force to make psychiatric records effective for forensic purposes, utilization review, and sound treatment planning. The utilization reviewer maintains a highly quantitative view, as if all forms of treatment were like poultices of a predetermined size and predetermined rate of application. The utilization perspective is, If it isn't written, it didn't happen. It is also important not to confuse progress with process notes; process material and conscious and unconscious content belong in a private set of notes, while the public records contain the facts. The author outlines other considerations, such as what to do at the realization that a significant detail was omitted from an earlier note and how to document a situation in which a clinically based calculated risk was taken.
D003134:Commitment of Persons with Psychiatric Disorders / Q000331:legislation & jurisprudence; D005260:Female; D005555:Forensic Psychiatry; D006801:Humans; D008297:Male; D008499:Medical Records; D010259:Paranoid Disorders / Q000534:rehabilitation*; D010817:Physician-Patient Relations; D011613:Psychotherapy; D014600:Utilization Review