This column was originally posted on Jeff Keller’s blog, Jail Medicine.
According to the fitness tracker I wear on my wrist, I slept for 7 hours and 13 minutes last night. I was restless eight times and woke up twice. What does that tell me? No idea. The Centers for Disease Control tell us that adults need seven or more hours of sleep each night. But what if I feel refreshed after five hours? Am I unhealthy? What if I slept 10 hours? Am I super healthy?
Mental health is idiosyncratic. What I define as healthy from an emotional standpoint is not likely to be the same as you would define it. This is true for our patients as well. Unlike physical health, we don’t have objective markers to define clinically significant depression or psychosis like we do with blood pressure or body temperature. We must rely on subjective markers and compare those markers to the patient’s baseline.
What is a baseline?
A baseline is defined as “a usually initial set of critical observations or data used from comparison or a control” according to www.merriam-webster.com. Before we can accurately assess a patient’s current functioning, we need to understand the patient’s “normal” level of functioning, likely to be unique to the patient.
Often, we need to rely on the patient to tell us about baseline. So, in my case, sleeping for a little over seven hours and waking up a few times is completely normal for me. No problems there. But with our correctional and psychiatric patients, self-report is not always reliable due to inability to self-reflect, poor memory, lack of trust and the intent to deceive, among a myriad of other reasons. Our best bet for understanding a patient’s baseline is our clinical documentation. What I write in the patient’s record today serves as a point of reference for me and all other clinicians treating this patient.
The value of documentation
Clinical documentation is not only a legal record of services provided to a patient, it is also a communication tool. It allows a team of providers to communicate with each other (and over time with themselves) about a patient’s functioning. Consider the following entry regarding a patient’s mental status:
“Patient Ox3. Mood euthymic, affect appropriate. Denies suicidal ideation/homicidal ideation. Reports no problems with sleep or appetite. Needed some redirection to stay on topic, as speech was tangential at times, slightly pressured, normal volume. Mildly disheveled in appearance, no odor. Cooperative with session, limited insight. Judgment WNL”
How’s this patient doing? Not a clue. If he’s normally smelly and distracted, angry and loud with active delusional ideation, he’s doing great. If he’s normally well-groomed, focused, quiet and sullen, we may have trouble on our hands.
Now, what if I tell you that this mental status description has been written in the mental status section of this patient consistently, for every session, for the past six visits? I think we have at least two choices – one is that the patient is at his baseline and has been for six weeks and the second is that we have a lazy clinician who is copying and pasting, note after note, the same mental status for this patient.
We need to be thoughtful about documentation. We need to write progress notes, not just status notes. We need to describe where the patient is along the path to mental health, rather than just taking a snapshot of this patient today and describing what we see in the absence of context. And we need to read each other’s notes.
I have previously written about treatment planning and the need to define where a patient is headed. Progress notes are the record of how the patient’s doing in getting to those goals. We need to be explicit about where the patient is today versus where he was yesterday, against where he’s headed tomorrow. Progress notes keep track of our patients and provide a way for the team to see how the patient is doing over time. If a psychiatrist sees the above patient the following week and notes a dejected patient who reports little sleep and a poor appetite, the psychiatrist will be immediately aware of a change in functioning and act appropriately, thanks to your documentation and the psychiatrist’s diligence about reading what you wrote.
My takeaways for today are simple – write a progress note, not a status note, and review the record. Document thoughtful and accurate descriptions of where the patient is today in comparison to previous sessions and in light of treatment goals. Read what you wrote previously as well as what others wrote recently, so you can clearly see how best to support patients in achieving their highest level of functioning and wellbeing.
