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Q: One of your relatives is a psychiatric patient and wants a copy of her medical records for her personal use. She wants to see what information is in her records. Her doctor will only give her the
general medical records but not the psychiatric notes. What is the difference between general medical records and psychiatric notes? Can you think of a time when psychiatric notes would be released?
A: The difference between general medical records and psychiatric notes: The terms medical record, health record, [ and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. The medical record includes a variety of types of "notes" entered over
time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. Psychiatric Notes means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. **During many court cases, psychiatric notes would be released to show how a patient was during a given time. These notes are used to either help the defendant or go against the defendant's story. ]
Expert answered|emdjay23|Points 2712|
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Asked 11/8/2013 8:49:53 AM
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