Diagnosing and Treating Psychiatric Patients: A Documentation Primer for Primary Care Physicians

Summary:

The mental health care of patients should be comprehensively documented in primary care medical records, including coordination of services with other providers.

Abstract:

Because many psychiatric patients are seen in primary care settings, primary care medical records contain valuable information about their mental and psychosocial functioning. Accurate and complete documentation of psychiatric diagnoses, substantiated by the clinical content of office notes and collateral sources of information, is essential for proper treatment and medical error reduction. Primary care medical records should contain observations regarding the patient’s mental status, including any cognitive abnormalities, and the impact of the patient’s psychiatric disorder(s) on temperaments and aptitudes. The severity of psychiatric symptoms can be quantified using rating scales. Patients affected by anxiety, mood, stress, substance use, trauma, and comorbid medical and mental health disorders are commonly seen by primary care physicians. Treatment, whether provided by a primary care physician, psychiatrist, or psychologist, or combination of clinicians, should maximize the clinical effects of psychotherapy and pharmacotherapy for optimal outcomes.