Your documents
The writing in psychiatric practice
In psychiatry, the notes record what the patient says and the way they say it. The documents are long, and many of them hold things a patient has told no one else.
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Initial assessment
Presenting complaint, psychiatric and personal history, mental state examination, risk and formulation. Several pages, written after a long interview, often in A&E or on the evening of an admission, while other requests keep coming in.
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Progress notes
Mental state that day, medication, leave and incidents, in the record of a patient on the ward or under the community team. Short, but written several times a week for every patient.
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Discharge and clinic letters
At discharge or at a handover of care, for the GP or the team taking over: diagnosis, medication, follow-up and the early signs of relapse. You have to choose what goes in the letter and what stays in the record.
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Tribunal reports
For a mental health tribunal: the history, the current mental state, the risk and your recommendation. They describe the clinical picture in carefully chosen words, and they tend to arrive in weeks that are already full.
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