Introduction
Documentation is a key medium in a clinical setting for conveying vital information concerning the patient. Concerned with the diagnosis, treatment, and results of each individual patient. Exchanging information between physicians, other providers, and payers. Needs to provide anticipatory responses to inquiries.
The Purpose of Documentation
Documenting behavioral health care records, whether on paper or digitally, improves patient safety, error reduction, service quality, and regulatory and payment compliance. These data also allow other experts to understand the patient’s history, allowing them to continue delivering the most effective treatment for each patient. Thorough and precise documentation reduces hazards for malpractice claims. In the case of a lawsuit for behavioral problem patients, a well-documented record reduces culpability. One is unlikely to recollect the details of a case from many years earlier when making a professional responsibility claim. In this case, one’s own documentation will be most useful. Well-documented medical records may streamline revenue cycle processes, speed up payment, reduce claims processing issues, and ensure correct reimbursement.
The Primary Diagnostic Systems Used in Behavioral Health and How They Work
The American Psychiatric Association (APA) released the DSM’s most recent version, the DSM-5, in May 2013. Psychiatrists, psychotherapists, and other medical practitioners may utilize the manual’s diagnostic criteria, symptom lists, and recommendations to assess if a patient or client fulfills the requirements for one or more disorder categories. It develops uniform and trustworthy diagnostic categories for studying mental diseases, and it standardizes the terminology used by physicians when discussing their patients. For instance, a doctor may use the information that the DSM provides for bipolar disorders to identify diagnostic criteria to follow in identifying these disorders in a patient. In the past, the World Health Organization (WHO) provided its method of classifying mental disorders within Chapter V of the International Classification of Diseases (First et al., 2013).
This method has been primarily utilized to calculate reimbursement costs and national and international health statistics. For instance, a doctor could use the ICD to establish the probable causes and consequences of anxiety disorders in a patient.
The Differences Between Electronic Health Records (Ehr) And Electronic Medical Records (Emr)
A patient’s electronic medical record (EMR) is the electronic equivalent of a paper chart used inside a single medical facility. The patient’s electronic medical record contains information on the patient’s medical history, diagnoses, and treatments received from specific physicians. Contrarily, an electronic health record (EHR) is a digital replica of a paper document that includes a patient’s whole medical history. Authorized users throughout a network of healthcare providers have real-time access to electronic health records (EHRs) of their patients (Table 1).
The Strengths and Limitations of Having Client Records Available in a Database
Strengths: Digital records are easy to read, unlike physicians’ often illegible handwriting. This reduces errors in areas like diagnosis and medical instructions, which may have catastrophic consequences. Precision in record-keeping speeds diagnosis and insurance claims submission, improving healthcare service.
The office and medical personnel no longer spend time looking for information in stacks of files. Digital information may be readily accessed with a few clicks. Doctors and patients may benefit from this advancement. A database system may assist providers in saving space and time by reducing paper charts. Patients may also access their health data via a database system’s gateway. This reduces the need for the patient to contact or visit for information that is easily accessible online.
Limitations: Hackers may attack database systems like any other computer system. The theft of sensitive medical records might harm patients and healthcare facilities. Risks and challenges accompany the transition from paper to digital medical records. Clinicians may be held accountable if they fail to give patients all relevant medical records, even if they are in electronic form, and should be easy to get. Moreover, establishing and switching to a new medical records system would cost a lot of money.
Conclusion
Behavioral health workers prioritize patient care. Thus, thorough, accurate, and timely recording of each patient encounter is necessary to address patient needs, including treatment organization. Professionals use written documentation to communicate and collaborate. The succeeding practitioner may be unable to give proper treatment without thorough and accurate documentation.
References
Bassingthwaighte, A. (2020) The social construction of the DSM-5 & its impact on patient dignity. [Masters Thesis, Brock University]. Brock University’s Digital Repository.
First, M. B., Gaebel, W., Maj, M., Stein, D. J., Kogan, C. S., Saunders, J.B., Poznyak, V.B., Gureje, O., Lewis-Fernández. R., Maercker, A., Brewin, C.R., Cloitre, M., Claudino, A., Pike, K.M., Baird, G., Skuse, D., Krueger, R.B., Briken, P., Burke, J.D., Lochman, J.E., Evans, S.C., Woods, D.W., & Reed, G. M. (2021). An organization‐and category‐level comparison of diagnostic requirements for mental disorders in ICD‐11 and DSM‐5. World Psychiatry, 20(1), 34-51. Web.
Fritz, Z., Griffiths, F. E., & Slowther, A. M. (2021). Custodians of information: Patient and physician views on sharing medical records in the acute care setting. Health Communication, 36(14), 1879-1888. Web.