Published online by Cambridge University Press: 05 March 2020
With the near-universal deployment of electronic health records (EHRs), the audience for clinical documentation is growing ever larger. People who might read inpatient psychiatric notes can be sorted into groups across several domains (Figure 9.1). Potential readers are clinicians (including trainees), overseers, patients, and participants in legal proceedings (discussed later) [1, 2]. The group of clinicians includes oneself, other team members, consulting colleagues, and the patient’s future providers. It also includes medical students, residents, and other trainees who are working with the patient. Overseers can include internal utilization review (UR) staff, individuals performing external UR (i.e., on behalf of third-party payers), internal quality assurance (QA) assessors, and external QA assessors (i.e., regulators and licensing agencies) [3–6].
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