Book contents
- Manual of Inpatient Psychiatry
- Manual of Inpatient Psychiatry
- Copyright page
- Contents
- Contributors
- Preface to the Second Edition
- Foreword: American Inpatient Psychiatry in Historical Perspective
- Chapter 1 The Inpatient with Schizophrenia
- Chapter 2 The Inpatient with Depression
- Chapter 3 The Inpatient with Mania
- Chapter 4 The Inpatient with Borderline Personality Disorder
- Chapter 5 The Inpatient with Dementia
- Chapter 6 The Inpatient with Traumatic Brain Injury
- Chapter 7 The Inpatient with Dual Diagnosis (Co-Occurring Disorder)
- Chapter 8 The Young Adult on the Inpatient Unit
- Chapter 9 Clinical Documentation on the Inpatient Unit
- Index
- References
Chapter 9 - Clinical Documentation on the Inpatient Unit
Published online by Cambridge University Press: 05 March 2020
Book contents
- Manual of Inpatient Psychiatry
- Manual of Inpatient Psychiatry
- Copyright page
- Contents
- Contributors
- Preface to the Second Edition
- Foreword: American Inpatient Psychiatry in Historical Perspective
- Chapter 1 The Inpatient with Schizophrenia
- Chapter 2 The Inpatient with Depression
- Chapter 3 The Inpatient with Mania
- Chapter 4 The Inpatient with Borderline Personality Disorder
- Chapter 5 The Inpatient with Dementia
- Chapter 6 The Inpatient with Traumatic Brain Injury
- Chapter 7 The Inpatient with Dual Diagnosis (Co-Occurring Disorder)
- Chapter 8 The Young Adult on the Inpatient Unit
- Chapter 9 Clinical Documentation on the Inpatient Unit
- Index
- References
Summary
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].
- Type
- Chapter
- Information
- Manual of Inpatient Psychiatry , pp. 183 - 197Publisher: Cambridge University PressPrint publication year: 2020
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