3E-2 Medical Records: How to Understand Them
Medical records can be confusing. They’re even confusing for people who went to medical school!
We’re going to walk you through some types of medical records below. Some facilities may not organize them exactly like we do. Or they may not have records for every section. But the information below should be enough to get you going in the right direction.
Biopsychosocial History
This is a summary of the patient’s medical, psychiatric and personal history. Doctors use it to see what happened in the past and pinpoint how the illness currently affects the ward. Notes of interviews with family members and significant others may be included in this medical record.
Psychiatric Diagnosis
A psychiatrist will look at the patient’s medical history, note any symptoms, and interview the patient. From that information, the psychiatrist will make a diagnosis.
Assessments
Assessments are used by doctors to determine whether a physical illness is causing or masking a mental illness.
- Physical exam
- Mental exam
- Neurological screening
- Psychiatric evaluation
- Diagnostic
- Lab tests
- Determination of daily functioning
Course of Treatment
Briefly describes the medical treatment plan, along with the plan for rehabilitative services. The treatment goal should be:
- To alleviate or reduce any symptoms and behaviors that are causing the psychiatric crisis.
- To address any functional deficits doctors found during their assessments.
Medication Orders
List of any medicines the doctor has ordered. The order will note:
- whether the medicine is a pill, patch or injection
- dosage amount and frequency
Except in an emergency, doctors must discuss all prescribed medications with the guardian before use.
Express and Informed Consent
You learned about Express and Informed Consent earlier. Before providing treatment, doctors must obtain consent. The only exception is when the ward poses an imminent danger to either themself or others. In those cases, a doctor may authorize emergency treatment until a court order or consent from someone legally authorized to act on behalf of the ward is obtained.
Goals and Measurable Objectives
A good treatment plan has customized goals for the patient. The goals should address things like jobs, relationships, housing, and money. Each goal should be measurable and lead to recovery and better functioning.
Daily Progress Notes
Medical providers document the care they deliver and the patient’s progress and status while in the medical facility.
Treatment Team Meeting Notes
Facility staff regularly meet to review the ward’s status, treatment progress, and plans. If possible and appropriate, you and the ward should be included in these meetings, and you should be allowed to provide input into the treatment plan.
Discharge Summary
This summarizes the initial problem, the treatments doctors provided, the outcomes, the arrangements for future care, and the expected recovery progress.