Friday, July 08, 2016

Taking Notes

When I told one of my friends that there's no way I would remember the most important, the most salient details of a therapy visit if I didn't take notes right then and there, she said, "Well, you wouldn't be my therapist. I need someone totally looking me in the eye."

I didn't tell her that I could type ninety words a minute and never have to look at the screen.

I'm not exactly sure how they teach note-taking in graduate schools anymore, hopefully the importance of a good genogram (family tree diagram that indicates alliances), among other things. In some Masters programs, surely, the old process recording is still taught.

A process recording is what is done in the courtroom. You write down, verbatim, word for word, what the client said, although he's not on the stand. It is useful in many ways, not the least of which is that when there's a need for clarification, nothing's more powerful than telling the patient, "Let me see what we talked about last time. Oh. Here it says, in your words. . . ."

People forget.

I've been deposed a few times, and in that process the lawyers on both sides of a case review your notes before the interview. They always joke about mind, tell me my notes are illegible, ask me to read back what I wrote. My response would be, Why do you think they're illegible? No one is supposed to read them but me. The writing would be difficult to discern, even for me, reinforcing the myth (maybe) about doctors and penmanship.

But that was back then, in the day, pre-electronic everything.

Shredding charts every seven years, over time, became quite the chore, and being more ecologically green, the whole thought of paper, paper, everywhere, just felt wrong. So, for a few years now, the typing began, and it is more elegant, and easier on the eyes, having the luxury of seeing words on paper and not having to wonder, What does that say?

Oh, but how to keep them safe from hacking.

Here's my system, feel free to try it. Each patient has a flash drive, their very own, that lives in the paper chart with a full name and account number, housed in a locked file drawer. Each visit, the record is typed, signed with my initials, encrypted with a password, and saved on two master flashdrives that are inserted into a USB hub that can hold several flash drives. Then, every month or so, the patient's own flash drive is inserted into that and the notes are copied to it.

This may seem tedious, but it avoids wear and tear on the flashdrives. They aren't inserted in and out so often that they lose their integrity.

Word 365 allows password encryption by going to "Review" on the menu and following instructions. Using a Mac, with "Pages," it is even easier. Go to File, set a password.

Once that note is complete, saved to the master flash drives, it is never changed, so the date never changes.

No names on any notes, no birthdays, nothing but a variation of the patient's true account number that I take off my billing program, also password encrypted on a old PC that is disconnected from the web.

Like paper charts, the master drives are locked in a file cabinet, still attached to the hub that I attach to my laptop the next time I return to the office to take notes. I turn off the Internet on my laptop while the hub with the masters is attached. Macs are supposed to be more secure, but still.

Nothing's saved on my computer. After the visit is copied to the flash drive, it is deleted.
But it is also saved on a cloud, later in the day, with visit information added to one long file, also password protected. That's done at the end of each day, when the Internet is turned on, briefly. Not that my service provider isn't safe, but it makes me uncomfortable working with patient charts.
Once the visit has been uploaded to the cloud to become a part of the patient's chart, when I need to review it, there's no waiting, no wear and tear on a flash drive. These won't last forever if they're swiped in and out regularly.

So when I need to refer to what was said last week, that's where I go, the cloud, where the entire chart is there for me to access, typed, not handwritten.

Lots and lots of passwords, but they are easy to remember because of an algorithm I made up with patient initials and two of the numbers in the account.

Here's a sample patient visit.

Pt Code and Date of Visit
Current Primary DX:
Process recording
Current Symptoms:
Plan for the week:
Long term Goals:   same  ___  new____
New Goals:
So let's say the patient's name is Jennifer McGooglestein Romiretsky. One could conceivably code her as JMR289703 if 289703. The 289703 would be the account number provided by the billing program. Or you could cut it back to JMR03-1. The 03 is the end of her account number, and the -1 means she's the first JMR03.  You might, for example, also be seeing John Miguel Robertsonsteinenvasser, who has the chart number 297403. He would be JMR03-2.

See how easy this is? And you thought therapists mostly think about despair, panic and suicide. Not so.

Now let's make up the rest of the visit note. Anything in parentheses wouldn't be in the note)
Visit Specs: Pt Code, Date of Visit, and Procedure Code : JMR03-1   6-30-16   90837
Current Primary DX:  F33.1  (Major affective disorder, depression, severe)
Process recording: OMG! I hate my life! Yesterday I slept too late, walked into the elevator with my boss. He said, "You look like ___. Why do you even bother coming to work?" And truthfully, I couldn't make it through the day, not sure how I did, and on the train home I fell asleep, realized I'd left my phone at work. I don't even know if I can stay awake for this visit.
(etc. only write what feels important)
Current Symptoms: fatigue, hopelessness, hypersomnia, 
Plan for the week: See Dr. Promtigyoplicweiner for medication re-evaluation, use imagination exercises discussed last week
Long term Goals:   same  _x__  new____
New Goals: none
           TD   (your initials)

How easy is all of that? Feel free to ask questions.


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