Continuing Patients
(revised August 2007)

For Continuing Patients

First, some philosophy about this...One of the most time consuming steps in medical care is writing the "medical record".  Traditionally this includes 4 parts:

1. Subjective data -- what the patient is thinking and feeling;
2. Objective data -- how she/he looks, talks, and acts;
3. Assessment -- what the doc' thinks explains these subjective and objective data; and
4. Plan -- what the doctor and the patient have planned to do about the current situation. 

This record is commonly called a SOAP note, reflecting these 4 parts.  The doctor usually writes all four parts, of course.  However, as a patient, you can provide the "subjective" data in a written form before your visit to save time.  This idea is not as weird as it might sound:  the Harvard Mood Clinic does the same thing with their patients, using this form.  In a few years this will be standard medical procedure, I think. 

Someday, you might be able to log the information below directly into your medical record; or graph your symptoms alongside medications you were taking at the time (here's a program that makes such a graph automatically for you).  If you will create the document described below, that is a great first step in this direction. 

One of the goals here is to allow you to talk with me without my having to take notes.  To make that work, I need you to send me this information before you come in, e.g. a day or two in advance.   The most practical way to do this is by email.  You may wish to read about the confidentiality of email, including different levels of security; of psychiatric records generally; or about computer security at Co-Psych.   

You can write the following information directly in an email note.  But to make the process easier, you might want to write it in a word processing program and then paste it into an email when you're done, or attach the file.  That way you can just pull up the last one you wrote, save it with a new date, and edit in any changes from the last time.   

Here is the information we want to end up in my head, and in your medical record:

Current Medications

Make a list of what you're currently taking.  Save this section and you can just start with it each time, with any recent changes. Here's one example, but try another format if you think it would be easier or better. 

Lithobid 300 mg: one per am, two per pm
Wellbutrin 150 SR: one twice daily
Verapamil 120 mg twice daily
Multivitamin: 1 per am
Aspirin: 1 baby size per am

Current Symptoms

1.  As you know, I usually want to start by looking at the "big picture": are things getting worse, better, or staying about the same since you were last seen?  On a 0-10 scale, where 10 is the best you've ever felt, and 0 is the worst, how are you today?

2. Specifically, what has happened to your "target symptoms" since you were last seen?  (we should have already named these symptoms as such; if not, ask about that on your next visit).

Side Effects

1. Any new ones?

2. Any old ones changing, for worse or better?

3. Weight: up, down, about the same?

New targets or issues

Do we need to adjust the focus of treatment, and identify new "target symptoms"?

Current events

Are there any current events affecting you overall?  Even if we don't adjust treatment because of it, describing an event (a paragraph or so) may help us remember what was going on at this point in time, when we look back in your record later.  For example, I might be looking for what happened when a medication was changed, and enlist your help by remembering "back when your aunt Mary was sick for 3 months from her ruptured appendix...", if we've documented that event in your record. 

Things I need to know about

You should tell me: 

• if you drink more than 2 cups of caffeinated coffee per day; 
• how many ounces of sugared drinks you have per day; 
• how many cigarettes you smoke per day; and
• how many drinks containing alcohol you have, per day or per week. 

If I'm doing my job well you won't feel blamed for any of these, and we can work them into our "big picture" plan.  

If you can do all this...Congratulations -- you're helping reform the medical care system! (one small step at least)

Thanks --
Dr. P'