What is the difference between general Medical Records and Psychiatric Notes?

In the healthcare field, documentation is an essential component to providing excellent patient care. It can be in the form of medical records, clinical notes, or test results. Whatever the form is, clear and accurate documentation is the primary way to assess patient needs and ensure the right treatment.

General medical records and psychiatric notes are equally important, but there is a clear distinction between them. This article will help you explore the main differences between the general medical record and psychiatric notes.

What are general medical records?

A general medical record is an organized documentation of a patient’s medical history and the health services provided by various health care providers for a certain period of time. Other terms that are interchangeably used are medical record, health record, or medical chart. 

Generally, a medical record contains all the information related to patient disease, diagnosis, treatment, prognosis, and payment records.

The information added in it helps the healthcare professionals know about the patient’s condition and plan to provide informed care. It is also a way of communication among patients, healthcare providers, and healthcare professionals.

Healthcare professionals can add various types of notes to the medical record. Traditionally, the type of notes that are part of the medical record is admission notes, drug administration notes, treatment notes, x-ray reports, test results, preoperative and postoperative notes, progress notes, delivery notes, mental health status, and discharge notes.

medical record

The medical record is considered sensitive information, and many legal and ethical issues are involved in its privacy. It requires strict security to prevent any unauthorized access or information tempering.  Although it’s a health care provider’s property, the patient can get a copy of his medical record upon request. Medical records can be subjected to state laws, but there exists great variability related to rules on their ownership, accessibility, and destruction. General medical records can be faxed with standard signatures.

An essential section of the medical record is the patient’s medical history from birth to the present. It gives an overview of the patient’s past health status. It includes demographics, chronic, major, minor illnesses, surgical history, obstetric history, allergies, family history, social habits, immunization history, growth, and development history. 

Another important part of the medical record is medical encounters by various specialists, physicians, nurse practitioners, or physician assistants. 

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What are psychiatric notes?

Psychiatric notes are the part of medical records that come under the section of medical encounters. The medical encounter involves the detailed evaluation of patients by specialists. When a psychiatrist performs that consultation, this documentation is named psychiatric notes. 

Psychiatric notes give an overview of the patient’s mental status. It helps the specialists understand the relationship of the patient’s illness with genetics and the family’s emotional aspect. It can be detailed documentation if the patient is inspected for the first time or requires hospitalization. Optionally, it can be written in shorter form in SOAP format for regular visits. 

Psychiatric notes can be added after a detailed evaluation performed in an inpatient setting or the emergency room.

Psychiatric notes cover information related to:

  • The chief complaint.
  • History of present illness.
  • Physical examination.
  • Past psychiatric history, past medical history.
  • Forensic history.
  • Substance abuse history.
  • Allergies.
  • Family psychiatric history.
  • Mental state examination (detailed information of patient’s behavior and cognition and description of consciousness, attentiveness, motor and speech activity, mood, perception, attitude).
  • Suicide or self–harm history, psychosocial history.
  • Diagnosis.
  • Informed consent.
  • Expected length of stay.
  • Treatment plan.

Moreover, just like other notes are added to a patient’s medical record with every visit, psychiatric notes are also added with every evaluation.

After the first detailed evaluation, regular psychiatric evaluation is documented daily in the form of psychiatric progress notes. These notes can help track the patient’s progress with the treatment. They can give a quick overview of the patient’s previous condition, current mental state, symptoms report, interventions delivered, short-term goals, and care plan.

As psychiatric notes are part of the medical record, they are also subjected to state laws and privacy issues. For the sensitivity of the content, psychiatric notes cannot be faxed.