Over the course of the past week or so I've been confronted by the question of what is enough when collecting information for a crisis assessment. These are the assessments conducted on the patient who presents in a behavioral health "crisis". The purpose of the assessment is to determine the most appropriate level of care and safety plan so the patient can be directed at the end of the session.
In general, this is a routine intervention. Get a little history to flesh out the presenting problem and make some recommendations for follow-up care.
It is a problem when the documentation does not support the diagnosis or justify the recommended level of care. At least that's the way my thinking has evolved.
Guiding Principle 1: Albert Roberts, PhD 7-stage crisis intervention model.
Guiding Principle 2: The patient's medical record describes the patient.
Guiding Principle 3: Recovery works best when the patient can see individual crisis events and treatment episodes as part of a continuum.
It offends my professional ego when these principles are violated/ignored/not attended to. Period. Breathe...1...2...3...4...5...better now....
But then I ask if I'm just being pretentious or overbearing or taking some other negative stance.
Probably.
And, I wonder, because I can't not argue with myself, what is the minimum of good documentation? Certainly there must be enough story to justify a diagnosis and medical necessity for the recommended level of care. I guess that can be done in 5 sentences or less.
But I doubt it. "When in doubt, get more history" one of my professors used to say. Should I say, "doubt is good?"
Yes, if it can be documented....
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