The Essential EMR Checklist for Psychiatry Practices

Posted by: Aparna Prasad

The Unique Requirements of Medical Documentation in Psychiatry & Psychiatry Electronic Medical Records

Psychiatry and psychology hold somewhat unique requirements among the medical specialties in that the diagnosis itself cannot be visualized or examined in the same way as a healing surgical incision or a growing infant. The physical results of some psychiatric disorders, however, are demonstrable by physical symptoms. Anorexia, for instance, can be clearly identified by individuals untrained in medicine. Psychiatrists, psychologists and psychiatric nurses can also identify the mania of a bipolar diagnosis, the usual physical presentation of a schizophrenic patient and even the slow-motion apathy of an untreated patient in the midst of depression. The interpretation of the severity of a psychiatric patient's condition, however, can be located along the normal to pathological continuum in various -- and markedly different -- locations depending upon the patient's presentation, the familiarity of the health care provider with the disease, the length of time the patient has suffered from the condition, the number of days or weeks that medication may have been stopped by the patient and the concomitant use of prescription medications, street drugs and alcohol.

Psychiatry EMR Software

Due to the difficulty in often objectively measuring the extent of a patient's pathology due to some of the issues noted above, this discipline has long sought discipline-specific methods of documentation, whether they be paper or electronic. For many years now, psychiatry electronic medical records have sought to document the following:

  • Psychiatric-specific practice mental health intake forms or psychiatric inpatient admission details of history;

  • Questionnaires to assess for depression, anxiety and suicidal ideation;

  • Questionnaires to assess the patient's degree of orientation and participation in agreed reality;

  • Review of physical and psychiatric symptoms;

  • Psychopharmacological history;

  • Pre-loaded templates specifically designed for children, adolescents, adults and geriatrics;

  • Pre-loaded templates specifically designed for evaluation of common psychiatric disorders, such as:

    • ADHD

    • Anxiety

    • Autism

    • Bipolar Disorder

    • Delirium

    • Depression

    • Eating Disorders

    • Mania

    • Obsessive-Compulsive Disorder

    • Organic Mental Disorder

    • Paranoia

    • Personality Disorders

    • Post Traumatic Stress Disorder (PTSD)

    • Schizophrenia

    • Substance Abuse

    • Suicidal history or attempt

    • Vertigo

  • Progress Notes designed for similar evaluations among varying health care workers;

  • Treatment Plan and review of such;

  • Discharge Notes;

  • Post-discharge Follow-up.

Psychiatry EMR Software also commonly provided features to decrease the staff required for a given practice, such as:

  • Medical billing with psychiatric-specific billing codes

  • Psychiatry-specific ICD and CPT codes;

  • Appointment Scheduling;

  • Patient alerts and reminders to decrease missed appointments;

  • Specific security measures to protect access to patient data;

  • Global Assessment of Functioning (GAF) scale;

  • Medication management;

  • E-prescribing;

  • Voice-recognition or handwriting-recognition software to facilitate documentation.

EHR Incentive Program Participation & EHR Transition

Psychiatric practices still interested in beginning the waning EHR Incentive Program will need to ensure that that system is certified Psychiatry EHR Software to qualify for meaningful use. Psychiatry Electronic Health Records -- capable of following any given patient throughout all inpatient and outpatient treatments and providers -- must also indicate movement toward the following capabilities:

  • The new term, patient portal, is intended to increase a patient's ability to interact with the practice in a positive way, while improving office management and efficiency. Examples of online patient portal programs include the ability to look up and/or confirm an upcoming appointment, schedule an appointment, complete necessary forms prior to upcoming appointments or medical records update and obtain diagnosis or medication-specific educational information.

  • Tablet-oriented.

Indeed and especially for this specialty, it's a buyer's market for psychiatric practices. Negotiation is often available in regard to training staff, software installation, intensive customer service as the system becomes operational and other issues. Speak with your partners, staff and vendors in order to garner your best and most efficient package.



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Topics: Psychiatry EMR Software

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