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.