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Hosp Community Psychiatry. 1980 Jul;31(7):479-82.

Paranoia and progress notes: a guide to forensically informed psychiatric recordkeeping.


Trainees in the mental health professions, and their teachers, might well use paranoia as a motivating force to make psychiatric records effective for forensic purposes, utilization review, and sound treatment planning. The utilization reviewer maintains a highly quantitative view, as if all forms of treatment were like poultices of a predetermined size and predetermined rate of application. The utilization perspective is, If it isn't written, it didn't happen. It is also important not to confuse progress with process notes; process material and conscious and unconscious content belong in a private set of notes, while the public records contain the facts. The author outlines other considerations, such as what to do at the realization that a significant detail was omitted from an earlier note and how to document a situation in which a clinically based calculated risk was taken.

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