Progress notes must convey that the psychiatrist provided quality care and respected the patient’s condition and wishes. Knowing what information to include—and what to leave out—can help you and your colleagues avoid a malpractice judgment.

Follow these 10 dos and don’ts of writing progress notes:

1. Be concise. Document all necessary information but avoid extraneous details, such as in this example:

“Patient moved to Kansas at age 4. Her parents separated when she was 6 and they moved back to Chicago, then reunited and moved to Indiana, where father took a job as a shoe salesman. When he lost that job, they moved back to Chicago and divorced for good. Mother remarried a fireman, who was an alcoholic; they stayed together for 2 years until …”

Instead, simply write:

“Patient’s childhood was chaotic with many moves; her mother remarried x 3. No physical or sexual abuse …”

2. Include adequate details. Do not exclude information critical to explaining treatment decisions. Describe the symptoms the patient is reporting and the signs you see—or do not see.

This example offers insufficient detail:

“Patient’s parents told her that they just bought a new car. She recalled the first car they had gotten when she was little, and how that made her happy. She talked about the first car she owned. Plan: Add lithium …”

By contrast, the following example explicitly describes signs and symptoms. Also be sure to include a short explanation when changing, discontinuing, or adding a medication:

“Patient reports her mood is much improved. She cannot recall what made her feel so depressed last week. She is hyperverbal, talking rapidly, gesticulating as she talks—much more animated, as compared to psychomotor-retarded presentation of last week, when SSRI was started. Assess: Bipolar switch. Plan: Add lithium, 300 mg bid, and titrate.”

3. Be careful when describing treatment of a patient who is suicidal at presentation. Your notes must contain clear, well-reasoned explanations for:

discontinuing suicide precautions

not hospitalizing outpatients who express suicidal ideation.

If the patient attempts or commits suicide shortly after the visit, your progress note may be your best—and only—defense against a malpractice claim. This example offers no convincing argument that the patient will not attempt suicide:

“Patient reports that he feels better. He denies suicidal ideation. He thinks the antidepressant is working. Nursing notes indicate no problems. He would like to get dressed and take a walk outside …”

Instead, verbatim patient statements offer more-concrete proof that the patient wants to live:

“He said he is his family’s sole support and could never abandon them …”

“He said it would kill his mother if he took his own life …”

“She said suicide is against her religion …”

Simply writing “No evidence of suicidal/homicidal ideation” raises the question of whether you asked the patient if he or she has considered suicide or just looked for a sign indicating suicidality. Always ask and record the patient’s exact response.

4. Remember that other clinicians will view the chart to make decisions about your patient’s care. Consider this example:

“Patient just moved to this area and requests amitriptyline and chlorpromazine. The risks of combining these medications were explained to him, but he insisted, so will order.”

If another provider is to grant the patient’s request, more details are needed:

“Patient states that he has been on every antipsychotic and antidepressant on the market—including the newest drugs—over 20 years. He says nothing works for him except this combination. The potential anticholinergic and other severe adverse effects associated with this combination were explained to him, and his responses indicated that he clearly understands the risks. He states, ‘These are the only drugs that have kept me from hearing voices and being depressed and suicidal. I want to stay on this combination.’ ”

5. Write legibly. Many doctors are encouraged to write illegible notes as a defense against legal action. The reasoning: the defendant can testify to anything since no one can read the notes anyway.

Illegible notes annoy and frustrate the people who cannot read them and inspire a lack of trust and confidence in the doctor who wrote them. And they are not likely to fool a jury.

6. Respect patient privacy. Do not name or quote anyone who is not essential to the record. Identifying another patient by name or Social Security number—even the last 4 digits—is a breach of privacy. For example:

“Charlene claimed R2803 followed her into the rest room and raped her…”

Did patient R2803 actually do this? What if Charlene’s psychosis prompted her to make delusional claims about other patients and staff? If her case ends up in court, patient R2803 is named in connection with an unproven allegation. Naming R2803 in Charlene’s chart identifies him as a psychiatric patient at that facility, thus violating his privacy.