What We’ve Said

What we’ve said about Documentation

8 points from 6 episodes, newest first

Also searched as charting, medical records, medical-legal documentation

In short

You are liable for a process, not an outcome: do the assessment within the standard of care and document it, and never write anything you would not testify to under oath. Use neutral descriptive language until you are reasonably sure, and do not let a checkbox replace the thinking it stands for. In outpatient work, document during the session, openly, and stay therapeutic while you do.

Why it matters

  1. What you are ultimately liable for is a process, not an outcome. Do your assessment within the standard of care and document it. You are not expected to be right every time, because no one can be, but you do need to follow the standard of assessment and treatment planning.

    “What you're ultimately liable for isn't an outcome. It's a process. So what you need to be doing is that you need to be actually doing your assessment process within the standard of care and also documenting it”
    56:35Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation TypesJun 2026
    Also said in 1 more episode
    “That's really more important than being right, that you followed the correct process. You're not expected to be right. It's not possible to be right all the time. This is an imperfect practice. Humans are imperfect, but you need to follow the standard of assessment and treatment planning”
    58:26Involuntary Treatment & Agency, Thoughts and Feelings | Episode 19Mar 2025

  2. Do not write anything you would not testify to under oath.

    “Don't write anything that you would not testify to under oath. OK, think about that”
    24:41Disability Claims 101 for Psychiatrists: Programs, Pitfalls, and Practical StepsDec 2025

How we write it

  1. Use neutral descriptive language until you have a more reasonable degree of medical certainty, and reserve specific terms for specific groups of diagnoses so they do not cause confusion.

    “I'm saying that you should use neutral descriptive language until you have a more reasonable degree of medical certainty and that to prevent confusion, we should reserve certain terminology for certain groups of diagnoses, certain syndromes”
    3:51What Makes a Belief a Delusion? Delusions, Thought Disorder, the TALD ScaleJan 2026

  2. In outpatient medication management you need a scribe or AI, or you document during the session. You can be psychotherapeutic while documenting; it just takes practice.

    “You got to have a scribe. You got to use AI. And me, I document during the session. I'm sorry. You can be psychotherapeutic while documenting. You just have to get used to it and know what you're doing”
    7:13Tips to Avoid Burnout in Psychiatry (Outpatient, mostly)Mar 2026

  3. Get a silent mouse and keyboard so the typing and clicking during the appointment is not noticed.

    “Get a silent mouse and keyboard. That's right. I have the Logitech MK295. So the patient doesn't know that I'm typing and clicking during the appointment”
    9:24Tips to Avoid Burnout in Psychiatry (Outpatient, mostly)Mar 2026

Talking to patients

  1. Patients always know when you are documenting, so be open about it (sometimes even say, give me a moment, I want to write that down). People do not mind documentation; they mind you doing things that are not about their treatment.

    “I think patients always know when you're documenting and I think we've got to be open about it. In fact, I'll even sometimes say, give me a moment. I don't want to write that down. I don't think people mind if you document. I think what they mind is if you're doing things that really aren't about their treatment”
    9:51Tips to Avoid Burnout in Psychiatry (Outpatient, mostly)Mar 2026

  2. Tell patients that they are the only single person who can coordinate their care and report everything to everybody.

    “you, the patient, are the only... Single person who can coordinate the care and report everything to everybody”
    48:27Lindsay Clancy Trial: A Forensic Psychiatrist Explains Psychosis, Malingering, & the Insanity DefenseSep 2026

Pitfalls and myths

  1. A box that forces people through what should be a complex thinking task ends up replacing the thinking. The box becomes a symbol in place of the actual process.

    “if you create a box that forces people to do something that properly is a complex thinking task, then it replaces the complex thinking task because it becomes a symbol in place of the actual process”
    10:23Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation TypesJun 2026

From these episodes

Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.

Educational content only. Everything here is what was said on the Psychofarm podcast, for clinicians. It is not medical advice and not a substitute for clinical judgment, current labeling or guidelines. An episode reflects what we thought when we recorded it, so check anything before you rely on it.