Posted by alexandra_k on September 17, 2006, at 21:01:07
In reply to Re: Psychiatric hospital records » alexandra_k, posted by vwoolf on September 17, 2006, at 14:52:42
Mostly I read them because I was trying to figure what was wrong with me and I figured the 'experts' would have some kind of special insight into that and it would be there in my file. I wanted to know THE TRUTH. But... It isn't like that... There are just things written there... And some of them are immensely hurtful. And I'd get into this cycle of 'but I'm not like that' and 'they misunderstood' and 'but they are the experts they must know what they are talking about' and 'I must be in denial' and 'they list denial as one of my coping strategies so that must be it' and... It hurt. A lot.
> Could you tell me more about the judgemental part?
I'm from NZ. I don't know if there is a standard format for notes or whether it varies by country.
They are chronological.
There are entries from p-docs there are entries from nursing staff there are entries from psychologists. Both inpatient and outpatient all there every visit recorded in chronological order.
So my admission assessment.
Have you seen a psych assessment.
There is stuff like 'patient presented as a 18 year old european female. Dress was tidy casual and appropriate. Flattened affect Minimal eye contact. Good rapport was established. Patient said that she had been feeling depressed for several weeks..'
Lots of technical terms and fairly by the book.
Then there are the 'interpretations' which can come across as judgemental. I had to look up 'La Belle Indifferent' (however you spell that) and one p-doc noted that I had carefully manicured nails which is extremely surprising to me since I've eaten my nails to the quick ever since I was a child.
There are the ward notes. Ranging from 'patient attended ward meeting and PMR. Was observed chatting with other patients. No problems this shift'.
There are psychology notes.
There are medication notes at the back.
The facts are okayish for the most part.
The interpretations can be judgemental.I don't want to go back there... I'm sorry.
Um...
I guess I was depressed for a long time...
They were fairly sympathetic and I thought things were going okay. Then... It was like they changed. I didn't know why they changed and started saying horrible things to me.
I can track that in my notes. Things like:
'patient was observed laughing and chatting with other patients on the ward. Mood is reactive even though the patient complains of feeling depressed'.
[Innocuous enough perhaps...]
'CAT call recorded at 8.15pm. Patient complained of feeling 'bad' and 'upset'. Patient was told to practice her skills and was informed that she would not be admitted'.
Those aren't judgements.
Just facts.
'Facts'
Interpretation filters through...
Even the neutral stuff can be hurtful...The judgements... So much worse...
poster:alexandra_k
thread:686571
URL: http://www.dr-bob.org/babble/psycho/20060911/msgs/686914.html