Modern Medicine Story

Iowa Man Reports:

D has been battling the hospital administration for two years. They are insisting that she keep two sets of medical records for her psych patients. Many man days have been spent on arguing this issue.

Unlike regular medicine, in Psychiatry there can be two type of notes kept in a psych patients medical record: Progress notes and Process notes.

Progress note is like a regular medical note: example: "patient complains of fatigue and insomnia. Drinks, smokes, takes Haldol."

Process note is a psychotherapy note: example: "this patient fidgets and admits they are confused about who they are. This may be the result of PTSD from witnessing a accident 20 years ago"

D's practice does not do psychotherapy, hence there are no process notes. I as the outside observer noted the possible confusion between the words process and progress. I then googled the words and found HIPAA regulations clearly spelling out the requirement. The hospital administration never bothered to educate themselves about the difference between the two terms. They just kept insisting that D maintain two sets of medical records.

Once the problem was defined to the top executive the two year problem was solved, in 10 minutes. One record for one patient.