A Question on Note-taking


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Last year when my physician was away, I visited another doctor. It was a minor problem, but because of insurance regulations the new doctor was required to do a complete intake on me. This took roughly forty-five minutes, and throughout the entire interview he typed my answers onto a standard form that was on a computer.

One can view this in a number of ways. Perhaps it is good that there is “a high level of being thorough.” On the other hand, it seemed wasteful. It was not relevant to my presenting complaint. And I had to get into a long discussion about not wanting the flu vaccine. Apparently there was some regulation that “they” had to ask everyone who came in the door this question: another aspect of managed care.

I have heard that there is one place where therapists work wherein the sessions are now one-half hour and throughout the session the therapist fills out a form. This may make for organized records, but who wants to open up when everything that is said is being recorded?

The medical and psychological fields are going in an uncharted (oops, pun) direction. It seems worthwhile to ask a question: “Is this what therapists and their clients want?” and to listen carefully to the answers.

Here is what the experts, Kaplan and Sadock, say about note-taking in their standard textbook, Synopsis of Psychiatry.


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