The therapeutic discharge II: An approach to documentation in the setting of feigned suicidal ideation

Abstract

Objective: The therapeutic discharge of patients assessed as misrepresenting suicidal ideation, though in the best interests of the patient, physician, and health care system, is an inherently risk-assuming action. The rationale and conduct of the therapeutic discharge has been written on previously. Here, we propose a method of documenting the therapeutic discharge in a way that is useful and teachable.

Method: After describing some other types of note-writing that can be needed in the care of deceptive patients, we describe an approach to each of the major sections of an initial consultation/encounter note as it applies to the therapeutic discharge.

Results: Each note section is handled slightly differently than ordinarily. The history of present illness follows the sequence, rather than the re-organization of the information obtained. The past medical history requires and reflects a more granular chart review than is usually warranted. The mental status exam is less cross-sectional than usual. The assessment and plan incorporates several components that reflect a reasoning process specific to the therapeutic discharge.

Conclusion: While labor-intensive, the documentation approach advocated for and exemplified here reaffirms aspects of one's identity as a physician, ensures responsible execution of a risk-involving decision, and potentially simplifies subsequent patient encounters.

Keywords: Consultation psychiatry; Deception; Factitious disorder; Malingering; Therapeutic discharge.