[Documentation in psychiatry and psychotherapy: prerequisites and clinical practice]

As a result of changes to the legal and economic framework over the past years, medical documentation has changed substantially.

Based on a literature search of important medicolegal studies and appeal decisions, an overview is given of legal principles and their practical consequences, especially for the fields of psychiatry and psychotherapy.

Documentation is a contractual and crime-related duty arising from the professional code for doctors and the legal obligation to provide documentation. In addition to being a memory aide for the doctor, its purposes are to safeguard and justify the treatment and to provide legal evidence. The documentation should be provided in a format that is sufficiently clear for specialist staff, using keywords, possibly handwritten, and use contemporary terminology. All important diagnostic and therapeutic measures must be documented. This is particularly important when the treatment deviates from standard treatment and in medical procedures aiming to protect the patient.

The legal requirements for documentation are becoming more stringent. The time spent on such activities has so far not been reimbursed by the financing bodies.