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

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.

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.

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.

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.