You won’t believe the stuff I saw today (part 2)

February 24, 2008 at 2:50 pm (Clinical rotations)

In most areas of medicine, you will encounter fairly mundane diagnoses carried by ordinary people. For example, a primary care physician might see 30 patients in one day, 25 of whom came in for cholesterol checks, blood pressure checks, or sugar checks. In psychiatry, however, each day brings with it a chance to meet the nation’s greatest citizens. Just this past week I met the inventor of the Knight Rider car, three millionaires, and a four-star general in the Air Force who ensured me that his commitment to the hospital was a mistake and that everything would be okay if I would just contact the Pentagon for him.

While documentation is important in any medical field, I have learned the art of buffing a chart on this rotation. On every other clerkship we students diligently note all of the patient’s complaints, their disease history, and all the findings on the physical exam. We do not bend any of the patient’s information, nor do we editorialize to make the patients seem sicker or healthier than what is presented to us. On this rotation, for whatever reason, we try to make the patients seem as ill as possible. “Buffing” is the act of adding information to a chart that was not stated by the patient, not found in the physical exam, or simply untrue for the sole purpose of trying to sway the reader in a particular direction. An example in emergency medicine might be a patient who comes in with a complaint of shortness of breath. To get the person examined by a cardiologist, you might also say that the patient has chest pain once an abnormal EKG is discovered. Buffing is highly illegal but is practiced by many physicians to varying extremes.

In psychiatry we make buffing seem like it’s a perfectly acceptable part of medicine. On any given morning I might round on a patient who tells me that he no longer hears voices and has no thoughts of hurting himself or others. He might further state that he wishes to be discharged so that he can go back home and live his life. The nurse’s report might state that the patient has been perfectly cooperative throughout the previous day, that he has mostly kept to himself, and that he slept throughout the night without any intervention or extra medication given by the nursing staff. In a chart I will then state that the patient continues to respond to internal stimuli (meaning that he’s hearing voices), that he is isolated and withdrawn, and that he needs continuous 24-hour monitoring to ensure that he is not a danger to himself or others. This practice of buffing the charts is not only encouraged—but required—by my attending.

I doubt that we will ever be caught because the laws protecting mental health charts are different than those for dealing with medical charts. In regular medicine, a patient has access to all of the information in his chart. If you want to see what your doctor has been writing about you, simply call his office and ask that your chart be photocopied and delivered to you. Mental health notes, on the other hand, cannot be revealed to a patient due to the sensitive nature of what they contain. Therefore, we already have one of layer protection separating our buffed notes from the patient’s inquisitive eyes. Further, if a court order should ever force us to turn over our notes, a patient is going to have a hard time arguing against a physician that he was “responding to internal stimuli.” We’ve done such an amazing job of painting all of our patients as psychotic, antisocial murderers that I’m sure we could charge admission fees to lectures on how to buff a chart. As my attending admitted, “Anyone could qualify to be a patient here.”



  1. Mephibosheth said,

    I don’t get it. Why buff a chart if the patient doesn’t seem to be ill anymore? Generate more money for the hospital?

  2. Ladyk73 said,

    Hm…..I am in grad school getting my MSW. I am interning at a partial hospitalization program. I am constantly….. hm…. polishing? my notes. Instead of documenting that someone is having homicidal thoughts, I sometimes use the word aggressive. Some of these guys have these thoughts all of the time (I intern at the VA). When they need to be hospitalized, the word homicide is sprinkled in the notes more often. Just my thoughts. It sounds like your rotation sucks.

  3. social worker said,

    i can generally tell who the psychiatrist is on my cases just from reading the diagnosis. lately, the diagnosis of the day is schizoaffective disorder….which really just blows my mind because it’s not all that common…and for every patient to come in with this diagnosis is beyond ridiculous.

  4. Carrie Nation said,

    I cannot fucking believe you people. You make me sick.

  5. Nia Hazel said,

    I wasn’t there to see your interaction, but what I’ve realized in working in in-patient psychiatry is that since there’s barely any objective or physical data, a patient can lie to you, much like drug and sexual hx are commonly doubtful. When a pt is discharged from in-patient is one of the highest risk of suicide. Before people attempt suicide, they may have a burst of energy and say that they’re feeling better out of nowhere. I used to believe at fact value what psych patients tell me but the more you are in that environment, the more you recognize the clues when patients lie or try to hide something. diagnosing a pt after one interview is inconclusive. On admission, you generally put in a NOS or a broad one: if they’re depressive, say depressive NOS, psychotic NOS etc then you rule out later on what brought up the psychosis, or if they’re bipolar etc. Much in the same way you can’t box a person’s identity after one conversation, you can’t do that in psychiatry either. The bottom line for in-patient is that you want to prevent your patient from killing/hurting themselves or others.

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