Joel Ortiz

Medical records are frequently exchanged between all professions in order to provide the best possible care for the patients. Medical records are a history of a patient’s medical history including care, previous treatment, prescriptions, diagnoses or medications taken. There are many different forms of medical records, but it seems as if none is growing more in today’s world than the records of mental illnesses. Professionals in the field inquire that, “Approximately 1 in 5 adults in the U.S. – 43.8 million, or 18.5% – experiences mental illness in a given year” (National Alliance on Mental Illness, 2018).  Every mental illness record must include the patients background and information because every single patient is unique in their circumstances. In every mental illness report there is also functional information that will document the specific mental illness that patient has as well as how it is affecting that person’s life. Another requirement of every mental illness report is the types of prescription, rehabilitation or therapy the patient has experienced. Due to its increase, it is crucial that doctors, therapist and even the average person should understand the significance of a mental illness report and the significant characteristics it contains.

In every mental illness record, there must be a section, usually the beginning, which describes the patient and the patient’s background. It is crucial to understand the patient because every single person is different therefore need their own unique care. The key features of the patient’s bio include their age, ethnicity, weight and any other significant background information including substance use, physical history and psychiatric history. Many people may believe that if two patients have the same illness they should have the same steps in their road to cure but every single person is different and react different to certain medications and rehabilitation. Knowing all this is important because unless you are a profession you can not advise someone with a mental illness just because you may know someone else who has that illness. The main purpose of a background section of a mental illness report is to give doctors and therapists a brief introduction to who the patient is and what has led to them being where they are with the illness. As demonstrated in the first sentence of a recent sample report, “Joan is a 45-year-old African American woman of medium height and is somewhat overweight” (Marshall, 2017, p. 1) the background can be very brief but mandatory just to have some insight to start the report.

The functional information will always be placed near the beginning of a mental illness report as it is important for the doctors to identify the patient’s illness, the severity of the illness and how it has and/or could be impacting the patient’s life. It is important that it is placed somewhere in the beginning of the report as it should be known right away what type of mental illness the patient is going through. This information needs to be given as soon as possible in order to access the type of issues the patient may be going through. As a result, Westgate (2017) states, “… who has a history of bipolar disorder with major depression and cocaine dependence to treat her symptoms” (p. 1) very early on in the sample report. After reading that statement a doctor or therapist immediately has a better understanding of the battles this particular patient has had therefore they would most likely take a less aggressive route with the therapy and prescriptions. The functional information may also show the frequency of the mental illness because there are some that seem to come and go, and also show the duration the mental illness has been in this person’s life. It would be recommended that this is added to any future mental illness report in order for everybody to have a better understanding of what exactly the patient is dealing with.

At the end of every single mental illness report you will find either a summary or a conclusion. They both have the same purpose which is to state the basic information of the patient’s background, information regarding the mental illness involved and the impacts it has caused, and finally a recommendation for the doctor regarding the patient’s future. This is really just briefing everything that has been discussed throughout the report but the new feature that must be focused on is the recommendation. This is crucial because many times the doctors and therapist will follow through with the recommendation due to the information the writer has gathered about the patient, so the recommendation is coming from a reliable source. In one sample report, Lime (2017) finishes the report stating, if he were to be approved for benefits, it is this writer’s opinion that he would require a representative payee to manage his funds” (p. 6). This is an example of the writer analyzing the patient and gathering information which then leads the writer to suggest certain criteria for this specific patient.

As we all know the medical field brings us new reports and information on a daily basics. New knowledge and medicine are curing people worldwide. Mental illness reports have come a long way in helping those who are having battles in their own minds. It is important that we can all compose and understand a mental illness report so that we can be part of the solution to helping others free their minds and allow their souls to live without barriers inside them. We have to stop the increase in mental illnesses report, but first we must understand them.

Reference

National Alliance on Mental Illness, NAMI. (2018). Mental Health by the Numbers. Retrieved from https://www.nami.org/learn-more/mental-health-by-the-numers

Westgate, A.M. (2017). Medical Summary Report. 1-9. Retrieved from https://soarworks.prainc.com/sites/soarworks.prainc.com/files/msr_sample_bipolar_disorder_revised_011717.pdf

Marshall, M.M. (2017). Medical Summary Report. 1-5. Retrieved from https://soarworks.prainc.com/sites/soarworks.prainc.com/files/msr_sample_personality_disorder_revised_011717.pdf

Lime, K.L. (2017). Medical Summary Report. 1-6. Retrieved from https://soarworks.prainc.com/sites/soarworks.prainc.com/files/msr_sample_schizophrenia_011717.pdf