That's just medical documentation. You are taught to include everything but as concisely as possible. What happens is that you get so used to the format you use that you automatically use the same structure. It's been 5 years since I did an evaluation and I could probably write the basic format....I tried and actually did it but figured it was kind of boring so I didn't actually post it. But the narrative stream comes out without thinking. It's bizarre.

A lot of places have really specific rules about how much detail is documented and how so they feel more covered in the case of lawsuits. I know if I was told by someone that they wanted to kill themself my notes would be extremely specific in that area where I would simply note a hallucination existed and what it was and move on. Not because I didn't care but because it was more important to help the suicidal ideation and someone besides me was going to deal with the hallucination.

I have seen several evaluations my therapist has done for me for SSDI and when I went into voc. rehab. It was hard, especially the first time, to read some of it. The 2nd time he read most of it to me before he gae it to me because I was not safe to be upset and some of what he was writing was tough. Things like I lack insight, neglect hygiene at times, have problems solving problems, etc. Nothing I didn't know but it's a lot to see all at once.

I'd love to see my last ER report. I got stuff in the ER for 30 hours because there were no psych beds in the city. It was so loud and uncomfortable and I spent a lot of time reading a children's book on my kindle, making it seem like I could focus better than I really could. Then they gave meds wrong and I finally slept after complaining I couldn't sleep. But by the end I was in tears because someone in the next room was angry and violent at being brought in and he was scaring me and I was so over being in that little ER room where it was a special privilege to be allowed to brush my teeth after 24 hours and they couldn't give me my klonopin so I just cried. It was not an easy time and I was not in a good place to be stuck in the tiny psych ER for so long.