Psychiatric Evaluation Reports
During the initial evaluation (diagnostic interview) of a new patient, the resident should record handwritten notes with information such as history, mental status, and disposition on the “Psychiatric Evaluation” form included in each new patient file. As soon as possible after the initial appointment, the formal psychiatric evaluation report is to be dictated by the resident to the clinic transcription service. This dictation needs to also include the name of “clinic attending-of-the-day.” Information such as dictation job number, date dictated or any other pertinent information should be noted on the handwritten evaluation form in the chart.
A rough draft of the transcribed report will be given to you for corrections and/or editing by you and the attending physician and then will be returned to the transcription service. The final report will be prepared for your signature. After the attending physician also signs the final report, it will be filed in the patient file.
Release of Information
An Authorization for Release of Information, signed by the parent/guardian, must be in the patient file in order to:
- Speak with or send anyone information concerning the patient (or to even admit the patient is seen in our clinic);
- Send or discuss patient information with the school;
- Give the parent/guardian any written information concerning the patient (psychiatric evaluation, psychological evaluation, etc.)
Acceptable Authorization for Release of Information forms sent to us by other agencies, physicians, etc. must contain the phrase: “including psychiatric and/or psychological information.” Therefore, releases requesting medical record information without the above referenced phrase are not acceptable releases for psychiatric information.
As provided by the Florida Statutes, when psychiatric or psychological records are requested by the patient or the patient’s legal representative, the health care practitioner may provide a report of examination and treatment in lieu of copies of records.
Laboratory Services
Pathology
The residents can request a variety of tests helpful in the management of their patients. The laboratories at Shands at AGH serve our inpatients at Shands at Vista, while the tests for our outpatients are performed at Shands at UF laboratories. The central laboratories at both hospitals perform all laboratory studies including emergency studies at night and on weekends. The lab results are available on the central computerized network HIS and all the residents are required to have access to this system.
The University of Florida Diagnostic Referral Laboratories (UF DRL) is a resource for physicians throughout the Southeast. They offer a range of diagnostic and prognostic tests that include applications of advanced technology and the latest research findings.
Electrocardiograms
Technicians perform electrocardiograms at all times at Shands Hospital. The pediatric cardiologists review the EKGs and results are available on the centralized computer system. Residents can also request consultations with cardiologists, if indicated.
Radiology
The Division of Child and Adolescent Psychiatry benefits from the full range of services provided by the Department of Radiology. Procedures such as CT scans, ultrasonography, nuclear medicine studies and angiography can be performed on routine and emergency basis. The residents, after consultation with faculty, can request these studies by filling in the appropriate request forms.
Electroencephalograms (EEG)
The Division of Pediatric Neurology performs the EEGs. Residents can request the EEG studies for their patients by filling request form and providing relevant data.
Library Services
Residents have full access to UF Health Science Center Library, which strives to be a leader and innovator in meeting the educational, research, clinical, and administrative needs of the residents by:
- Providing equitable access to information and knowledge when and where it is needed
- Promoting skill development in support of independent information management and lifelong learning
- Evaluating and acquiring relevant information resources reflecting the dynamic nature of biomedicine
- Providing an inviting environment conducive to exploration, discovery, and understanding
- Investigating, developing, and utilizing technological advancements in information management and delivery.
- The UF Health Science Center Libraries serve as a major biomedical resource by:
- Collaborating with other UF Libraries in supporting the educational needs of the students, staff, and faculty of UF
- Serving health professionals, health care consumers and residents of the State of Florida
- Cooperating with the National Library of Medicine in serving the southeastern United States.
Additionally, the Division of Child and Adolescent Psychiatry is equipped with a small library within the division to serve the residents’ ongoing needs locally. Residents have access to the worldwide web, video equipment to tape interviews for teaching purposes and a collection of useful references, used commonly in the practice of child and adolescent psychiatry
