Careers in health information technology: medical records by Institute for Career Research Editors

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Information used in the evaluation. The information used in the evaluation must be accurate and complete. Thus it should include, at minimum, 1) a detailed history of the event, its consequences to the claimant, changes in living patterns, and treatment efforts; 2) collateral information about the traumatic event, including witness statements and police reports, and interviews with family members; and 3) a psychiatric history, medical history, litigation history, and criminal record (see Resnick, Chapter 8, this volume; Simon, Chapter 3, this volume).

These kinds of questions proliferate in the courts. Although the DSM raises these questions about legally relevant behavior through the use of broad diagnostic nomenclature, it offers little guidance in their resolution. Elsewhere, I (Shuman 1989) have argued that, either in the DSM or a separate document, the American Psychiatric Association should provide guidance to the courts in defining the boundaries of accepted professional knowledge about legally relevant behavior rather than leaving this to be defined in court on a case-by-case basis—decisions often based on less than all the best, most current research.

Madison, University of Wisconsin Press, 1985 Wilkinson CB: Aftermath of a disaster: the collapse of the Hyatt Regency Hotel skywalks. Am J Psychiatry 140:1134–1139, 1983 Yehuda R (response); Sapolsky RM (reply), Stress and glucocorticoid. Science, March 14, 1997, p 1662. Also see Summerfield D: Post-traumatic stress disorder in doctors involved in the Omagh bombing (letter). BMJ 320:1276, 2000 C H A P T E R 2 Recent Research Findings on the Diagnosis of PTSD Prevalence, Course, Comorbidity, and Risk Bonnie L.

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