Abstract

In Reply: Because cases of outright fraud are relatively rare and obviously wrong, Dr. Shih and I focused most of our attention on cases in which psychiatrists tailor charts for the benefit of their patients. I agree with Dr. Ginsberg that even the seemingly good reasons for tailoring charts are short-sighted. They tend to ignore the effects on professionalism, social trust, and systems of care. Payers, providers, and patients all need to take a long-term view that fosters a cooperative and honest system of care. Dr. Melnick adds to the ethical discussion by raising issues that Dr. Shih and I did not adequately address. We all agree that effective communication needs to be audience directed. The problem is that the medical chart addresses multiple audiences. The chart is used by physicians who are trying to provide treatment, by reviewers who are trying to control costs and monitor quality, by lawyers who are trying to argue cases, and by others as well. Notes that are tailored to one particular audience can hinder the work of others. But what if some audiences use the notes in an unfair way? Are psychiatrists justified in tailoring charts, when they know that lawyers