DORIS FISCHER-SANCHEZ MSN, APN-BC, CPHRM
Assistant Vice President, Healthcare & Psychiatry Group
During the first visit, the psychiatrist develops initial impressions and a treatment plan based on the interview, physical assessment, cognitive testing, diagnostic testing and utilization of collateral resources when available. Psychiatrists are the one of the least likely medical specialties to be sued.1 When a claim is filed however, one of the most frequent reasons for litigation is medication management and/or lack of patient follow up. This article will look at some helpful strategies for psychiatrists regarding medication management and patient follow up care.
It is important to complete a thorough assessment along with accompanying documentation. Whether using a written or electronic medical record, this should be retained in your record. Having complete documentation will not only create an accurate record but in the event of a lawsuit or board complaint, documentation will be critical in defending the matter. If a patient has suicidal or homicidal ideation, it is important to reassess and document this with each and every visit. In the event that the patient does not meet inpatient commitment criteria, ensure you have proper follow up procedures with him/her in order to reduce risk.
• Policies and Procedures
In any type of outpatient setting, whether you are in solo practice or a group practice, there always is potential for follow up issues to fall through the cracks. However, it is important to have office policies and procedures in place so that issues that need follow up are addressed. These may include follow up with the patient or other providers on issues such as laboratory values, missed appointments or other issues. Make sure that you follow procedures and train your office staff to do the same upon hire and annually. Consider having periodic reviews that staff are following the policies and procedures concerning patient follow up and address issues as they arise.
• Laboratory Results
If you or another provider orders laboratory studies for your patient, consider having a “sign off” process in place so that your initials and date of review are on the document/results. Also, have a process in place to follow up with the patient in communicating results- both benign results and results that are vital to convey. In other words, inform the patient of both good and bad results and document.
Consideration should be given to: the patient’s setting, clinical presentation and the type of medication being considered and whether it requires prior and/or ongoing laboratory or other diagnostic follow up. For example, with Lithium, is there a process in place for laboratory monitoring, patient notification and follow up?
• Missed Appointments
It is common for patients to miss appointments or stop and restart treatment. If you have a patient who misses an appointment, ensure that you have a process in place for follow up. Your office should have a tracking system in place when patients miss or “no show” for an appointment. All missed appointments should be documented in the record. In addition, it is suggested that you send a letter and, in some higher-risk circumstances, also call the patient. In the event that an adverse issue occurs, documentation will be important.
In the event that a patient lapses from treatment, have a set timeframe when you send a termination letter to the patient. It is important to have documentation when your treatment ends. Treatment can certainly be resumed, however, ensure that you have a process in place when a letter will be sent. This should be for all patients within your practice and followed consistently. When terminating with a patient, be aware of your state’s regulations on what is required. Although it may not be statutorily required in your state, consider sending a letter by both regular and certified mail. This will provide additional documentation in the medical record and can refute a claim that the patient did not receive the letter.
• Prescribing Medications
When prescribing medications, it is important to discuss and document informed consent with the patient. In addition, with each visit, review with the patient how he is taking the medication. Is he taking the medication as prescribed and if not, it is important to document this. Is the patient taking the medication too frequently or sporadically? Have a system in place to make sure you are following up with the patient to address the issue. In some circumstances, you may need to terminate care or recommend that the patient seek alternative treatment. The American Psychiatric Association (APA) provides practice guidelines for over 20 diagnoses: www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines.
• Patients With Co-Morbid Medical Issues
You may have patients who have complex medical issues. There may be circumstances where you obtain sign off from the patient’s PCP or specialist, particularly when prescribing medications. As such, it may be important to have consent to speak to the patient’s other providers to minimize risk. Prior to prescribing psychiatric medications, have you received medical clearance, where indicated. This information should be incorporated into the patient’s medical record. In addition, have you checked the state PDMP system to determine if the patient may be on other controlled substances?
• Potential Treatment Issues
From time-to-time, you may have patients who are high-risk but do not meet civil commitment criteria. It is important to have follow up procedures in place after he leaves your office. Documenting follow up and your discussion with the patient or his family member may be important. There also may be circumstances when the patient or family member contacts you by phone to report a concerning issue. You, your staff or answering service should have a process in place where you or the covering physician would need to be contacted. Issues may occur on nights and weekends. In the event of an emergency, safety is always a priority and contacting the appropriate authorities may be indicated. In addition, in the event of an emergency, it may be necessary to obtain risk management or legal advice.
There are many risk considerations when working with complex patients in the outpatient setting. The patient has the responsibility to be an active treatment team member and inform the psychiatrist when medications are not being taken or are not effective, lab tests have not been completed or appointments cannot be kept. The psychiatrist has the obligation to provide medication management, follow up, refer when necessary and document. For higher risk and potential litigation issues, consistent custom and practice supported by policies and procedures will help mitigate risk of legal action. Do not hesitate to obtain risk management or legal advice should you have any questions.
1 Anupam, J., M.D. (2011). Malpractice Risk According to Specialty, New England Journal of Medicine, 365(7), 629-636. American Psychiatric Association (2015). Practice Guidelines for the Psychiatric Evaluation of Adults, (Third Edition): https://doi.org/10.1176/appi.books.9780890426760.pe02. Anupam, J., M.D. (2011). Malpractice Risk According to Specialty, New England Journal of Medicine, 365(7), 629-636. Peckham, Carol (2015). Medscape Malpractice Report 2015: Why Most Doctors Get Sued. https://www.medscape.com/features/slideshow/public/malpractice-report-2015#page=1