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PRACTICE GUIDELINES
GUIDELINES OF PRACTICE FOR ADULT OUTPATIENT PSYCHIATRIC SERVICES
The Guidelines of Practice for Adult Outpatient Psychiatric Services was
developed by the TSPP Professional Practices Committee. After being published in
the December 1997/January 1998 TSPP Newsletter, the Guidelines were further
modified by the Professional Practices Committee on February 7, 1998 and on
April 25, 1998. The revised Guidelines were distributed to Chapter Presidents,
published in the October/November 1999 TSPP Newsletter and reviewed by the
Professional Practices Committee on November 12, 1999 and May 27, 2000. The
Guidelines were adopted by the TSPP Executive Council May 28, 2000.
I General
A. These Guidelines will be reviewed and revised periodically as the Society
continues to assess guidelines for the practice for psychiatry. They are
intended for adult patients, although certain components may pertain to
treatment of children and adolescents. These guidelines are not prescriptive for
all patients due to the wide variety of circumstances associated with the
presentation of patients for psychiatric care. If the psychiatric physician's
practice deviates from these Guidelines, the documentation can express the
rationale.
B. Our identity is as physicians with special training and expertise in the
evaluation, diagnosis, and treatment of mental and physical disorders with
biological, and psychosocial features.
C. The psychiatric physician may be involved with other physicians and/or allied
health professionals in the treatment of patients. The exact nature of the role
of the psychiatric physician may vary, and can be either supervisory, parallel,
collaborative or consultative. When clinically appropriate, further aspects of
the relationship between psychiatric physicians and other caregivers are
described in “The Guidelines of Practice for Medication Management in
Psychiatry” of the Texas Society of Psychiatric Physicians.
D. Unless coverage by another psychiatric physician has been arranged, the
psychiatric physician should be available to his/her patient at all times. The
psychiatric physician should attempt to respond within a reasonably prompt time.
II Ethics
A. The psychiatric physician must comply with the laws and ethical
considerations. The psychiatric physician shall abide by ethical guides,
including the standards and guidelines of the American Medical Association and
the American Psychiatric Association. The psychiatric physician should not take
advantage of the physician/patient relationship for personal needs.
III. Financial Issues
A. When appropriate, the terms of the treatment contract are discussed with
patients at the start of treatment, or as soon as is deemed clinically
reasonable. These terms should include an agreed-on reasonable fee, time and
place of appointments, length of sessions, charges (if any) for phone time and
missed appointments, and policies regarding third-party payers.
IV Initial Diagnostic Evaluation for Treatment Planning
A. Initial assessment parameters in psychiatric evaluations ordinarily include
the following components:
1. Clinical interview, to include chief complaint or presenting problem, history
of present illness, past psychiatric and medical histories, family and
developmental histories, medical review of systems (including medications, drug
use, alcohol and tobacco use, known allergies, and other pertinent information),
and mental status exam.
2. Access to data regarding a recent physical examination, including appropriate
lab data, or arrangement for these to be done, unless this can be shown not to
be indicated. It is understood that, as physicians, psychiatric physicians may
choose to perform their own physical exams for their patients, when indicated.
3. Appropriate use of other sources of information, such as interviews with
family members (with consent), psychological testing, and other data sources.
4. Documentation in the patient's medical record is made of the essentials of
the presenting complaint, history, mental status exam, physical condition,
diagnosis, treatment plan or recommendations, and data about any medications
prescribed.
B. Diagnoses are made using the current nomenclature systems of the American
Psychiatric Association or the International Classification of Disease. As
indicated, additional diagnostic information can be included, such as dynamic
formulations.
C. The psychiatric physician will typically use his/her understanding of
biological, psychological, and social forces in evaluation and diagnosis, in
order to design and follow through on a competent, reasonable treatment plan.
This process includes use of knowledge of medical and drug-related causes of
psychiatric disorders and symptoms, as well as the competent use of psychotropic
medications, other somatic treatments, and/or the skilled practice of
psychotherapy.
V Criteria for Outpatient Treatment
After consideration of the initial evaluation data any of the following are
indications for outpatient psychiatric treatment:
A. The patient has a psychiatric illness defined by DSM-IV or ICD9 and/or
subjective distress.
B. The patient presents with signs and symptoms indicative of a partial
remission or residual state of psychiatric illness, with significant potential
for serious regression to more severe state of illness.
C. The patient exhibits a psychiatric illness consisting of pervasive patterns
of maladaptive traits and/or behaviors, characteristic of the patient's current
and long-term functioning, which result in subjective distress and/or
social/occupational impairment.
D. The patient exhibits significant defects in cognitive, language, motor and/or
reciprocal social interaction skills, associated with maladaptive functioning
and/or subjective distress.
E. The patient is not actively and imminently suicidal and/or assaultive. If
suicidal or assaultive, such a patient will be evaluated for a more intensive
level of care (in-patient care).
VI Components of Outpatient Treatment
The treatment plan for the patient may typically consist of any of the following
components, separately or in combinations.
A. Psychotherapy services - Patient interaction in which the focus is on the
treatment of mental illness through verbal and behavioral therapies in the form
of individual or group settings. Examples include individual psychotherapy,
group psychotherapy, hypnotherapy, conjoint couples therapy, conjoint family
therapy, and psychoanalysis.
B. Medication Services - Services for the purpose of prescribing, providing,
delivering, storing, and administering medications. Services include evaluation
for the need of appropriate medication, medication monitoring, response to
medications, assessment of symptoms, assessment of impact of medication for the
individual and family, laboratory monitoring, provision of medication, physical
examinations, and medication education.
C. Medical Services - Provision of or referral for needed medical and/or dental
care.
D. Other somatic treatment services - Treatments designed to improve mental
health through treatments affecting the body. Examples include biofeedback,
electroconvulsive therapy and light therapy.
E. Social services - Provide referral to access community resources such as
housing, food stamps, vocational rehabilitation services, and legal services.
VII Documentation
A. Documentation of initial evaluation and diagnosis.
1. Documentation of the patient's initial evaluation includes the essentials of
the presenting complaint, history, mental status exam, physical condition,
diagnosis, treatment plan past or present, response to previous treatment and
any past or present medications prescribed. Documentation throughout the medical
record is sufficient to allow a psychiatric physician unfamiliar with the
patient to understand the rationale for treatment. Assessments are updated as
clinically indicated.
2. Components of the initial written assessment commonly include:
a. identifying data
b. chief complaints
c. relevant history and present status, including social history, family
history, educational and employment status, legal, military, developmental and
current available social support systems
d. determination of comorbid substance abuse and mental illness disorders and
influence of existing physical or medical conditions.
e. relevant past and current medical and psychiatric information, documented
diagnosis based on the DSM-IV or the International Classification of Disease
diagnostic systems.
f. information regarding the individual's preferences for and objections to
specific treatments
g. the needs and desires of the individual for family involvement in treatment
and services
h. strengths and natural supports
i. recommendations and conclusions regarding treatment needs.
3. The treatment plan is based on the assessment information and is tailored to
the patient’s preference where clinically appropriate. The treatment plan often
includes measurable outcomes targeted to identified symptoms/needs, individual
functioning, treatment intervention, time frames, and responsible professionals;
4. Before prescription of any treatment, including medication or
electroconvulsive therapy, the psychiatric physician carefully assesses the
benefits of such treatment and determines if they are outweighed by the
potential risks. Appropriate informed consent is obtained from the patient or
his/her guardian. Potential benefits and risks of the treatment are discussed
with the patient and/or another person responsible for the patient, and this
discussion is documented in the record.
B. Documentation of continuing treatment
1. A comment by the physician concerning the patient's condition is entered into
the medical record at the time of each visit. If there are significant changes
in the patient's condition or in the treatment, these are entered in the record
at that time.
2. Session notes record progress toward goals in the treatment plan and other
clinically significant activities or events.
3. Psychiatric physicians accurately represent in the medical record and in
billing who has seen the patient, as well as the nature, frequency, and extent
of service rendered at any time.
4. The clinical rationale for any deviation from these Guidelines is documented.
VIII Frequency of Treatment Sessions
Depending upon the initial treatment plan, patients are seen at a frequency
necessary to accomplish treatment goals. The more severely ill patients may need
more frequent treatment sessions. As the patient improves and treatment goals
are accomplished, treatment frequency will sometimes diminish and/or treatment
will be terminated.
The exact nature of the treatment will depend upon the necessary treatment plan
and will consist of various combinations of services: psychotherapies,
medication services, and medical services described in the preceding section
entitled "Components of Outpatient Treatment." Unusual circumstances might
require more frequent sessions. Psychoanalysis typically requires 4 or 5
sessions per week.
Sufficient time is spent during each visit to ensure that the patient's current
clinical status has been adequately assessed, the course of treatment
appropriately monitored and modified if needed, and appropriate therapeutic
interventions provided.
IX Termination of Treatment
The following five criteria are typically required for successful termination of
treatment.
A. Patient satisfaction with treatment - As a result of agreed-upon treatment,
the individual's needs are addressed and problems are reduced or resolved to
his/her satisfaction.
B. Symptoms management - Individuals exhibit the ability to identify and manage
symptoms of mental illness.
C. Medication efficacy - Medication regimens, if applicable, are effective in
treating the targeted symptoms.
D. Informed consent - Individuals have ongoing capacity to understand,
participate in, and consent to treatment recommendations.
E. Improved functioning - As a result of treatment, individuals demonstrate
improvement in carrying out activities of daily living and skills to maintain
and improve functioning, without significant risk of relapse.
F. Treatment goal resolution - The initial treatment goals and any subsequent
goals identified in the course of treatment have been met.
X Consultations
A. Consultation with another psychiatric physician is sought whenever the
treating psychiatric physician is in doubt about the patient's treatment or
whenever the patient requests it.
B. If the treating psychiatric physician and the patient concur on the need for
a consultation, the consulting psychiatric physician addresses his/her
recommendations to the primary psychiatric physician. It is then up to the
patient and the treating psychiatric physician to choose what course to take in
treatment or decide on the suitability of the consultant's suggestions.
C. If the patient seeks an independent second opinion, the patient should be
free to seek care from the physician of his/her choice. In the case of patient
dissatisfaction with the treating psychiatric physician, or in a treatment
impasse of any sort, the second psychiatric physician should consider
recommending that the patient and his/her treating psychiatric physician first
attempt to work out the problem themselves as a part of therapy, prior to any
change in doctors. Ultimately it is the patient's freedom of choice that
determines choice of treatment.
D. Appropriate consent (written or verbal) is obtained from the patient prior to
the psychiatric physician's communicating about the patient with other parties,
except the referring physician and others permitted by statute. It is considered
an appropriate standard of care for the consultant to communicate his findings
to the referring psychiatric physician. In addition, requests by patients to
have a record of treatment sent to other physicians or mental health workers are
honored.
XI Source Documents
1 . Houston Psychiatric Society - Standards of Practice for Outpatient
Psychiatric Care
2. Texas Department of Mental Health and Mental Retardation - 1997 Mental Health
Community Services Standards
3. Texas Society of Psychiatric Physicians - Standards of Practice for Medical
Psychiatric Partial Hospitalization
4. Texas Society of Psychiatric Physicians - Standards of Practice for Inpatient
Psychiatric Care
5. American Psychiatric Association - Draft Criteria for Psychiatric Standards
for Admission/Intensive Nonresidential/Outpatient Treatment
6. Texas Workers' Compensation Commission - Mental Health Treatment Guideline
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FEDERATION OF
TEXAS PSYCHIATRY