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PRACTICE GUIDELINES
GUIDELINES OF PRACTICE FOR MEDICAL PSYCHIATRIC PARTIAL HOSPITALIZATION
The Guidelines of Practice for Medical Psychiatric Partial
Hospitalization were developed by the Professional Standards Committee of the
Texas Society of Psychiatric Physicians and were adopted by the TSPP Executive
Council on February 27, 1994. An amendment to the document was adopted by the
TSPP Executive Council on April 26, 1998.
These Guidelines are not considered to be prescriptive for all patients due
to the wide variety of circumstances associated with the presentation of
patients for psychiatric care.
GUIDELINES
A. Criteria for Psychiatric Partial Hospitalization in a Medical Setting
1. A Medical Director is a psychiatrist who is licensed to practice medicine,
who is either Board Certified or on an approved path toward certification, and
who is credentialed and privileged by the Medical Staff to oversee and be
responsible for the clinical care of patients, the Quality Assurance Program,
and the Utilization Review Program of the Medical Psychiatric Partial Hospital.
2. Each patient must have an attending psychiatrist who is responsible for the
patient's care and treatment plan. The psychiatrist must be privileged, and
credentialed on the hospital Medical Staff.
3. A physical examination and a psychiatric history should be done and be
documented on the patient's chart.
4. Vital signs are done and monitored in an appropriate fashion as ordered by
the attending psychiatrist, and are documented in the patient's chart.
5. Appropriate laboratory and diagnostic work-up are done as ordered by the
attending psychiatrist, and are documented in the patient's chart.
6. Appropriate medicines are given and are monitored for potential side effects
as ordered by the psychiatrist from orders written in the medical chart.
7. A Quality Assurance, Risk Management, and Utilization Review Program are
active and in place, and are monitored by the Medical Director.
8. A clinical psychologist is available for psychometric testing.
9. A psychiatric social worker is available for social histories, group therapy,
and family therapy.
10. A nurse is present at all times to monitor the patient's physical and
psychiatric status, and for the administration of medications and observation
for potential side effects.
11. Activity therapists and mental health workers are available to conduct
appropriate therapeutic modalities as ordered by the attending psychiatrist.
12. A pharmacist is available to consult on potential negative interaction of
medications and side effects.
13. A laboratory is available to perform emergency lab work.
14. An emergency room is available to handle acute medical emergencies.
15. A psychiatric inpatient unit is available for immediate transfer for acute
psychiatric emergencies.
B. General
1. These guidelines are those considered by the TSPP Professional Standards
Committee to be the minimum guidelines for the delivery of quality
care for patients hospitalized in a licensed medical psychiatric partial
hospital facility.
2. The attending psychiatrist (or his or her psychiatrist designee) shall have
responsibility, which shall not be delegated to a non-physician, for the
admission or transfer to a partial hospital service.
3. The attending psychiatrist (or his or her psychiatrist designee) is
ultimately responsible for the patient's treatment. The psychiatrist shall have
primary responsibility for the following, which shall not be delegated: review
of physical examinations; review of consultations; review of progress notes;
review of vital signs; review of medications; review of laboratory work;
personal contact with the patient; informal discussions with staff members
concerning the patient's progress; progress note documentation; treatment team
leadership; and, decisions about discharge.
4. The attending psychiatrist (or his or her psychiatrist designee) shall comply
with existing laws regarding involuntary commitment, confidentiality, informed
consent, patients' rights, patient abuse and neglect, and shall conform to the
standards and guidelines of the American Medical Association and the American
Psychiatric Association regarding ethical conduct.
5. If the psychiatrist's practice deviates from these guidelines, the reasons
for this must be documented.
C. Admissions
1. No patient should be admitted to a licensed medical psychiatric partial
hospital facility prior to examination by a physician within 72 hours of the
admission.
D. Physician Visits
1. Patients being treated in medical psychiatric partial hospital services and
who are attending such services at least five (5) days per week, including
children and adolescents, will be seen by a psychiatrist a minimum of two (2)
days a week. Patients attending medical psychiatric partial hospitalization less
than five (5) days per week will be seen by a psychiatrist a minimum of one (1)
day per week.
2. Sufficient time shall be spent on visits with each patient and with hospital
staff to ensure that the patient's current clinical status has been adequately
assessed and the course of treatment appropriately monitored and modified if
needed.
3. Group treatment cannot substitute completely for individual contact; the
psychiatrist shall see patients individually (ie without other patients present)
at least one (1) time per week. Even if a group approach is used, the patient
has the right to see his or her psychiatrist without other patients present.
4. If group psychotherapy is considered to be one of the two weekly visits for
those patients attending partial hospitalization at least five (5) days per
week, it will last at least forty-five (45) minutes and include not more than
twelve (12) patients. Community meetings or administrative groups, regardless of
size, will not be considered to be group therapy.
5. Psychiatrists will 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.
E. Documentation
1. An initial assessment will be done and documented by the attending or
responsible psychiatrist within one (1) working day of the patient's admission.
2. Assessment parameters which should ordinarily be part of psychiatric
evaluation include:
a. A mental status examination and a clinical
interview, to include chief complaint or presenting problems, history of present
illness, past psychiatric and medical histories, family and developmental
histories, and medical review of systems (including medications, drug use,
sexual activities, history of sexual abuse, alcohol and tobacco use, known
allergies, and any other pertinent information). If the patient has been
transferred to medical psychiatric partial hospitalization from another level of
care, a copy of the original Psychiatric History and Mental Status Examination
will be placed in the new chart, and a transition/update progress note will be
entered into the record by the psychiatrist.
b. Physical examinations, including appropriate lab or other
diagnostic data will be a part of the medical record. Physical examinations will
be completed within three (3) working days of admission. The medical record will
also have included in it appropriate lab data or results of other diagnostics
where appropriate. It is understood that, as physicians, psychiatrists may
choose to perform their own physical examinations for their patients, when
indicated. In those cases where the patient has been transferred to medical
psychiatric partial hospitalization from another level of care, a copy of the
original physical examination and copies of any lab work or diagnostic results
will be placed in the new chart.
c. Appropriate use of other sources of information, such as
interviews with family members, psychological testing, and other data sources.
d. Documentation in the patient's medical record should be
made of the essentials of the presenting complaint, history, mental status
examination, physical condition, diagnosis, treatment plan and response to
treatment, including recommendations and data about any medications prescribed.
Documentation throughout the medical record will be sufficient to allow a
psychiatrist unfamiliar with the patient to understand the rationale for partial
hospitalization and treatment.
3. It is implied with the admission of a patient to a medical psychiatric
partial hospitalization program that he or she is neither actively suicidal
and/or homicidal. Such patients will not be admitted to medical psychiatric
partial hospitalization settings. Should a patient who is in medical psychiatric
partial hospitalization become actively suicidal and/or homicidal, he or she
shall be reevaluated and considered for immediate transfer to a more restrictive
level of care.
4. A comment by the physician concerning the patient's condition will be entered
into the medical record at the of each visit. If there are significant changes
in the patient's condition or in the treatment, these will be entered in the
record at that time.
F. Treatment Team Contact
1. The attending psychiatrist (or his or her designee) will have sufficient
direct contact with those treatment team members carrying out his/her treatment
plan to be able to take an appropriate leadership role in the treatment team.
This direct contact ordinarily will take place one (1) time per week. If the
treatment team members do not make themselves available for formal staffings or
informal direct contact, the psychiatrist should vigorously address this with
the hospital or day hospital administration.
G. Medications/Treatment
1. Except in an emergency, or with over-the-counter medications, patients will
be seen by a physician before newly prescribed medication is ordered or started.
It is generally accepted that patients in medical psychiatric partial
hospitalization are expected to be responsible for their own medications.
However, patients in a medical psychiatric partial hospitalization setting may
have medications administered to them by staff as ordered by the psychiatrist.
Reasons for this can include (but are not limited to) the following:
a. IM administration of long acting
neuroleptic medications.
b. One dose orders for antidepressants, anxiolytics, or
antiparkinson drugs when problems/needs arise during partial hospitalization
attendance.
2. Before prescription of any treatment, including medication or
electroconvulsive therapy, the psychiatrist shall have carefully assessed the
risks of such treatment and decided that they were outweighed by the potential
benefits. Potential side-effects and benefits of the treatment shall be
discussed with the patient and/or another person responsible for the patient.
This discussion should be documented in the medical record. Appropriate informed
consent should be obtained from the patient or his or her guardian.
3. Psychiatrists will be generally familiar with the hospital's charges for
treatments and services administered under his or her direction. He or she will
be familiar with his or her own charges and will respond adequately to questions
from the patient and/or his or her family about physician charges and general
hospital charges.
4. No treatment modality will be administered unless ordered by the attending
psychiatrist (or his or her psychiatrist designee), or consulting physician. The
psychiatrist is responsible for supervising the patient's treatment and deciding
the appropriate length of hospitalization. The psychiatrist shall protest any
efforts by hospital administration or third party to interfere in a medically
required treatment plan.
H. Consultation
1. Consultation with another psychiatrist will be sought whenever the treating
psychiatrist is in doubt about the patient's treatment or whenever the patient
requests it.
Notes:
1. On April 26, 1998, the TSPP Executive Council adopted an amendment to change
the title of the document to Guidelines of Practice for Medical Psychiatric
Partial Hospitalization and to change references to "standards" in the document
to "guidelines" where appropriate.
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FEDERATION
OF TEXAS PSYCHIATRY