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

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

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