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.