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GUIDELINES OF PRACTICE FOR INPATIENT PSYCHIATRIC CARE
The Guidelines of Practice for Inpatient Psychiatric Care were developed by the TSPP Professional Standards Ad Hoc Committee and were initially adopted by the TSPP Executive Council on February 18, 1990. Subsequent amendments were adopted by the Executive Council on September 16, 1990, September 15, 1991, and April 26, 1998.
Recognizing that psychiatric treatment may be approached in a variety of styles, these Guidelines provide for a latitude in style while ensuring a minimal guideline of personal attention and involvement by the hospital physician with his/her patient…the foundation for good psychiatric care.
These Guidelines will be reviewed and revised periodically as the Society continues its efforts to assess guidelines of practice for psychiatry.
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.
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GUIDELINES
A. 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 hospitalized psychiatric patients.
2. The psychiatrist shall have responsibility, which shall not be delegated to a non-physician, for the admission or transfer to an inpatient psychiatric service.
3. The psychiatrist 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 psychiatrist shall comply with existing laws regarding involuntary commitment, confidentiality, informed consent and patients’ rights, and shall conform to the standards and guidelines of the American Medical Association and the American Psychiatric Association regarding ethical conduct.
5. If, under exceptional circumstances, the psychiatrist’s practice deviates from these guidelines, the reasons for this must be documented. An example of such deviation may include cases of long term patients in public mental health facilities.
B. Admissions
1. No patient should be admitted to a psychiatric facility prior to examination by a physician.
C. Daily Visits
1. Patients on general psychiatric services, including children and adolescents, will be seen by a psychiatrist a minimum of five days a week. Those patients in “intensive care” settings will be seen by a psychiatrist daily.
2. Sufficient time shall be spent on daily visits with each patient and with hospital staff to insure that the patient’s current clinical status has been adequately assessed and the course of treatment appropriately monitored and modified.
3. Group treatment cannot substitute completely for individual contact; the psychiatrist shall see patients individually (i.e. without other patients present) at least three times per week. Even if a group approach is used, the patient has the right to see his psychiatrist without other patients present. This request will be met within a working day.
4. If group psychotherapy is considered to be one of the five weekly visits, it will last at least forty-five minutes and include no more than twelve patients. Community meetings or administrative groups, regardless of size, will not be considered to be group psychotherapy.
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.
D. Documentation
1. An initial assessment will be done and documented by the attending or responsible physician within twenty-four hours of the patient’s admission.
2. Assessment parameters which should ordinarily be part of psychiatric evaluations:
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, alcohol and tobacco use, known allergies, and any other pertinent information).
b. Physical examinations, 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, psychiatrists may choose to perform their own physical exams for their patients, when indicated.
c. Appropriate use of other sources of information, such as interviews with family members, psychological testing, and other data sources.
d. Documentation of the patient’s medical record should be made of the essentials of the presenting complaint, history, mental status exam, 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 hospitalization and treatment.
3. If warranted by the patient’s clinical state, note will be made as to whether he is, in the opinion of the psychiatrist, suicidal. If there is serious question as to the patient’s impulse control, a comment about whether he is, in the opinion of the psychiatrist, suicidal or homicidal will be included.
4. A comment by the physician concerning the patient’s condition will be 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 will be entered in the record at that time.
E. Treatment Team Contact
1. The psychiatrist 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 will ordinarily take place at least once a week. If the treatment team members do not make themselves available for formal staffing’s or informal direct contact, the psychiatrist should vigorously address this with the hospital administration.
F. Medications/Treatment
1. Except in an emergency, or with over-the-counter medicines, patients will be seen by a physician before newly prescribed medication is ordered.
2. Before prescription of any treatment, including medication or electroconvulsive therapy, the psychiatrist shall have carefully assessed the risks of such treatment and decide that they were outweighed by the potential benefits. Potential side-effects and benefits of the treatment should be discussed with the patient and or another person responsible for the patient, and this discussion should be documented in the record. Appropriate informed consent should be obtained from the patient or his/her guardian.
3. Psychiatrists will be generally familiar with the hospital’s charges for treatments and services administered under his direction. He will be familiar with his own charges and will respond adequately to questions from the patient and/or his family about his own charges and the general hospital charges.
4. No treatment modality will be administered unless ordered by the 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.
G. Consultations
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. Upon recommendation of the TSPP Professional Standards Committee, the Standards of Practice for Inpatient Psychiatric Care were adopted by the Executive Council on February 18, 1990.
2. Upon recommendation of the TSPP Professional Standards Committee, the Executive Council adopted an amendment to Section C.4 on September 16, 1990, as follows:
C. Documentation
“4. A comment by the physician concerning the patient’s condition will be entered into the medical record at least three times a week the time of each visit. If there are significant changes in the patient’s condition or in the treatment, these will be entered in the medical record at that time.” (Note: This Section was changed from Section C to Section D with the amendment adopted on September 15, 1991).
3. On September 15, 1991, the TSPP Executive Council adopted an amendment to add a new Section B entitled Admissions, as follows:
“B. Admissions
1. No patient should be admitted to a psychiatric facility prior to examination by a physician.”
4. On April 26, 1998, the TSPP Executive Council adopted an amendment to change the title of the document to Guidelines of Practice for Inpatient Psychiatric Care and to change references to “standards” in the document to “guidelines” where appropriate.
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