Table of Content
I. CASE DOCUMENTATION
A. The Physician Initial Note
must contain the following:
-
Date of patient contact (month, day,
year)
-
Reason for referral
-
Recent course of illness
-
Mental Status Exam
-
Clinical impressions
-
Five Axis DSM-IV diagnosis
-
Treatment plan specifying target
symptoms and behaviors
-
Documentation of completed or
non-completed Medication Consent Form
-
Prior medication trials and duration
-
Past and current
drug, ETOH and smoking use
-
Allergy assessment
-
Current medication and dose
-
Patient medical history including
concurrent disease states
-
Family history
-
Physician signature
(with degree)
-
Clinical risk
assessment for patients who are pregnant or breast-feeding
B. The Physician Progress Note,
on each medication visit, must contain the following:
-
Date (month, day, year)
-
Location where service provided
-
Type and duration of service
-
Description of service related to diagnosis, symptoms, established
goals, and expressed in terms of changes in the individual’s
functioning. If there is little progress, a clear explanation of the
limited progress must be included.
-
Description of response to/outcome of
medication therapy
-
Assessment of lab data if applicable
-
Assessment of medication compliance
-
Description of adverse drug experiences
or documentation if none present
-
Clinical risk assessment for patients
who are pregnant or breast-feeding
-
Physician signature (with degree)
C. The Discharge Summary is complete
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II. PRESCRIPTION AND
MONITORING PRACTICES
A. Informed Consent form completed and
current
B. Medication Orders
-
Each medication order includes the date,
drug name, route, strength, and directions for administration
-
Each order is signed or co-signed by the
attending psychiatrist
-
The Medication Order Sheet “Pink Sheet”
is self-explanatory, current, complete and updated on each patient
visit as indicated
-
The IM Medication Administration Record
(MAR) is completed and accurate
C. The psychiatrists must see each patient
in a face to face evaluation at least once every three months
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III. ANTIPSYCHOTIC
MEDICATIONS
A. Usual indications
-
Schizophrenia
-
Delusional disorders
-
Schizo-affective disorders
-
Schizophreniform disorder, brief
reactive psychosis, or psychotic disorder NOS
-
Bipolar disorder
-
Major depressive episode with psychotic
features
-
Borderline personality disorder
-
Other appropriate indications as
documented
B. Antipsychotic dosage range within the
approved dosing guidelines for Alameda County BHCS or, if antipsychotic
dosage range outside the dosing guidelines, chart documentation
supports dosage. Please note:
quetiapine (Seroquel)
doses should be at least 400mg within 3 months of initiation.
aripiprazole (Abilify)
initiated at doses of 5-15mg, and should be maintained at that dose
for at least 4 weeks.
ziprasidone (Geodon)
should be titrated to 120-160mg within the first two months of
treatment
C. Dosing
-
No “as needed” dosing (prn) of
antipsychotic agents without documented rationale
-
Clozapine Monitoring Committee
Guidelines are being followed for all patients taking clozapine
D. If an additional antipsychotic
medication is simultaneously prescribed, the rationale is documented.
E. Adjunctive Monitors
-
Baseline assessment of movement
disorders documented
-
If possible symptoms of T.D. are noted,
AIMS examination done at least every 6 months
-
Weight: Measured at baseline, at every
visit for 9 months, then every 3 months thereafter
-
Glucose: Measured at baseline, at 6
months, then annually
-
Cholesterol/triglycerides: Measured at
baseline, at 6 months, then annually
-
Prolactin (for clients on risperidone or
any conventional agent): Measured at baseline, at 6 months, then
annually
-
Electrocardiogram (for clients on
thioridazine or ziprasidone): Obtain baseline ECG only in clients at
risk* for QTc prolongation. Periodic monitoring would be dependent on
changes in electrolyte status (hypokalemia or hypomagnesemia) as a
result of diuretic therapy, diarrhea, etc.
*These drugs are
contraindicated in clients with a known history of QT prolongation
(including congenital long QT syndrome), with recent acute myocardial
infarction, with uncompensated heart failure, or with a history/family
history of syncope or sudden cardiac death. These agents should not be
used with any drug that prolongs the QT interval, and should be
discontinued in patients who are found to have a QTc interval
over 500 milliseconds.
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IV. MOOD STABILIZERS
A. Usual indication
-
Bipolar disorder
mixed, manic or depressed
-
Schizoaffective
disorder
-
Bipolar disorder
NOS
-
Cyclothymia
-
Borderline
personality disorder
-
Refractory
depression
-
Other appropriate
indications as documented
B. Mood stabilizer dosage range
within the approved dosing guidelines for Alameda County BHCS, or if
dosage range outside the dosing guidelines, chart documentation supports
dosage
C. No “as needed” dosing (prn) of mood
stabilizers
D. If more than one mood
stabilizer is simultaneously prescribed, the rationale is documented
E. Serum Levels
-
Serum level assessed both prior to and
after a dosage adjustment as indicated, except for patients taking
divalproex sodium (valproic acid), when levels at these times may be
ordered solely based on clinical judgment of need
-
Serum level of the mood stabilizer, when
measured, is within the therapeutic range:
-
Lithium 0.6 – 1.2 mEq/L
-
Valproic Acid 50 – 125
mcg/ml
-
Carbamazepine 4 – 12 mcg/ml
-
If serum level outside therapeutic
range, chart documentation supports dosage
-
Once stabilized, serum levels of
carbamazepine and valproic acid drawn at least every 6 months; for
lithium, every 12 months
F. Adjunctive Monitors
-
Prior to initiation: assessment of
renal, hepatic, hematological, thyroid function, and electrolytes, as
well as pregnancy status
-
Maintenance assessment:
-
Lithium: renal and
thyroid function tested yearly
-
Valproic
acid: hematological and hepatic functions tested twice yearly
-
Carbamazepine: hematological and hepatic function tested quarterly
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V. ANTIDEPRESSANTS
A. Usual indication
-
Major Depression
-
Dysthymia
-
Bipolar disorder, depressed
-
Schizoaffective disorder, depressed
-
Anxiety disorders (Panic, OCD, GAD, PTSD)
-
ADHD
-
Other appropriate indications as
documented
B. Antidepressant dosage range is within
the approved dosing guidelines for Alameda County BHCS or if dosage range
outside the dosing guidelines, chart documentation supports dosage
C. No “as needed” dosing (prn) of
antidepressant agents, without documented rationale.
D. If an additional antidepressant
medication is simultaneously prescribed, the rationale is documented.
E. Laboratory studies
-
Baseline and
maintenance laboratory assessments as indicated for tricyclic agents
-
Baseline liver
function tests upon initiation of nefazodone
-
Maintenance liver
function tests every six months during continuation of nefazodone (in
addition to monitoring for clinical signs and symptoms of hepatic
dysfunction in medical progress notes)
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VI. ANXIOLYTICS
A. Indication
-
Anxiety disorders
(Panic, OCD, GAD, PTSD)
-
Acute psychomotor
agitation
-
Alcohol or sedative
withdrawal
-
Anxiety associated
with other mental disorders
-
Akathesia or
tardive dyskinesia
-
Bipolar disorder (clonazepam
or lorazepam recommended)
-
Other appropriate
indications as documented
B. Dosage Range
Anxiolytic dosage range is within the
approved dosing guidelines for Alameda County BHCS or if dosage range
outside the dosing guidelines, chart documentation supports dosage
C. No more than one antianxiety agent at
one time, unless from different pharmacological class, except during the
transition from one agent to another.
D. No use of benzodiazepines in patient
with history of, or concurrent abuse of drug and alcohol, or history of
addiction to antianxiety agents, unless supported by chart documentation.
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VII. HYPNOTICS
A. Indication
-
Insomnia
B. Dosage Range
Hypnotic dosage range is within the approved
dosing guidelines for Alameda County BHCS or if dosage range outside the
dosing guidelines, chart documentation supports dosage
C. No more than one hypnotic agent
prescribed at one time
D. No use of benzodiazepines in a patient
with history of, or concurrent abuse of drug and alcohol, or history of
addiction to antianxiety agents, unless supported by chart documentation.
E. No use of chloral hydrate in patients
with marked hepatic or renal impairment
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VIII. PSYCHOSTIMULANTS
A. Indication
-
ADHD
-
Refractory Depression
-
Other appropriate indications as
documented
B. Dosage Range
Psychostimulant dosage range is within the
approved dosing guidelines for Alameda County BHCS or if dosage range
outside the dosing guidelines, chart documentation supports dosage
C. Adjunctive Monitors
-
Height
and weight every 6 months
-
Pulse
every 3 months, and blood pressure in patients > 12 years every 6
months
D. No use of stimulants in a patient
with history of, or concurrent abuse of drug and alcohol, or history of
addiction to stimulants, unless supported by chart documentation.
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IX. ANTIPARKINSONIANS
A. Indication
-
Alleviation
of extrapyramidal side effects (EPS) induced by antipsychotic drugs
-
Prophylaxis
of EPS induced by antipsychotic medications
B. Dosage Range
Antiparkinsonian dosage range is within the
approved dosing guidelines for Alameda County BHCS or if dosage range
outside the dosing guidelines, chart documentation supports dosage
C. Documentation
-
If
antiparkinsonian medication is used with any atypical antipsychotic (clozapine,
risperidone, olanzapine etc.) justification of specific need must be
documented.
D. No more than one antiparkinsonian
agent prescribed at one time, unless documentation supports use
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X. MISCELLANEOUS
A. Gabapentin: The literature has
demonstrated no efficacy of this agent in mood stabilization. Specific
rationales for use should be clearly written into the progress notes and
medication treatment plans.
B. Topiramate: At present, there is no
evidence-based literature to support its use as a mood stabilizer.
Specific rationales for use should be clearly written into the progress
notes and medication treatment plans.
C. Controlled
Substances: No use of any controlled substance in a patient with a history
of substance abuse, unless supported by appropriate chart documentation.
References
-
Kahn DA, Ross R,
Printz DJ. The expert consensus guideline series: medication treatment
of bipolar disorder 2000. Postgraduate Medicine Special Report. April
2000.
-
McEvoy JP, Scheifler
PL, Frances A. The expert consensus guideline series: treatment of
schizophrenia 1999. J Clin Psychiatry 1999;60 (supp 11).
-
McIntyre JS, Charles
Sara. APA Practice Guidelines 1996. American Psychiatric Association.
347pages.
-
Marder SR, Essock SM,
Miller AL et al. The Mount Sinai Conference on the Pharmacotherapy of
Schizophrenia. Schizophr Bulletin 2002; 28(1): 5-16.
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