STANDARD 19: Psychiatric and Behavioral Services

19.1 Medical Records

1. The medical records maintained by a psychiatric hospital shall describe the treatment provided within the healthcare organization scope of service.

2. Medical records within the psychiatric service shall contain the necessary components to include the history and treatment provided for the relevant psychiatric condition. These require components are:

a) identification of the patient's legal status;

b) a provisional or admitting diagnosis for each patient and at the time of admission;

c) records of intercurrent diseases and co-morbidities as well as the psychiatric diagnoses;

d) documented reasons for admission as offered by reliable sources;

e) social service records, reports, interviews, with patients, family members, and other data relating to the psycho-social condition of the patient; if they are available;

f) when indicated, a complete neurological examination must be recorded at the time of the admission physical examination.

3. Each patient shall receive a psychiatric evaluation with the following requirements:

a) completion within 96 hours of admission (See 8.9.);

b) inclusion of a complete medical history if it is available;

c) a record of mental status evaluation;

d) details surrounding the onset of illness and the circumstances leading to admission;

e) description of attitudes and behavior;

f) estimation of intellectual and memory function and orientation;

g) an accurate and descriptive inventory of the patient’s belongings shall be made upon admission in closed wards.

NOTE 1 The parameters of this section regarding a psychiatric evaluation do not supersede the requirements of section 8.9. regarding an admission history and physical describing available history and current physical condition including co-morbidities relevant to treatment in the acute phase.

4. Each patient shall have an individual, comprehensive, treatment plan based on the patient's strengths and disabilities. This plan shall include but not limited to:

a) a working diagnosis;

b) short-term and long-range goals;

c) treatment specific modalities contemplated;

d) identification and responsibility of each member of the treatment team;

e) adequate documentation to justify the diagnosis, treatment, and rehabilitation activities involved.

5. The treatment received by the patient shall be documented in the medical record.

6. Progress notes shall be made by the responsible Doctor of Medicine, nurse, or others significantly involved in active plan of care. (See 23.6.)

7. The frequency of progress notes shall be determined by the condition of the patient but no less than weekly for the first 2 months and at least once a month thereafter.

8. These notes shall contain recommendations for revisions in the treatment plan as indicated, and an accurate assessment of the patient's progress in accordance with the original or revised treatment plan.

9. Each patient shall have a discharge summary that includes a recapitulation of the patient's hospitalization and recommendations from appropriate services concerning follow-up or aftercare. It shall also include a brief summary of the patient's condition on discharge.

19.2 Staffing and Facility Requirements

1. The healthcare organization shall have adequate numbers of professional personnel in order to:

a) evaluate patients;

b) formulate written individualized, comprehensive treatment plans;

c) provide active treatment measures;

d) engage in discharge planning.

2. Inpatient psychiatric services shall be under the supervision of a Doctor of Medicine, recommended by the medical staff and approve by the Governing Body, in accordance with healthcare organization policy.

3. The director shall monitor and evaluate the quality and appropriateness of services and treatment provided by the medical staff.

4. Doctor of Medicine and other appropriate professional personnel shall be available to provide medical and surgical treatment as indicated.

5. If medical and surgical diagnostic and treatment services are not available within the institution, the institution shall use appropriate outside services to ensure that they are immediately available.

6. The Director of psychiatric nursing services shall be a registered nurse who is qualified by education and experience in the care of the mentally ill as per healthcare organization policy

7. There shall be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide nursing care necessary for each patient's active treatment program and record maintenance.

8. The staffing pattern shall insure the continual availability of a registered nurse.

9. The psychiatric hospital must provide a therapeutic activities program appropriate to the needs and interests of patients in order to restore and maintain optimal levels of physical and psychosocial functioning.

10. There shall be adequate numbers of qualified personnel to support these therapeutic activities.

11. The healthcare facility shall provide and maintain appropriate facility conditions for the treatment of mental illness within its scope of service. (See 28.1.).

19.3 Social Services

1. Where policy or regulation requires defined social services participation in psychiatric care, there shall be a Director of social services who monitors and evaluates the quality and appropriateness of social services furnished. The services must be furnished in accordance with accepted standards of practice and established policies and procedures.

2. The Director of the social service shall be qualified in accordance with healthcare organization policy and approved by the medical staff and Governing Body.

3. Social service staff shall participate in at least but not limited to:

a) participation in discharge planning;

b) arranging for follow-up care;

c) developing mechanisms for exchange of appropriate information with sources outside the healthcare organization.