October 2011

Documentation for Mental Health Disorders

Introduction to Harvest HealthcareExperience. Education. Excellence.Harvest is a leading full-service behavioral health

provider, specializing in the delivery of progressive and innovative consultative behavioral health services for patients and residents residing in skilled nursing, rehabilitation, and assisted living facilities. Our multidisciplinary team of highly skilled professionals work together to offer a broad menu of services including but not limited to 24-hour prescriber on-call services and hospitalization support, comprehensive cognitive assessments, documentation review, OBRA compliance support and customized educational programs designed for the individual needs of your facility.

ObjectivesThis presentation on documentation was

developed for the continuing education of healthcare providers.

At the conclusion of this presentation, participants will have a basic understanding of documentation of mental health issues in long term care facilities.

Mental health professionals should be consulted for management of patients with mental health issues.

Why do we document? The common answers are to prove we did something or to protect

our professional decisions. The real reason for documentation is to promote quality and

coordination of care. In the end, the documentation that is produced may be used for accreditation and licensing, performance improvement, peer review, reimbursement, and legal protection.

There are many organizations that set standards or have requirements related to documentation: The Centers for Medicare & Medicaid Services (CMS) and the MDS 3.0

is only one standard. Others include:

• CMS/federal certification• State survey agencies—licensure• Professional practice acts (state specific) such as RN, LPN/LVN, PT, PTA, OT,OTA,

SLP• Accreditation organizations (i.e., The Joint Commission)• Professional associations: American Nurses Association, American Medical

Directors, Association, American Physical Therapy Association, The American Occupational Therapy Association, Inc., and American Speech-Language-Hearing Association

• American Health Information Management Association• Insurance carriers (i.e., liability and workers compensations)• Payers (e.g., Medicare, Medicaid, Medicare Advantage, Insurance, Veterans

Affairs [VA])• Medicare A/B MAC (former Fiscal Intermediaries)

Documentation by inclusion or exceptionIn the clinical setting (long-term care [LTC])

clinical documentation is done by inclusion and/or exception.

Documentation by inclusion is done on an ongoing, regular basis and makes note of all assessment findings, interventions, and resident outcomes.

Documentation by exception makes note of negative findings and is completed when assessment findings, interventions, or resident outcomes vary from the established assessment norms or standards of care.

Charting by inclusion and exceptionCharting by exception replaces the long held

belief of “if it was not charted, then it was not done” with a new premise, “all standards have been met with a normal or expected response unless documented otherwise.”

Documentation by inclusion in the skilled nursing facility (SNF) includes: weekly/monthly summaries, routine vital signs, weights, target behavior monitoring, MAR/TAR, etc.

Documentation by exception in the SNF could include: falls, skin tears, pressure ulcers, pain, change in mood/behavior, weight loss, change in vital signs, change in cognitive status, etc.

Documentation for Assessment & Planning In clinical contexts, clear and comprehensive

documentation of all case-related facts and circumstances is essential.

Careful and thoughtful information collection ensures that practitioners have an adequate foundation for their clinical reasoning and intervention plans.

In addition, the data provide a reliable source of measuring performance and outcomes.

Incomplete records may lead to inadequate planning and intervention, critical judgment errors, and poor outcomes for clients.

Documentation for Service Delivery

Comprehensive records are necessary for competent delivery of clinical, community-based, and agency-based services and interventions.

Thorough documentation provides a solid foundation for practitioners' efforts to design and deliver high-quality services, whether they involve clinical intervention, supervision, or agency administrators' management and evaluation of personnel and programs.

Continuity and Coordination of ServicesDocumentation facilitates professional

and interdisciplinary collaboration and coordination of services.

• In clinical settings, documentation ensures that staff members have up-to-date details concerning clients' needs.

• Administrative records facilitate coordination among supervisors, managers, and administrators in programs and agencies.

Risk ManagementRisk management is the identification,

assessment, and prioritization of risks followed by coordinated and economical application of resources to minimize, monitor, and control the probability and/or impact of unfortunate events

or to maximize the realization of opportunities.Risk-management guidelines related to

documentation and case recording can be placed into four conceptually distinct categories:

1) the content of documentation2) language and terminology3) credibility4) access to records and documents

Language and TerminologyWording in documentation is just as

important as the substance of the content. Loose and casual language and

terminology can be catastrophic to the client, practitioner, supervisor, and agency.

Practitioners must choose their words carefully, taking care to be clear, to fully support conclusions drawn, to avoid defamatory language, and to write knowing there is always an audience.

The importance of clarityPractitioners should use clear, specific, unambiguous,

and precise wording. Lack of clarity, specificity, and precision provides considerable opportunity for adversarial parties to raise doubts about practitioners' claims, observations, and interpretations.

Conversely, clear, specific, unambiguous, and precise wording enhances the delivery of services and strengthens practitioners' ability to explain and defend prior decisions and actions.

Avoid the use of professional jargon, slang, or abbreviations that may be misunderstood. For example, the abbreviation "DD" could mean dual

diagnosis or developmental disability. The abbreviation "BPD" could mean bipolar disorder or borderline personality disorder. "SA" could mean substance abuse or sexual assault. Such ambiguity could prove disastrous if the abbreviations are misinterpreted by a colleague or debated in an ethics hearing, licensing board inquiry, or litigation.

Documentation Review QuestionsClinical note: Is the content and intent of the

documentation clear?• Does the note show compliance with the care

plan including continuity and consistency?• How does the clinical note show cooperation

and collaboration?• Is there congruence or contradiction within

the documentation?• Does the note identify change?• Are resident comments identified as

comments?

Tips for Accurate Documentation

• Document concisely and factually, using precise language and specific behaviors

• Start each entry with the date and time• Do not offer your opinions discuss

observations (i.e., resident slept poorly vs. resident up walking in hall six times between 3 a.m. and 5 a.m.)

• Do not repeat information that is stated elsewhere in the health record, such as on a flow sheet

Mental Health DocumentationDocumentation for mental health issues include

the following:Psychiatric Assessment (completed by psychiatric

consultants)Mental Health Progress Notes by LCSW &

PsychologistCognitive Assessments by PsychologistsPhysicians order sheetNursing notesMedication Administration Record (MAR)

Behavior tracking recordPRN medication

CNA behavior flow /tracking sheet

Psychiatric AssessmentThe psychiatric assessment from Harvest

Healthcare will be located in the psychiatric section of the paper chart for each individual patient.

It will include the identified problem/problem behaviors, diagnosis and the treatment recommendation(s).

If a cognitive assessment or psychotherapy has been recommended, the corresponding paperwork for these will also be located in the psychiatric section of the chart.

Physicians OrdersOnce a mental health diagnosis has been

made, the diagnosis will be on the order sheet. Medications for mental health issues will be

found on the order sheet as well as the reasons the medication has been ordered. • i.e. zoloft 25mg one po daily for depression• Labs and other assessments required for specific

medications also need to be added to the order sheet

i.e. AIMS every six months for antipsychotics Orthostatic bp checks monthly secondary to Seroquel use

Nursing NotesEach long term care facility has methods for

documenting nursing notes (electronic/paper/ daily/weekly/monthly assessments) driven by credentialing bodies, payer source, level of care, etc.

For the purpose of this presentation: Nursing notes should follow the SOAP format.

S: subjective findings regarding the mental health issueO: objective findings of the mental health issueA: assessment of the mental health issueP: plan for the mental health issue

Medication Administration Record

The MAR is the “Bible” for medication the patient is receiving. It is what the nurse uses when administering medication and states medication, dose, administration route, & time.

The MAR includes both scheduled and as needed (PRN) medications.

As needed medications are given in response to specific symptoms. The nurse is responsible for documenting when the symptom occurs and how the patient responded to the PRN medication.

Behavior Tracking Sheet for Psychotropic MedicationWhen psychotropic medications are ordered a

behavior tracking record should also be included in the MAR. This behavior tracking sheet lists the specific behaviors that the psychotropic medication should be addressing. For each shift the nurse documents the occurrence and severity of each behavior. This is important for the prescriber as it provides a clear picture of whether or not, from the perspective of the nurse, the medication is working. It also provides a time line that is easy to see what time of day the patients behaviors worsen.

CNA Behavior Flow SheetThe nursing assistants spend a great deal of

time engaging in 1:1 and very personal activities with the patients. They often are the primary witness to problematic behavior.

CNAs often act as the ‘barometer’ of mental health issues in the long term care facilities making it extremely important to view their assessment of problem behaviors.

This is an important source of information for the mental health consultant.

Continuity of informationEach one of these areas of documentation

should relate to the next. Information won’t be exactly the same in

each documented area, but they should be similar.

Audits will check for continuity in physicians orders, nurses notes, psychiatric documents, flow sheets and MAR.

Targeted Behavioral MonitoringAntipsychotic

Targeted behavior requirements:1.Need to be documented daily.2.Should not be caused by preventable means.3.Cause the resident to be a danger to self and/or othersAccepted behaviors for antipsychotic use:

Spitting, Biting, Kicking, Scratching, Fighting, hallucinations, Extreme fear, Delusions, Pinching, Slapping, Head banging, Self-inflicted injury, Tripping others, Purposeful vomiting, Continuously crying, Continuously yelling, Continuously screaming, Inappropriate sexual behavior; Purposeful pushing, Purposeful throwing objects, Purposeful ramming others.

Behaviors-which by themselves DO NOT warrant antipsychotic use.Wandering, Insomnia, Restlessness, Impaired Memory, Poor

self care, Anxiety, Fidgeting, Nervousness, Uncooperativeness, Depression w/o psychotic features, Agitated behaviors which do not dose a threat to self or others. Occasional yelling, crying out, screaming, pacing.

Targeted Behavioral Monitoring for Antidepressants

Targeted behavior requirements if no dx of depression is in place:1. Need to be documented daily.2. Should not be caused by preventable means.3. Cause the resident to be a danger to self and/or others.

Behaviors are warranted if antidepressant is used for behavior modification. Spitting, Biting, Kicking, Scratching, Fighting, hallucinations,

Extreme fear, Delusions, Pinching, Slapping, Head banging, Self-inflicted injury, Tripping others, Purposeful vomiting, Continuously crying, Continuously yelling, Continuously screaming, Inappropriate sexual behavior; Purposeful pushing, Purposeful throwing objects, Purposeful ramming others.

Behaviors-which by themselves DO NOT warrant antidepressant use. Wandering, Insomnia, Restlessness, Impaired Memory, Poor self

care, Anxiety, Fidgeting, Nervousness, Uncooperativeness, Depression w/o psychotic features, Agitated behaviors which do not dose a threat to self or others. Occasional yelling, crying out, screaming, pacing.

Targeted behavior requirements for anxiolytics

Targeted behavior requirements:1. Need to be documented daily.2. Should not be caused by preventable means.3. Cause the resident to be a danger to self and/or others.

Accepted behaviors: Spitting, Biting, Kicking, Scratching, Fighting, hallucinations,

Extreme fear, Delusions, Pinching, Slapping, Head banging, Self-inflicted injury, Tripping others, Purposeful vomiting, Continuously crying, Continuously yelling, Continuously screaming, Inappropriate sexual behavior; Purposeful pushing, Purposeful throwing objects, Purposeful ramming others.

Behaviors-which by themselves DO NOT warrant anxiolytic use. Wandering, Insomnia, Restlessness, Impaired Memory, Poor

self care, Anxiety, Fidgeting, Nervousness, Uncooperativeness, Depression w/o psychotic features, Agitated behaviors which do not dose a threat to self or others. Occasional yelling, crying out, screaming, pacing.

Targeted Behavior Monitoring for Sedative/ HypnoticDOES NOT REQUIRE TARGETED

BEHAVIOR MONITORING WITH PROPER DX IN PLACE:

Do not require monitoring if given for sleep disorder.

Descriptive wordsIt is important to use descriptive words and

to avoid general words like agitation. Agitation by definition includes up to 50 different types of behaviors.

Be specific in documentation : Mr. Jones was agitated after lunchMr. Jones had to be redirected by staff four times after lunch due to repeated attempts to stand up without assistance while seated in his wheelchair next to the north nursing station.

There are lists of descriptive words like the following one that can be used to assist you in documentation.

List of descriptive words

Care PlanThe care plan will be developed from the

assessments and diagnoses.Using descriptive words will improve the

quality of documentation. Descriptive words will make documenting

more efficient by improving the clarity of what we are assessing for and what the goals are.

Thought Provoking Questions:Why is it important for continuity in documentation?

Where will the mental health consultant seek out information about a patient?

How can you improve your own documentation?