F329 and Psych Meds

Davey Do · Jul 8, 2010

pielegniarka:

Here's a site that may get you started. If the link doesn't get you to the site, the article is called "Appropriate Use of Psychotropic Drugs in Nursing Homes".

Here goes:

http://www.aafp.org/afp/2000030//437.html

Please feel free to send me a PM if you have any specific questions or have a need to discuss the fine points.

Good luck to you, pielegniarka.

SuesquatchRN, BSN, RN · Jul 8, 2010

We don't do the reduction, thank the FSM. My doc refuses to mess with stable people. Bless her.

Kooky Korky, BSN, RN · Jul 8, 2010

I need support if anyone can spare some. I have the fun task of managing the psychotropic medications in our LTC facility to help keep up compliance with state regulations.
What I am finding is, it is like pulling teeth to get the MD to chart on what I need them to say... why is it so difficult for the MD to understand that I either need a nice comprehensive note with rationale or an order for dosage reduction? I'm trying out some cheat sheets for the doctors to use in their dictation, but still running into a lot of botched dictations and confusion.
Then... THEN...THEN!... it's so hard to have to do reductions on new patients that first year and the result being the patient is in hysterics until we get them stablized again with meds. Then to put them through it AGAIN the next quarter just so we can justify continued use of the medication.
Is anyone else in charge of psych meds in LTC that I can bounce some ideas off of and maybe get some support from? Please? I have not gone through any formal training just reading through CMS manuals related to uneccesary meds.

This practice of reducing dosages sounds really cruel. I'm sure the original intent was good, but it sounds like the patients are being tortured. Who do you turn to when it is CMS itself that is forcing this on patients?

If your docs are non-compliant, can't your Admin give them a little talking to, explaining the financial facts of life?

CapeCodMermaid, RN · Jul 9, 2010

There are CMS guidelines....doesn't mean that the docs can't do what they want. They don't HAVE to do a dose reduction if they can justify the reason. We very rarely change the meds of any of the short term residents and a good 80% of my residents have notes which say they will not attempt any dose reductions. All the reasons for the meds and the diagnoses are spelled out in the charts. DPH surveyors had no issue with any of it.

pielęgniarka, RN · Jul 9, 2010

But what I am finding is that the doctor.... instead of doing the research on the psych meds... documenting that a GDR is contraindicated.... then including risk vs benefit statement... & then detailed rationale to indicate why a reduction would be detrimental... the doctor would just as soon write out an order for a reduction. Writing the order takes 2 seconds. Sign it. Done. Dictation takes longer. The MD doesn't have to deal with the patient on a daily basis. Getting the documention right takes too much time and thought. What I am doing now is actually typing up what I want the doctor to say and asking them to dictate that so it gets printed out in a progress note and it is STILL getting botched up. They will dictate the wrong dosages, or talk about the wrong med or something else, even with me spelling it out for him, so that the documentation doesn't even do me any good. Can I just type something up and have the MD sign it and put it in the chart? It seems wrong to me to do that though? What kinds of dicatation are the rest of you seeing from the MD? Last time state came around we got quite a few tags on psych meds and now that I am responsible for directing this I don't want any tags!!! I just want this to be easy on the patients and accurate for our charts and have it be enough to keep us in compliance with state. I'm frazzled, man. Thank you all though, for the reply and especially for the link. I read through it and emailed the link to my work so I can print it out there and have it on hand.

SuesquatchRN, BSN, RN · Jul 9, 2010

My doc is really good about this, but understand that the docs are as overworked and overwhelmed as the nurses. They often rotate through 3 to 4 facilities.

CapeCodMermaid, RN · Jul 9, 2010

Dictation? Our docs still hand write their notes. If I want to make sure they do it correctly, I will sit with them and tell them word for word what to write. Some of them get pissy. Some want me to write the note for them to sign. You have to find what works best for you and the docs you have to deal with. And they don't need to write a novel. All they have to write is "Pt. stable on current dose. Failed last GDR. No further dose reduction to be trialed at this time."

I have more patients on antipsychotics than any other facility in the state and the DPH was fine with the way we were doing things. The chart tells the story (that and they sat with some of my residents for a few minutes and saw first hand how crazy they really are!!)

pielęgniarka, RN · Jul 10, 2010

Yes our MD dictates, it gets sent out and the progress notes get mailed to us which we upload in the electronic chart.

So the notes or dictation don't need to be very specific? The reason I ask is when state was here they nitpicked the heck out of the psych dictation we had on file. If a decimal point was in the wrong place or the psych med name was misspelled they (surveyers) were going on about how wrong it was for hours and how it related it to inappropriate monitoring for adverse effects. So maybe less information is better in this case. Maybe I'll try it out and see what the surveyers think next time around.

I've been requesting a whole paragraph for the docs to dictate!!! I provide the information and ask them to dictate verbatim:

1) Med name, dosage, diagnosis. Some pts are on several psych meds so this is where it keeps getting botched and runs together in the dictation.

2.)Target behaviors.

3.) Any failed tapers and that there was a return or worsening of target behaviors when it failed.

4.) Current mood/behavior.

5.) Presence of any adverse effects or decline in ability

6.) And no GDR indicated.

So now you can see why they just elect to do a GDR and keep doing them and not dictate all that crap I prepared, so lovingly.

Dictation? Our docs still hand write their notes. If I want to make sure they do it correctly, I will sit with them and tell them word for word what to write. Some of them get pissy. Some want me to write the note for them to sign. You have to find what works best for you and the docs you have to deal with. And they don't need to write a novel. All they have to write is "Pt. stable on current dose. Failed last GDR. No further dose reduction to be trialed at this time."
I have more patients on antipsychotics than any other facility in the state and the DPH was fine with the way we were doing things. The chart tells the story (that and they sat with some of my residents for a few minutes and saw first hand how crazy they really are!!)