Prescribing medications in an emergency situation? Document your rationale

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Emergent medication use is indicated in numerous clinical scenarios, including psychotic agitation, physical aggression, or withdrawal from substances. While there is plenty of literature to help clinicians with medical record documentation in various other settings,^1-3 there is minimal guidance on how to document your rationale for using psychiatric medications in emergency situations.

I have designed a template for structuring progress notes that has helped me to quickly explain my decision-making for using psychiatric medications during an emergency. When writing a progress note to justify your clinical actions in these situations, ask yourself the following questions:

What symptoms/behaviors needed to be emergently treated? (Use direct quotes from the patient.)
Which nonpharmacologic interventions were attempted prior to using a medication?
Does the patient have any medication allergies? (Document if you were unable to assess for allergies.)
Why did you select this specific route for medication administration?
What was your rationale for using the specific medication(s)?
What was the rationale for the selected dose?
Who was present during medication administration?
Which (if any) concurrent interventions did you order during or after medication administration?
Were any safety follow-up checks ordered after medication administration?

A sample progress note

To help illustrate how these questions could guide a clinician’s writing, the following is a progress note I created using this template:

“Patient woke up at 3:15 am, ran out of his room, and demanded to be discharged: ‘Get me out of here now!’ He started cursing and threatened to attack staff. Multiple members of the nursing staff and I initially tried to calm him down by talking with him and asking him to return to his room. He refused. Patient has no known medication allergies. I ordered oral risperidone, 2 mg, but he refused to take any oral medication to treat his agitation. Because of his continued safety threats toward staff, I decided to administer a 5-mg IM injection of olanzapine to treat his agitation. I selected olanzapine per contemporary agitation treatment guidelines. Because patient is unknown to our psychiatric emergency room and had admitted to frequent alcohol use, I did not select the higher 10-mg dose to avoid oversedation and respiratory depression. Multiple nursing staff, sheriff deputies, and I were present when IM olanzapine was administered. Patient was physically held/restrained by nursing staff and deputies to administer IM olanzapine. After olanzapine was given, patient was moved to a seclusion room by nursing staff and deputies, and I started a locked seclusion order for safety concerns. I instructed a nurse to document any adverse effects and check vital signs 45 minutes after olanzapine was administered.”

References

1. Gutheil TG. Fundamentals of medical record documentation. Psychiatry (Edgmont). 2004;1(3):26-28.
2. Guth T, Morrissey T. Medical documentation and ED charting. Clerkship Directors in Emergency Medicine. https://saem.org/cdem/education/online-education/m3-curriculum/documentation/documentation-of-em-encounters. Updated 2015. Accessed October 10, 2019.
3. Aftab A, Latorre S, Nagle-Yang S. Effective note-writing: a primer for psychiatry residents. Psychiatric Times. http://www.psychiatrictimes.com/couch-crisis/effective-note-writing-primer-psychiatry-residents. Published January 13, 2017. Accessed October 10, 2019.

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CP03111025.PDF

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Dr. Kalapatapu is Assistant Professor of Psychiatry, University of California, and Attending Psychiatrist, Psychiatric Emergency Services, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California.

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The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

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Current Psychiatry - 18(11)

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Current Psychiatry

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Raj K. Kalapatapu, MD, FAPA

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Raj K. Kalapatapu, MD, FAPA

Author and Disclosure Information

Dr. Kalapatapu is Assistant Professor of Psychiatry, University of California, and Attending Psychiatrist, Psychiatric Emergency Services, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California.

Disclosure
The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Author and Disclosure Information

Dr. Kalapatapu is Assistant Professor of Psychiatry, University of California, and Attending Psychiatrist, Psychiatric Emergency Services, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California.

Disclosure
The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Article PDF

CP03111025.PDF

Article PDF

CP03111025.PDF

Emergent medication use is indicated in numerous clinical scenarios, including psychotic agitation, physical aggression, or withdrawal from substances. While there is plenty of literature to help clinicians with medical record documentation in various other settings,^1-3 there is minimal guidance on how to document your rationale for using psychiatric medications in emergency situations.

I have designed a template for structuring progress notes that has helped me to quickly explain my decision-making for using psychiatric medications during an emergency. When writing a progress note to justify your clinical actions in these situations, ask yourself the following questions:

What symptoms/behaviors needed to be emergently treated? (Use direct quotes from the patient.)
Which nonpharmacologic interventions were attempted prior to using a medication?
Does the patient have any medication allergies? (Document if you were unable to assess for allergies.)
Why did you select this specific route for medication administration?
What was your rationale for using the specific medication(s)?
What was the rationale for the selected dose?
Who was present during medication administration?
Which (if any) concurrent interventions did you order during or after medication administration?
Were any safety follow-up checks ordered after medication administration?

A sample progress note

To help illustrate how these questions could guide a clinician’s writing, the following is a progress note I created using this template:

“Patient woke up at 3:15 am, ran out of his room, and demanded to be discharged: ‘Get me out of here now!’ He started cursing and threatened to attack staff. Multiple members of the nursing staff and I initially tried to calm him down by talking with him and asking him to return to his room. He refused. Patient has no known medication allergies. I ordered oral risperidone, 2 mg, but he refused to take any oral medication to treat his agitation. Because of his continued safety threats toward staff, I decided to administer a 5-mg IM injection of olanzapine to treat his agitation. I selected olanzapine per contemporary agitation treatment guidelines. Because patient is unknown to our psychiatric emergency room and had admitted to frequent alcohol use, I did not select the higher 10-mg dose to avoid oversedation and respiratory depression. Multiple nursing staff, sheriff deputies, and I were present when IM olanzapine was administered. Patient was physically held/restrained by nursing staff and deputies to administer IM olanzapine. After olanzapine was given, patient was moved to a seclusion room by nursing staff and deputies, and I started a locked seclusion order for safety concerns. I instructed a nurse to document any adverse effects and check vital signs 45 minutes after olanzapine was administered.”

Emergent medication use is indicated in numerous clinical scenarios, including psychotic agitation, physical aggression, or withdrawal from substances. While there is plenty of literature to help clinicians with medical record documentation in various other settings,^1-3 there is minimal guidance on how to document your rationale for using psychiatric medications in emergency situations.

I have designed a template for structuring progress notes that has helped me to quickly explain my decision-making for using psychiatric medications during an emergency. When writing a progress note to justify your clinical actions in these situations, ask yourself the following questions:

What symptoms/behaviors needed to be emergently treated? (Use direct quotes from the patient.)
Which nonpharmacologic interventions were attempted prior to using a medication?
Does the patient have any medication allergies? (Document if you were unable to assess for allergies.)
Why did you select this specific route for medication administration?
What was your rationale for using the specific medication(s)?
What was the rationale for the selected dose?
Who was present during medication administration?
Which (if any) concurrent interventions did you order during or after medication administration?
Were any safety follow-up checks ordered after medication administration?

A sample progress note

To help illustrate how these questions could guide a clinician’s writing, the following is a progress note I created using this template:

“Patient woke up at 3:15 am, ran out of his room, and demanded to be discharged: ‘Get me out of here now!’ He started cursing and threatened to attack staff. Multiple members of the nursing staff and I initially tried to calm him down by talking with him and asking him to return to his room. He refused. Patient has no known medication allergies. I ordered oral risperidone, 2 mg, but he refused to take any oral medication to treat his agitation. Because of his continued safety threats toward staff, I decided to administer a 5-mg IM injection of olanzapine to treat his agitation. I selected olanzapine per contemporary agitation treatment guidelines. Because patient is unknown to our psychiatric emergency room and had admitted to frequent alcohol use, I did not select the higher 10-mg dose to avoid oversedation and respiratory depression. Multiple nursing staff, sheriff deputies, and I were present when IM olanzapine was administered. Patient was physically held/restrained by nursing staff and deputies to administer IM olanzapine. After olanzapine was given, patient was moved to a seclusion room by nursing staff and deputies, and I started a locked seclusion order for safety concerns. I instructed a nurse to document any adverse effects and check vital signs 45 minutes after olanzapine was administered.”

References

1. Gutheil TG. Fundamentals of medical record documentation. Psychiatry (Edgmont). 2004;1(3):26-28.
2. Guth T, Morrissey T. Medical documentation and ED charting. Clerkship Directors in Emergency Medicine. https://saem.org/cdem/education/online-education/m3-curriculum/documentation/documentation-of-em-encounters. Updated 2015. Accessed October 10, 2019.
3. Aftab A, Latorre S, Nagle-Yang S. Effective note-writing: a primer for psychiatry residents. Psychiatric Times. http://www.psychiatrictimes.com/couch-crisis/effective-note-writing-primer-psychiatry-residents. Published January 13, 2017. Accessed October 10, 2019.

References

1. Gutheil TG. Fundamentals of medical record documentation. Psychiatry (Edgmont). 2004;1(3):26-28.
2. Guth T, Morrissey T. Medical documentation and ED charting. Clerkship Directors in Emergency Medicine. https://saem.org/cdem/education/online-education/m3-curriculum/documentation/documentation-of-em-encounters. Updated 2015. Accessed October 10, 2019.
3. Aftab A, Latorre S, Nagle-Yang S. Effective note-writing: a primer for psychiatry residents. Psychiatric Times. http://www.psychiatrictimes.com/couch-crisis/effective-note-writing-primer-psychiatry-residents. Published January 13, 2017. Accessed October 10, 2019.

Issue

Current Psychiatry - 18(11)

Issue

Current Psychiatry - 18(11)

Page Number

25,70

Page Number

25,70

Publications

MDedge Psychiatry

Current Psychiatry

Publications