Psychotropic Medication: Prescribing and Monitoring Protocol

Psychotropic Medication: Prescribing and Monitoring Protocol

Introduction 

The use of psychotropic medications is often an integral part of treatment for persons receiving care for behavioral 

health conditions. As such, the use of psychotropic medications must be monitored closely to help ensure that 

persons are treated safely and effectively. 

The Ship Group Community Services , LLC.’s approach to medication management is that medication is used 

only when absolutely necessary. However, in cases where it is deemed to be an appropriate part of therapeutic 

treatment, our approach emphasizes education regarding the safety and potential side effects of psychotropic 

medications, thus, the patient is better able and supported in making an informed decision. 

Guidelines and minimum requirements are designed to: 

▪ Ensure the safety of persons taking psychotropic medications; 

▪ Reduce or prevent the occurrence of adverse side effects; and 

▪ Help persons who are taking psychotropic medications restore and maintain optimal levels of functioning 

and achieve positive clinical outcomes.

Medication Monitoring and Guidelines

A person’s target symptoms and clinical responses to treatment must be identified for each medication prescribed 

and documented in the person’s comprehensive clinical record. Also, the use of psychotropic medication must 

always be referenced and incorporated into the person’s individual treatment plan. 

Education regarding all prescribed medications must be routinely provided to persons, family members, guardians, 

or designated representatives in a culturally competent, language appropriate manner. 

Psychotropic medications that are not clinically effective after reasonable trials should be discontinued, unless the 

rationale for continuation can be supported and is documented in the person’s comprehensive clinical record. 

Behavioral health medical practitioners must coordinate with primary care providers (PCPs) or other health care 

providers to minimize the potential for adverse clinical outcomes when prescribing psychotropic medications. 

Objectives 

To ensure that psychotropic medications prescribed for persons are prescribed and monitored in a manner that 

provides for safe and effective use. 

To ensure that medication will be used only as necessary, only for the benefit of the patient, and only as an adjunct 

to a comprehensive plan of treatment. Medications will be given in the least amount medically necessary with 

particular emphasis placed on minimizing and monitoring for side effects.

Procedures 

A. BASIC REQUIREMENTS 

Medications may only be prescribed by credentialed and licensed physicians, licensed physician assistants, or 

licensed nurse practitioners.

Psychotropic medication will be prescribed by a psychiatrist who is a licensed physician, or a licensed nurse 

practitioner, licensed physician assistant, or physician trained or experienced in the use of psychotropic 

medication, who has seen the client and is familiar with the client’s medical history or, in an emergency, is at least 

familiar with the client’s medical history. 

When a client on psychotropic medication receives a yearly physical examination, a physician or non-physician 

practitioner will review the results of the examination. The practitioner will note any adverse effects of the continued use of the prescribed psychotropic medication in the client’s record. It is preferable that the prescribing practitioner when possible conducts this review.

Whenever a prescription for medication is written or changed, a notation of the medication, dosage, frequency or 

administration, and the reason why the medication was ordered or changed will be entered in the client’s record. 

B. ASSESSMENTS 

Reasonable clinical judgment, supported by available assessment information, must guide the prescription of 

psychotropic medications. To the extent possible, candidates for psychotropic medications must be assessed 

prior to prescribing and providing psychotropic medications. 

Psychotropic medication assessments must be documented in the person’s comprehensive clinical record and 

must be scheduled in a timely manner consistent with appointment standards and timeliness of service. 

Behavioral health medical practitioners can use assessment information that has already been collected by other 

sources and are not required to document existing assessment information that is part of the person’s 

comprehensive clinical record. It is appropriate to complete a Clinical Addendum if during the assessment 

information is assessed that has not been otherwise noted in the clinical record. 

At a minimum, assessments for psychotropic medications must include: 

▪ Detailed medical and behavioral health history; 

▪ Mental status examination; 

▪ Diagnosis; 

▪ Target Symptoms; 

▪ Review of possible medication allergies; 

▪ Review of previously and currently prescribed medications including any noted side effects and/or 

potential drug-drug interactions; 

▪ For sexually active females of childbearing age, a review of reproductive status (pregnancy); 

▪ For post-partum females, a review of breastfeeding status. 

Reassessments must ensure that the provider prescribing psychotropic medication notes in the client’s record: 

▪ Appropriateness of the current dosage; 

▪ All medication being taken and the appropriateness of the mixture of the medications; 

▪ Any side effects, abnormal and/or involuntary movements if treated with an anti-psychotic medication; 

and 

▪ Reason for the use of the medication and the effectiveness of the medication. 

C. INFORMED CONSENT 

Informed consent must be obtained from the person and/or legal guardian for each psychotropic medication prescribed. When obtaining informed consent, the behavioral health medical practitioner or registered nurse with at least one year of behavioral health experience must communicate in a manner that the person and/or legal guardian can understand and comprehend. The comprehensive clinical record must include documentation of the essential elements for obtaining informed consent.It is preferred that the prescribing clinician provides information forming the basis of an informed consent decision. In specific situations in which this is not possible or practicable, information may be provided by another credentialed behavioral health medical practitioner or registered nurse with at least one year of behavioral health experience. 

D. PSYCHOTROPIC MEDICATION MONITORING

Psychotropic medications must be monitored. Medical monitoring: lab tests, vital signs, body weight/height/BMI should be completed on a routine basis (after initiation of medication, monitoring is monthly for 3 months, then quarterly) or according to signs/symptoms. EKGs, eye exams, dental exams will be monitored annually or more often per need. If diagnostic testing for the purpose of medical monitoring is not directly ordered by or reported to The Ship Group Community Services , then The Ship Group Community Services Care will contact the ordering practitioner to obtain copies of the report(s). 

While The Ship Group Community Services may establish additional minimum requirements, at a minimum, these must include at the below timelines:

Heart Rate and Blood Pressure

On initiation of any medication, after initiation of the medication, monitoring is monthly for three months, then quarterly; 

Weight

On initiation of any medication, after initiation of the medication, monitoring is monthly for three months, then quarterly; 

Body Mass Index (BMI)

On initiation of any medication, after initiation of the medication, monitoring is monthly for three months, then quarterly; 

Abnormal Involuntary Movements (AIMS)

On initiation of any antipsychotic medication and at least every six months thereafter, or more frequently as clinically indicated.

E. REPORTING REQUIREMENTS 

An incident report must be completed for any medication error, adverse drug event and/or adverse drug reaction 

that results in harm and/or emergency medical intervention. 

ADMISSION 

Prior to admission, the following information must be verified:

1. Insurance or lack of insurance 

2. Co-pay or "fee for service" arrangement for new evaluation and follow-up visits

3. Guardianship arrangements, when applicable (if patient is psychotic or demented, identify if there is a legal guardian, if so, appointment should be arranged via guardian) in case of children: if single parent calls to make appointment, be sure that divorced parent has joint custody for medical decision making) 

WRITTEN REQUEST and REVIEW of MEDICAL RECORDS

4. Mental health records: Request all psychiatric records from current prescriber(s) of psychiatric drugs. 

5. Hospital records: Request ALL records of first and recent psychiatric hospital admissions (if extensive, 

then request first hospitalization and request hospital records from past 2-3 years). 

6. Request specialists' progress notes from neurology or neurosurgery evaluations and treatments including 

neuro-imaging (MRI, CT, MRA of brain). 

7. Request Primary Care progress notes and the most recent medication profile. For adults: notes from most 

recent 2 years; For kids: request all progress notes, growth charts, and immunization records. 

8. Prepare or forward records to psychiatrist or non-physician practitioner for review. Ideally, each 

psychiatrist or non-physician practitioner should plan up to 1 hour to review records prior to first 

consultation with new patients; Clarification: up to 1 hour for the collective review, report, and briefing, not 

1 hour per new patient. 

SCHEDULING APPOINTMENTS

9. Schedule new patients with psychiatrist or non-physician practitioner AFTER he or she has given 

expressed or implied approval (i.e., verified availability/confirmed an open appointment slot on the 

calendar); Interpretation: Where conflict does not present, new patients and follow-up visits will be 

scheduled on the appointment calendar based on openings and priority level of the appointment and not 

based on the practitioner approving each and every appointment request individually

10. Appointment reminder card is provided for next visit 

11. Administrative Assistant will call patients 48 to 72 hours ahead of their upcoming appointments to remind 

them of upcoming visit 

12. When patients miss an appointment, Administrative Assistant will call to inquire about status of patient. 

13. When patient is not reachable by telephone, Administrative Assistant will send out general letter ("we 

missed you on …")

ESTABLISHMENT OF THE MEDICAL RECORD

14. Prepare medical chart with following recommended sections relative to Medication Management, in no 

particular order:

▪ Face sheet (demographics, primary care physician, drug allergies, pharmacy used, etc.

▪ Appointment Tracker (summary of clinician's work on each case) 

▪ Consents (consents for drugs, release of information, etc.) 

▪ Psychiatric Evaluation & Summary Reports 

▪ Progress Notes (follow-up visits) 

▪ Lab Trends (flow sheet/report for tracking trends in specific lab tests) 

▪ Lab Orders and Results 

▪ *Physician’s Order Log (running log of each med change and/or refill) *May be filed in a separate “Master” 

binder in the office or online using the approved electronic database

▪ *Drug Orders (carbon copies of each prescription made) *May be filed in a separate “Master” binder in 

the office or online using the approved electronic database

▪ AIMS (abnormal involuntary movement scale) 

▪ MSE (mental status exams) 

▪ Medical history (chronological order: all outside records including imaging & radiology reports) 

▪ Correspondence in 

▪ Correspondence out (i.e. referrals)

▪ Miscellaneous (e.g., key research articles pertinent to case) 

NEW PATIENT EVALUATION

15. Instruct patients to bring copies or bottles for all current prescriptions. For residents of group homes/nursing homes/assisted living facilities, request current Medication Administration Record (MAR) 

16. For adults: allow up to 60 minutes for first appointment 

17. For children: allow up to 90 minutes for first appointment

PATIENT FOLLOW-UP VISITS

18. Instruct patients to bring copies or bottles for all current prescriptions 

19. For residents of group homes/nursing homes/assisted living facilities, request current Medication  Administration Record (MAR) 

20. For complex adult patients (group home, nursing home, assisted living) psychotic, demented, and/or  intellectually limited): allow up to 60-90 minutes 

21. For complex child cases (group home residents, psychotic, cognitively disabled, and/or medication damaged) allow up to 60 to 90 minutes 

22. For stable adult cases: allow up to 30 minutes 

23. For stable child cases: allow up to 30-45 minutes 

DOCUMENTATION/ADMINISTRATIVE TIME

24. For each clinical contact, prescribers should be given 10-15 minutes for chart work that may include: 

▪ Finalizing progress note (preferably typed or dictated during or immediately following each appointment) 

▪ Updating appointment tracker (running log of work done on case) 

▪ Completing Super Bill 

▪ Updating Physician’s Order Log/Medication Summary (running log of drug orders and/or refills) 

▪ Creating reminders (tickler) for new labs/referrals/radiology 

▪ Participation in clinical case reviews in order to identify active or potentially imminent emergencies 

▪ Documentation of "no-show" or "late arrival" 

▪ Link patients to aftercare programs (Primary Care Physician, discharge, step-down, step-up)

TERMINATION OF SERVICES

▪ Patients who miss 3 or more scheduled appointments without notification will be subject to termination of           services.

PRESCRIPTION PADS

▪ Federal government requires that Medicaid prescriptions be made using Duplicate Copy 

(carbon copy) pad. Ideally, each prescription pad will feature the following: 

▪ Name of the prescriber 

▪ NC medical license number 

▪ DEA number 

▪ NPI number 

▪ Address/location of practice

▪ Office phone number

▪ Office fax number 

AUTHORIZATION FOR AND FOLLOW UP LAB TESTS

A Psychiatrist/Physician/Non-Physician Practitioner will give a written order for any The Ship Group Community Services Care lab tests. A copy of the lab test order will be placed in the lab/testing section of the client’s record when The Ship Group Community Services Care orders the lab. When the results are received for review, a copy of the results will forwarded to the consulting or coordinating practitioner for review and placement in the 

client’s record.

Lab results filed in a client’s record will include:

▪ Name and date of test ordered

▪ Name of physician ordering tests

▪ Date and time (if noted) specimen obtained

▪ Copy of the report of lab results