This is week 2 of an educational series, created to help attorneys, paralegals, and legal nurse consultants review psychiatric-mental health patient records efficiently and thoroughly.
Last week, I posted a few questions about psychiatric-mental health records. This week, we are going to review them and discuss some of the many possible answers.
Have ALL records been provided?
This can be tricky to determine, for several reasons:
- Gaining access to mental health records can be exceedingly difficult because laws and policies prevent the disclosure of these records to parties who are not fully authorized.
- Providers can block the release of mental health records, or portions thereof, if such disclosure would likely result in harm to the patient/client and/or others (including staff).
- The client might not remember where, when, and why they received treatment.
Suggestions for locating records and determining if they are complete:
- Start by asking the client, their significant others, care providers, and/or case managers about any history of Baker Act(s), Marchman Act(s), and/or Ex-Parte orders. ALL of these require legal documentation and must be provided upon admission to a hospital emergency department, Baker Act receiving facility, or substance abuse treatment center. These documents are PAPER documents and are clearly marked. Even if the patient is sent to a medical unit, the original legal documents must follow; A SCANNED COPY is not sufficient.
- Review billing statements from insurance companies, healthcare providers, and facilities.
- Request and view the patient/client’s visit list (sometimes called “patient encounters”) for each facility. There should be a date, time and visit reason, at minimum.
- Locate and review emergency department records to see if the patient/client was admitted, transferred, or discharged, and why.
- Review outpatient pharmacy records to see who prescribed the client’s medications and where they practice. The prescription dates may also prove helpful.
- For clients in nursing homes, make sure the Preadmission Screening and Resident Review Process (PASRR) form was completed.
- Consult with a mental health expert who has extensive experience using both paper and electronic mental health records.
What additional documentation must be included in all inpatient records?
To be fair, this is a loaded question! Possible answers include:
- Patient rounding sheets (location, behavior, etc.)
- Safety precaution documentation
- Psychotropic medication consent forms
- Treatment Team notes
- Suicide screenings
- Health Care Surrogate documents (if applicable)
- Competency Evaluations
- Voluntary admission forms (if applicable)
- Add your answer by submitting a comment!
What state documents are required in Florida?
Did you know?
Next week, I will share some laws and policies that just might surprise you! Here’s the first one:
If a patient arrives under Baker Act, the facility has a maximum of 24 hours for the patient to be evaluated by a psychiatrist. If the patient is not evaluated within 24 hours of arrival, the patient must be discharged.