VA Inpatient Psychiatry Quick Start

Specific Ninth Floor Pearls and Procedures to Get You Started (10/10/11), (edit
4/13/15)
A. Steps to Discharge (6) in best order:
1. Discharge Appointment- You can find this order in the orders tab to the left
under "Anticipated Date for Patient Discharge". The idea here is that as soon as you
know when you plan to discharge a patient, you enter this order to notify the other
services to smooth the discharge process. In reality, it doesn't always work that we
can predict discharges in advance on psych. However, put in your best guess of the
day and time as soon as you know (the social workers will often tell you something
like- "put him in for 3pm tomorrow"). This is tracked by the hospital and we get
credit for a) having a discharge appointment and b) if we discharge pt w/in one hour
of our predicted time. If, ahead of time, the plan changes dramatically, you can edit
the order. If it is delayed close to discharge, don't worry about it.
2. Discharge Meds- This step is VERY IMPORTANT TO DO EARLY. Waiting for
the pharmacy to process meds is a main reason discharges are delayed. If you know
a patient will leave the next day (mornings in particular and especially for Thursday
mornings), do these the afternoon before. These orders can be easily entered by
highlighting all inpatient meds you want to fill for the patient and then selecting
"transfer to outpatient" from the "action" button above. Choose the "release
immediately" option when prompted. The computer will then bring up each med
you have highlighted individually for you to review and transfer to outpt meds. We
typically fill a 30 day supply with no refills (some exceptions depending on situation)
as they should see their outpt doctor w/in 30 days. Make sure you choose "window"
for each drug you want the patient to leave in hand. The next step, MEDICINE
RECONCILIATION is also VERY IMPORTANT. You need to review the outpt med list to
clean it up, deleting any meds you no longer want the pt to take (i.e. pt had an
olanzapine order pta, but you changed to risperdal during the stay- that olanzapine
order and any refills remain active on the outpt list unless you discontinue it).Not
doing this step can have serious consequences for patients who are then quite
confused about what they should be taking.
3. Discharge Note- This step must be completed before pt can go out the
door. If you delay in doing this one, nursing WILL urgently page you. To complete,
choose "psychiatry discharge note" from the note menu. A template will pop up.
Click the box in the upper left corner to complete. Mandatory sections include name
of attending, primary diagnosis, med reconciliation, type of discharge and diet
advice. You cannot get out of this template without putting something in the
required sections noted (*). A trick that makes it more workable is to enter a few
characters in any such section which will allow you to complete the template. It will
then be pasted into CPRS where it is easier to work with. This note is what is given
directly to the patient on discharge so do not use medical jargon. Probably the most
important thing in this note is medicine reconciliation which means making sure the
medicines listed are what you really want the patient to be on. Edit this list carefully
getting rid of any meds/ prns that will not be outpatient meds. Fix any errors you
may have discovered while reconciling medications. Do a good job on the
New/Changed, Stop and OTC fields. This really helps the patient when done well.
Finally, all upcoming appointments (psych and otherwise) will import. Make sure the

follow up applicable to this discharge appears. In some cases, SW may have already
made the appointment but it has not made it to the system. Check on this and
make sure the appt. gets typed in manually (if not already imported) so the patient
knows when to follow up.

4. Discharge day PROGRESS NOTE- In addition to the Discharge Note (3)

which is for the pt, a brief progress note is required. This does not have to include
med list, VS etc. but instead should include three elements. First, it should briefly
describe the patient's progress- focusing on the improvements & safety factors that
have led you to discharge the patient. Second, you should note that you and the
attending have discussed the case and are in agreement about the discharge.
Finally, check to make sure all psych related CLINICAL REMINDERS have been
completed (especially atypical anti-psychotic and +Audit C). If not, complete them
within the body of the note. See "E" below for instructions on their completion.
5. Discharge Order- Another step that must be done to get pt out the door. Go
to the left side of orders tab and choose "discharge pt from hospital". Self
explanatory- only caveat is to make sure you specify who will pick patient up for pt's
that you do not feel comfortable discharging on their own.
6. Discharge Summary- These must be completed w/in 24 hours of discharge.
They are so much easier to do when the pt is fresh in your mind, and believe me,
you do not want to end up on a deficiency list that gets reported up the chain. To
complete, click on the discharge summary tab and then on new summary. Choose
any one of the d/c summary titles. You will have to put in your attending and then
link the document to the appropriate admission by double clicking on it. Once your
document opens in CPRS, click on Templates->Shared Templates->Psychiatry>Discharge Summary Template. This will bring up a template that has been
designed to be easy to use. The only fields required to exit the template are the 1 st
four fields and the last one. You can fill these in and then click OK which sends it to
the note proper where it easier to complete. Please note the 3 sections of "read
only" text in the template that instruct you on requirements of the document:
a) You may use admission data here though please update and edit for accuracy. DO NOT include
admission medications or admission
represent a DISCHARGE MSE.

mental status exam. MSE exam should be documented below and

These instruction follow " Elements of HPI, past psychiatric history, family
history, social history,
allergies, past medical history, ROS and physical exam
with updates were obtained from note by
____, dated ______. " At the VA, we do
allow cutting and pasting as long as you give credit and edit appropriately. I find
myself cutting a big section of the H&P that includes the required
elements,
editing it, and then deleting the sections that do not belong in the Discharge
Summary. Note that we do not want admit meds or an admit MSE. Instead we
want a
DISCHARGE MSE that you will type in and discharge meds (see B)
b) Please use the same discharge medication list printed in your discharge note including the
New/Changed/Stopped/OTC portion
of the note. Also please make sure you have accurately reconciled the
medications and that the outpatient med list in CPRS
matches your discharge medications.

Note that you have already done a good job with this in the discharge note
(right?). If you have, you can cut and paste your perfect med list from that

note here. You also should have already cleaned up the outpt med list as
described in #2 (above) under discharge meds (right?).
c) If patient is being followed in our local VA system, including CBOC's, please add the outpatient
psychiatrist AND Mental Health
document.

Treatment Care Coordinator (if assigned) as additional signers to this

Use the additional signer function (right click anywhere on the note to find it)
and add their primary mental health clinician to the discharge summary. As
needed, add more signers if there are others who need to know about this
admit (i.e. PCP, additional MH clinician closely involved)

B. H&P's
The H&Ps are the responsibility of the inpatient team unless you have other
arrangements with your peers in PEC or on consults. You have 24 hours to
have an H&P on the chart, but patients must be tucked in with at least
documentation indicating that on the day of arrival.
You can use info from the PEC noted in your note, but make sure to verify all
info yourself. Make sure you fill in ALL sections of the H&P template. Medicine
reconciliation is just as important on entering the hospital as it is on
discharge. The list you document should be what the patient is ACTUALLY
TAKING and not a large imported list that you do not bother to look at! If the
system imports a DVAMC list and a remote list, edit these to one accurate
master list. Like discharge summaries, always add the primary mental health
clinician as additional signer. Patients coming from PEC typically arrive with
orders. Make sure you discuss all new admits with an attending and edit the
plan as discussed. Admits from C/L can be signed out with the C/L attending
who saw the patient. Direct OSH inpatient to inpatient transfers will arrive
directly to the ward so you will be responsible for the full admission process
(H&P, orders, d/w attending).
C. Medicine Reconciliation
Do you see a point of emphasis here? This is important! See the above
sections where this
talked about repeatedly. Do it on both admission (in H&P)
& discharge (in discharge note,
outpt med list & discharge summary).
D. Additional Signers
Ditto. See the above sections where this talked about repeatedly.
Communication between
providers is key. Add the appropriate additional
signers to both H&P and D/C Summary.
E. Clinical Reminders
This is the VA's way of making sure important screenings get done. We are
responsible for doing all Psych related reminders due on inpatients. To see
what reminders are due, look at the middle section of the coversheet. If one
is due, you complete WITHIN a progress note. Do NOT do them as an
addendum. The system does not count them as done. Within a progress note,

click on the reminders button and a template will pop up. Follow the
instructions which are usually intuitive and self-explanatory. Depending on
the answers, the reminder may direct you to enter orders or educate pt's. In
particular, pay special attention to the Atypical Anti-Psychotic and +Audit C
(alcohol screen) reminders. The hospital tracks their completion. You will be
paged and hassled if you do not complete them. Easier just to do them! BTW,
the Atypical reminder goes active as soon as you order a new atypical so
save yourself a page and do it then. Nursing does the initial Audit C screening
and should notify you if positive. Even without prompting, you should look for
and complete any due reminders daily.
F. Daily Progress Note
The easiest way to learn progress notes is to read peers notes. Notes are
SOAP format. They
typically include VS, the med list, a MSE and mostly
importantly a good A/P. Every progress note
should be mention of the reason
for continued stay. This helps greatly for UM purposes. Also you MUST have a
statement that you have discussed the plan with the attending (name them)
and they agree with it. Many of your peers have templates for progress notes
that import many
of the required elements they can share with you.
Creating your own templates is also easy in
CPRS. Ask someone who knows
once you've got the basics down. You DO NOT have to write a
daily note
when your attending writes a full stand alone note. This cuts down on the
documentation load.
G. Treatment Team/Morning Report/ Interdisciplinary Work
Once a week, your treatment team will meet (check with your attending for
your time slot). The
resident will run this meeting with the assistance of the
attending. The goal of this meeting will
be to review each patient on your
service with regards to their treatment plan as an
interdisciplinary team.
The resident will typically give a thumbnail presentation of the each pt
and
their progress and then facilitate a discussion. The skill here is to learn how to
lead a team
and encourage true interdisciplinary functioning (make sure
everyone participates and has a
voice). On inpatient psychiatry at the VA, we
respect the wisdom and unique viewpoints of each
discipline and value how
much we can learn from each other.
On Mondays and Fridays at 9am, nursing leads "Morning Report". The
meeting includes all three services and the interdisciplinary team. This is
nursing's chance to talk through the issues
with each patient on the ward.
After a brief review of how the pt is doing, the discussion is opened up to all in
the room. Both clinical and disposition issues are coordinated at this meeting
H. Team Huddles
"Team huddle" is jargon for the team coming together to discuss your
patients. We consider morning report (Mondays and Fridays) and your treatment
team (either Tues or Wed depending
on your service) Team Huddles for
those days. On the other two days, you should perform a
"team huddle" on
your arrival. This entails asking which nurse is working with your team ("who
is working with the green team") and having them quickly run down how folks
are doing and any
concerns they may have. If one or all SW's are around,

invite them to be a part of the discussion.

This is just good practice and
will likely help you prioritize your day. If the social workers are not present for
this
impromptu meeting, make sure you are talking with them throughout
the day. Let them know, IN ADVANCE, of people
you hope to discharge.
I. Notes on Call
When you are on call, make sure to write a progress note (may be brief if
appropriate) for any significant change that you were called to assess. This
would include any behavior or medical
change, contact with collateral
sources, and anything that requires a new order (excepting something like a
tylenol prn order). Add the ward resident and attending of record as additional
signers. For any concerning behavior or medical change, also make sure you
talk to your
attending (see "J" below). Also for any transfer, every seclusion,
every injury or serious medical
change, please notify next of kin.
J. Reasons to Call Your Attending
1. For any new patient
2. For any change in behavior/psychiatric symptoms
3. For any exacerbation of or new medical condition
4. For any situation that generates an incident report
5. For any situation requiring seclusion or forced medication
(preferably before if clinically possible)
6. To report any collateral history obtained that would change the
treatment plan
7. For any change in discharge plans that occurs after rounds
8. Anytime you are unsure how to handle a patient situation
9. Anytime you are uncertain if you should call, CALL
(we'd much rather you call than hear about a patient situation later)
K. Seclusion
On (hopefully rare) occasion(s), seclusion is required for pt behaviors that
represent an imminent danger to self or others on the ward. There are very
specific rules and orders that govern this. The most important things is to follow
these rules precisely. These rules are found in the S drive->Psy folder-> 9A
Seclusion Forced Meds Subfolder. Open this file and follow the instructions
EXACTLY. Important points include orders have to be entered within one hour of
the initiation of this event and are good for up to four hours. This event requires
a face-to-face evaluation (the document says within four hours but I would say
ASAP- this is considered an emergency!). Make sure to also to write a progress
note documenting your assessment and that you spoke to the attending and
next of kin. We try to get patient calmed and out of seclusion ASAP. However, if
the seclusion event continues for >4 hrs, the orders and documentation have to
be redone.
L. Forced Medication
There are two situations for forced medications. One is Emergency Forced Meds
which are for patients that are felt to be an imminent danger to self or others. If
you decide a situation is emergent, you may use IM meds as required. Always try

to offer PO meds first (sometimes you are surprised when they take them).
Offering PO meds shows you tried the least restrictive intervention. Always talk
to your attending when forced meds are given (depending on the nature of the
emergency, this sometimes occurs after they are given). Always write a note
documenting your rationale for why this was an emergency and that you
discussed with your attending. Refrain from writing emergency IM meds as prns.
The second situation is Non-Emergency Forced Meds which are intended for
patients who are not an imminent danger to self or others but who are refusing
meds and will not improve to discharge without them. This is a very different
policy that requires an outside team assess the patient and agree they are
needed. Ask your attending to explain the steps required as the need arises.
M. Commitment Issues
Commitment is a huge topic and full details and computer forms for commitment
paperwork can be found in the S drive-> Psy folder-> Commitment paperwork
subfolder. Issues for the inpatient resident are covered here.
One issue is the 2nd QPE. When any new patient is admitted, knowing whether
they are voluntary or involuntary is important. If both the 1 st and 2nd QPE's have
been appropriately completed prior to their arrival, you do not have to fill out a
QPE. However, the most common scenario is the 1 st QPE was done in the PEC. In
this case, the ward resident will fill out the 2 nd QPE (see the protocol on S drive).
This QPE has to be completed within 24 hours of the 1 st QPE. If you delay beyond
this point, you will have to start the process over! Thus, it is important that
residents communicate the need for a 2nd QPE to each other. This is especially
important over the weekend where this duty may fall to the on-call person (i.e.
Friday night on-call does 1st and needs to communicate to the Sat on-call to do
the 2nd). For patients, admitted over the weekend involuntarily, the ward resident
should review the commitment paperwork on Monday to make sure it was
completed properly. If the 1st QPE was done but the 2nd was not (and the pt still
needs commitment), you have to start all over. There is a special note in CPRS
that alerts you that IVC has been initiated by PEC. Pay attention to this note.
Ideally you should be cosigned on this note as person to do the 2 nd QPE.
Commitment forms need to be filed with Durham County (the AOD may assist
with this after hours). Make sure they are faxed to the correct fax number at the
Durham County Court (919) 808 3001. This paperwork is easily misplaced in the
process. It is required that you make copies of all commitment work and place
it with the patients paper chart. The paper charts can be found, sorted by room
number, in a drawer to the right of the clerks desk on 9A. These copies, while
not legal, do protect you by showing you did complete the work if the paperwork
is lost by others. During the day, you should also follow up with a call to Karla
Kostkas, the Deputy Clerk for commitment issues in Durham, at (919) 808 3054,
to confirm receipt. It is also required that in your note for the day, you
document what you did, for example-Petition and 1 st QPE completed and faxed,
2nd QPE completed and given to AOD, Smith etc.
Another commitment issue for inpatient is the case where commitment status
changes. If it does, a change of commitment form needs to be filled out and

faxed to the Durham Deputy Clerk at (919) 808 3001. These forms can be found
in the resident's office. If the forms run out, talk to Dr. Kirchmann for additional
copies. One reason for this form would be allowing a previously committed
patient to change to voluntary status. To do so, check the appropriate box and
fax the change of commitment form and also open pt's CPRS record and change
the order that reads "Admission is involuntary" to voluntary. The other primary
use of this form is when a committed patient improves and is discharged, check
the "patient is no longer in need of inpatient hospitalization" box and fax to the
Public Defender. You do not need to change the order in this case.
One final commitment issue is patients who challenge their commitment. The
Public Defender will visit the patient on the ward. Patients who wish to challenge
have the right to do to a court hearing within 10 working days (this happens
infrequently and is often continued). Court happens on Fridays at the Durham
County court house. The resident will testify as an expert witness at the hearing.
Relax; this is an educational and interesting experience! Talk to your attending
about this process if it happens.
N. Medical Back-Up
Your medical back-up depends on the time of day and severity of medical issues.
For non-emergent medical issues beyond you and your attending's medical
knowledge base (we manage most of the day to day medical needs), there is a
Gen Med consult team. They are a typical consult service and are not staffed for
emergencies. Please do not overuse this team. If what you really need is some
curbside help, ask if they would rather just answer your question vs. do a full
consult. If the help you need is more specfic to a specialty, a full range of
specialty consults are available. Your attending will help direct you when a
consult is needed and whom to call.
For emergent issues during the day, our first back-up is the Medicine Assistant
Chief Resident. Try to involve this person as early as possible once you identify a
serious condition needing help very soon. After hours, our first back-up is the
MICU resident. If you need help their help right away, make sure they realize
this. If the condition progresses and you need help immediately, have the nurses
call the Rapid Response Team (for conditions short of a code) or if necessary the
Code Team.
Update 1/3/12

O. NO Verbal Orders
Verbal orders are not allowed on inpatient psychiatry. This really should not be a
problem as CPRS is accessible throughout the hospital. If you dealing with an
emergent issue somewhere else in the hospital and an urgent order is needed on
inpatient, enter the order for inpatient in CPRS and get to the ward, if needed, as
soon as you are able.
Update 1-24-13

P. CIWA Protocol
The CIWA[Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWAAr)] protocol is an evidenced based method for alcohol detoxification. Basically

it is a symptom triggered approach to detoxification that uses nurse ratings of

withdrawal symptoms on a validated scale (CIWA-Ar). The CIWA score guides the
next step in treatment, stratified and ranging from no treatment to
administration of detox medications. The CIWA score allow dictates the
frequency of re-evaluation. Educational material on the CIWA can be found at
the following link:
http://www.chce.research.va.gov/apps/PAWS/Default.htm
To order the CIWA protocol, go to 5-Admission/Transfer, then 1-Psychiatry, then
19-CIWA AR
assessment. In the initial screens, there is info on starting the
CIWA with an option for more
information and then a choice to begin
ordering either a Lorazepam or Chlordiazepoxide CIWA
protocol. Clinicians
may choose to use either CIWA or, in certain circumstances, a traditional taper
for alcohol detoxification. Discuss this with the attending to whom you are
signing out.
Update 6-4-12- updates to Commitment and Daily Progress Note sections above
Update 1-24-13- updates to H&P rules and addition of CIWA section
Original 10/10/11- This document was meant to be added to over time. If you
see errors or think of things that would be helpful to add, contact Dr. Kirchmann.
The most up to date version can be found on the S drive