Pre-Psychiatric Consultation Chart Review
Some of these are easy, like plucking out a few particular lab results. Some of them can be rather arduous, like trying to dig up what happened when the patient took fluoxetine/Prozac. And some of them are challenging, like gleaning what you can about the patient’s mood or anxiety problem from a series of primary care notes where the focus is on pain or G.I. symptoms. Don’t spend too long on this. In many cases you could spend hours. Shoot for about one hour or less.
Open a Word document (no patient name; and remember to delete it when done, though of course you’ll want to Save it as you go). Use that for notes and to write most of your Review. You’ll cut/paste to EPIC later. You’ll be using EPIC to look at the patient’s chart for everything below.
Later, in EPIC, create a Staff Message to send your work to your supervisor. Paste your Word text into the Message. Send yourself a copy to keep track of it and confirm that your work was saved in EPIC. Then delete the Word version.
Suggestion: look at the whole list of things you’re hunting for, below. Track them all at once as you go through notes, not one section below at a time.
Question /Data
1. When you are asked to prepare a chart review, see if you can find out: who asked for this? Did she/he offer any details about why they wanted this or what they want? (this generally requires asking the person who gave you the review if they received any of those specifics from the PCP or psychologist)
2. Has the patient been assessed or seen by the health psychologist? Scan Encounters in Chart Review for the psychologist’s name (listed by clinic below). Note date of the initial evaluation, their BioPsychoSocial intake. (sometimes the 2nd visit) Summarize their note briefly: diagnosis, one-line summary of their impression.
Geary St. Family Medicine / Christopher SmithMid-Valley Medical Plaza,
Main St. Family Medicine / Laura Sisson
Lebanon Medical Home,
Park St Family Medicine / Lea Burns
Sweet Home Family Medicine,
Brownsville Family Medicine / Allegro Johnson
Samaritan Family Medicine / Michael Herman
Samaritan Internal Medicine / Michael Bachop
3. Does the patient have any screening questionnaires beyond those the Psychologist did (e.g. PHQ-9)? Try looking in the Documentation Flow Sheet in EPIC; or maybe in scanned documents, often right near the psychologist’s initial visit-- look for a paper clip, right click to view. What are the results of these over time if there is more than one? [Goose Chase Warning! Don’t hunt here, usually there is nothing]
4. Relative to the question being asked, what is the primary care provider’s diagnosis? The psychologist’s?
5. (The following is like taking a History of the Present Illness, as best you can glean it from chart notes. This is supposed to be the fun part, sleuthing) Are there progress notes which provide any insight into the diagnosis? E.g. what symptoms are noted; are they consistent with the current diagnosis? Any symptoms described which are not consistent with that diagnosis? Summarize your findings, keeping track of the date of the note containing important findings.
6. Lab review
Wt/BMI; thyroid (TSH); renal (creatinine); hepatic (ALT/AST); blood (platelets).
7. Past psych’ treatment [these data are perhaps the most important for helping the consultant, but can be very difficult to find.]
Fill in a table like the one below, as much as you can, without sweating it too much. Here’s an example:
Treatment / from/by whom? / when / duration of rx / benefits? / adverse effects / why stopped?amitryptiline / PCP, Jones / 1990’s / 1-2 years / sleep / wt. gain / wt. gain
cognitive rx / psychologist,
Ramirez / 2002 / 4 months / less anxiety / completed rx course
fluoxetine / PCP, Berea / 2009 / 2 weeks / Jittery / jittery
Continue as warranted.. (this is not easy, we know)
8. Past medical history
Review the Problem List. Which items on the Problem List might affect psychiatric care in significant way?
One specific we should always check for that’s not as obvious as thyroid, for example: Obstructive Sleep Apnea. Consider digging for this if there is any problem with insomnia, daytime fatigue – e.g. trazodone, benzodiazepines, or Z-drugs on med list, or stimulants; or if BMI > 25. Has there been a polysomnogram test or any other evidence of consideration of sleep apnea?
9. Substance use
AUDIT should provide data on alcohol use, if done. Summarize any notes which include data on use of other drugs. Any treatment received?
10. Social circumstances
Primary relationships, if you can find anything on that (spouse, kids, parents). Work situation; if on disability, is there any mention of why? Any social history that’s relevant to the question/problem. (This can be the fun part of chart sleuthing. What can you find here that might shed light on why this patient is not doing well? )
(end of chart review process guide)
At the end of your review, please write down your Impression and Recommendations. You won’t be confident about this part but have a go. Your entire note above is a valuable database that will be used by the psychiatrist. But we want you to think through what you found diagnostically, and therapeutically. We’ll review these with you later, as time allows. And we’ll cut them from your note when pasting your data into the record so you don’t have to worry about condemning a patient to an everlasting fate by declaring a bad idea. Might as well learn now…
Impression
What do you think is the main problem and the basis of that problem. You only get one short paragraph for this, or maybe two short ones. Some examples follow in the appendix below.
Recommendations
List 2 or 3 next steps the primary care team might take. Number them as such. Bold the medication or other intervention you’re recommending in each of these three paragraphs. See examples appended.
Interviewing Guide
(If you have the opportunity to interview the person that goes with the chart, some ideas on approach:)
Our routine Initial Evaluation is similar to your routine H&P: HPI, Past Medical History, Family History, Social History, Substance use.
Flesh out the Past Psychiatric History you obtained from chart review, particular the patient’s recollection of outcomes from prior treatments.
Mental status exam in most cases is just a matter of observation: affect, memory, attention, motor activity. If depressed, assess suicidality.
If warranted, consider a MOCA (mocatest.org) rather than more informal tests of memory and attention. / Enlarge the HPI a bit. You can go anywhere the interview takes you, but if you need some structure (or want some, because the patient is taking you all over the place) follow up on positives from the screening tools (e.g. “You said ‘loss of interest or pleasure in doing things” was “nearly every day”. What have you noticed there?”) . You probably won’t be able to follow up on everything. Pick the ones pertinent to the primary problem (aka chief complaint) including those indirectly relevant. For example if the patient’s main problem is depression and she is not sleeping well, is that initial insomnia (long time falling asleep) or middle insomnia (difficulty getting back to sleep) or terminal insomnia (waking up too early, unable to return to sleep)?
Appendix: Impression/Recommendation Example
Psychiatric Chart Review
Psychiatric consultation requested by K. Lane; prior evaluation and limited f/u by Dr. Mandi Hudson, psychiatrist.
Impression
Per Dr. Hudson's sessions and outcome, bipolarity fairly well established. So the question appears to be: what to add to make current rx work better? There are two clear steps to try; if not effective, things then get more complicated.
Recommendations
1. Increase lamotrigine dose to maximum that's fully tolerable, or 400 mg
2. Lithium augmentation (TSH and creatinine currently okay)
Lamotrigine dosing: limiting side effect is cognitive side impairment, and mild impact on balance. These will be mild if titration is by 50 mg steps and will go away completely with no remaining effects when the dose is decreased, within 2-4 days. Increase by 50 mg steps per week until:
A) better; keep that dose
B) side effect; lower to previous dose
C) 400 mg daily (if better, but SE's, try split dose before lowering)
After that, if still not where she wants to be, consider low-dose lithium augmentation. Target is symptom response, not blood level. Increase by 150 mg steps until:
A) clearly better, keep that dose
B) side effect, lower to previous dose
C) 600 mg.
Once dose is stable, check a lithium level. After 6 weeks, check TSH again. Repeat prn to establish that TSH is not moving. Follow creatinine every 6 months, and prepare to d/c lithium if it's clearly going up, even if lithium is working well (usually a high-dose lithium problem, usually takes a decade).
Another example:
Psychiatric Chart Review
Requested by Dr. Godek
Impression:
Bipolar I dx seems firm. Question is what to do w/o lamotrigine.
Recommendations:
1. In quick chart review, lithium does not appear on any lists. If she's really never had it, it's the obvious option. Creatinine, TSH okay on labs 1.5 yrs. ago, that's recent enough for this purpose. But as you know, that's a tricky explanation sometimes, helping the patient go for that option.
2. After that, options are divalproex or carbamazepine. Trickier to use, weight gain risk versus drug interaction complexities. Hopefully these will not need to be contemplated, in part because of #3 below.
3. Escitalopram is at 20 mg. This can be destabilizing. If on low dose lithium she was not doing well, instead of turning it up or turning to another agent, another option would be to begin a slow taper of escitalopram, e.g 4 months, by 2.5 mg steps (1/2 of a 5 mg form). The goal is to gradually remove it without seeing depression worsen, hoping for a steady improvement in "cycling" and/or a reduction in mixed state symptoms (irritability, insomnia, agitation, difficulty concentrating).