AMERICAN ACADEMY OF CHILD PSYCHIATRY
GUIDELINES FOR PSYCHIATRIC STANDARDS OF CARE
Signature Guidelines Regarding the Use of the Psychiatrists\’ Signature
Task Force on Psychiatrists\’ Signatures
Task Force on Psychiatrists\’ Signatures: Alan A. Axe/son, M.D. (Chair); Joel Goldstein, M.D.; Joan Kinlan, M.D.; and Harvey Tullin, M.D.
Staff Virginia Q. Anthony, Executive Director; L. Elizabeth Sloan, L. P.C., Director of Clinical Affairs; and Sloan Mahone, Deputy Director of Research
Approved by Council on June 6, 1997 1997 American Academy of Child and Adolescent Psychiatry
Ordering Information: American Academy of Child and Adolescent Psychiatry, Publications Department, (202) 966-7300 or www.aacap.org
At the May 1996 meeting of the Assembly of Regional Organizations of the American Academy of Child and Adolescent Psychiatry, a Task Force was appointed to consider the ethical uses of psychiatrists\’ signatures.
The Assembly was mindful of the often erratically changing practice climate of the last several years, and of the strains that these changing conditions place on psychiatrists\’ ability to practice in the best interests of patients and in professionally sound ways. Previously unforeseen clinical, financial and administrative relationships among and between psychiatrists, patients, and administrative and business entities have developed, and continue to evolve in a dizzying way.
Because of this, the Assembly authorized this document to establish some locus of re-control over psychiatrists\’ combined professional destinies, and to define principles for signature rights and responsibilities. What follows is an irreducible and practical operational foundation for psychiatrists in one very important area of practice, and backed by the full authority and support of the Academy.
The Task Force\’s goal was to be inclusive in identifying situations where psychiatrists\’ signatures might be needed or required. The following areas were considered:
Consents to Treatments
Written and Telephone Prescriptions
Peer Review Documents
Signing for Other Physicians
Necessity for Treatment
Treatment Authorization Requests
Admission and Discharge Notes
Other Medical-Psychiatry documents
1. Guidelines Regarding the Use of Psychiatrists Signatures
Tasks Force on Psychiatrists Signatures
This document is a position statement of the American Academy of Child and Adolescent Psychiatry and is directed primarily toward its membership. It is designed to be distributed widely, to clarify Academy members\’ operating principles for all who use psychiatrists\’ services.
Among that wider audience are: patients and their families, all psychiatrists, other physicians, all psychiatric practitioners, trainees, insurers, managed care companies, the American Bar Association, the Trial Lawyers Association, legislators and regulators, consumer organizations, advocacy groups, business organizations, labor unions, community mental health center directors, members of the judiciary, school personnel, hospital administrators, and members of all branches of the media.
The members of the Task Force on Psychiatrists\’ Signatures believe these principles have broad application. For this reason, the word \’psychiatrist\’ has been used throughout the document this document takes a national perspective. Individual states may have laws or regulations that address specific issues and affect practices in a particular jurisdiction.
Task Force on Psychiatrists\’ Signatures
1.0 General Principles
In signing a document, a psychiatrist assumes a number of legal and ethical responsibilities associated with that document. Signing documents therefore, should be done thoughtfully and in accordance with legal and ethical principles.
1.1.0 Role Implications
Unless otherwise specified, the signature of a psychiatrist on a clinical document implies that he or she has prepared the document personally, has had personal contact with the patient, and takes responsibility for the content of the document.
Psychiatrists may endorse documents ethically in other situations, for example, when they are functioning in adjunct roles. Appropriate other roles may include administrative or clinical supervisor; treatment team member and collaborating psychiatrist or consultant (Appelbaum, 1991). The psychiatrist\’s role should be explained either in the body of the document or near the signature. When the psychiatrist is providing supervision, the supervisee\’s name and role should also appear in the document (California Psychiatric Association, 1995a, 1995b). The same procedures should be followed in collaborating relationships.
1.2.0 Use of Colleagues\’ Names
A colleague\’s name on a document may imply co-authorship or shared responsibility for the document. This principle may apply to the use of colleagues\’ names in a description of an informal consultation concerning a patient\’s treatment. Colleagues\’ names, therefore, should be included in documents only with their permission.
1.3.0 Use of Dates
A date is a component of the authentication of a document. A date near a signature ordinarily indicates when the document was signed. If the document is a summary of an evaluation performed on another date, a statement should be made to that effect.
The date on a prescription order must coincide with the date the order was written. It is fraudulent and unethical to post-date or otherwise incorrectly date a prescription, and those doing so may be subject to prosecution by the Drug Enforcement Agency. For Schedule II substances, including stimulants, it is also unlawful to include a refill order in a prescription.
1.4.0 On-Call Responsibilities
Physicians frequently provide coverage for medical colleagues who are not available. The on-call coverage relationship should be preestablished in an oral or written formal agreement. Afterward, it is appropriate for a covering psychiatrist to use his or her signature or telephone authorization to manage treatment prescribed by the patient\’s psychiatrist.
2.0 Clinical Documents
2.1.0 Disability Documents
A psychiatrist\’s signature on a document to determine eligibility for disability or other benefits indicates that the psychiatrist has objectively assessed the medical condition of the patient, and has not based the determination solely on a patient\’s request, a family need, or other social factors.
2.2.0 Forensics Documents
In forensic evaluations, such as those to determine custody or responsibility for criminal behavior, the psychiatrist\’s signature indicates that he or she has evaluated the patient and accurately answered the questions asked. The psychiatrist\’s role as an agent of the court should be indicated in the document so that this role is not confused with the usual psychiatrist-patient relationship.
2.3.0 Treatment Plans
The signature of a psychiatrist on a treatment plan does not necessarily signify that he or she has examined the patient, but it does indicate that the psychiatrist has reviewed written or verbal clinical material sufficient to support the diagnosis and treatment plan. A psychiatrist may sign a treatment plan in this manner as part of his or her role as attending psychiatrist, treatment team leader, treatment team member, supervisor, or consultant. The role should be indicated with the signature or in appropriate administrative policies (American Psychiatric Association, 1989).
Although a treatment plan may be based on the assessment of others, by signing, the psychiatrist accepts responsibility for the treatment plan consistent with his or her specified role. Therefore, psychiatrists should allow for sufficient time for the review and completion of documentation before signing a treatment plan.
2.4.0 Admininistrative Reviews
Signatures on documents related to quality assurance review, or other administrative review of clinical records indicate that the psychiatrist has executed his or her responsibility as established by the guidelines of the facility. By signing a quality assurance or review document, the psychiatrist is indicating that to the best of his or her knowledge, the guidelines under which he or she is working comply with professional, ethical, and legal standards. When involved in administrative or quality review, therefore, psychiatrists assume considerable responsibility for the quality of the treatment process. The nature of the psychiatrist\’s involvement should be indicated in the document or in appropriate administrative policies.
2.5.0 Prescriptions for Medications
A psychiatrist\’s signature on a prescription is a statement that he or she has seen and evaluated a patient and selected an appropriate medication. An accurate evaluation can be made only when the psychiatrist has spent sufficient time in clinical interviews and evaluation of collateral information or diagnostic testing. Signatures on subsequent prescriptions imply that the psychiatrist is reevaluating the patient\’s continuing need for the medication at intervals consistent with the patient\’s condition.
When the prescription is written for a patient who is receiving psychotherapy from a non-physician therapist, the prescribing psychiatrist risks being held legally responsible for not only the medication management but also the treatment being provided by the non-physician therapist.
2.5.1 Prescription Privilege
The prescription of psychotropic medications for the treatment of complex psychiatric illnesses is an intervention to be made only by an appropriately trained psychiatrist. In no case should a psychiatrist prescribe medications
Solely at the direction of a non-psychiatrist, which would enable another clinician to assume a role outside the scope of his or her license.
Signing blank prescriptions is unethical and illegal. There may be situations, such as medication monitoring of a stable patient, where nurse practitioners or physician assistants, operating within their scope of practice, may prescribe under the supervision of psychiatrists.
Psychiatrists in the role of “physician” may use their signatures to support the prescribing activities of resident physicians practicing under a limited license.
2.5.2 Telephone Transmissions of Prescriptions
Telephone contact or facsimile transmission to a pharmacist by a psychiatrist may be substituted for a signed prescription. Delegation of a verbal order for a prescription, however, should be made only to registered nurses or other professionals who are licensed to accept it. In certain jurisdictions a telephone or fax prescription may require authentication with an original signature.
2.6.0 Billing Documents
Psychiatrists\’ signatures commonly authorize insurance or other billing documents. The psychiatrist\’s signature indicates responsibility for the integrity of the billing information, including accurate identification of the treatment provider and the nature of the treatment provided (American Psychiatric Association, 1991).
It is illegal and unethical to submit a bill or to have a bill submitted on a psychiatrist\’s behalf for treatment not provided by that individual. If the bill is for treatment provided by a professional working under a psychiatrist\’s supervision, the relationship must be specified and the treating professional\’s degree identified on the bill.
The psychiatrist is responsible for the uses of his or her name and signature on billing documents prepared by administrative support staff. This includes the uses of the psychiatrist\’s signature stamp. Psychiatrists must be certain that the procedures followed by support staff are ethical, legal, and accurate to the payer\’s requirements.
2.7.0 Treatment Authorizations
When psychiatrists, by signature or name, request treatment authorization from a managed care company or other agent, an accurate description of the patient\’s condition and treatment needs should be provided. Using an incorrect diagnosis to gain insurance coverage, or misrepresenting treatment modalities in order to gain authorization is unethical, even when motivated by concern for patients. This principle reflects the Code of Ethics, Principle XVII (American Academy of Child & Adolescent Psychiatry, 1980).
2.8.0 Authorization Reviews
When a psychiatrist, as the agent of a managed care organization, makes a determination regarding the authorization of treatment, his or her signature indicates that he or she has made a medical judgment determining that the treatment meets or does not meet the utilization criteria of the organization. Furthermore, the psychiatrist\’s signature affirms by implication that the utilization criteria being followed comply with professional, ethical, and legal standards, and that the psychiatrist subscribes to these criteria. This principle applies even when the documents are intended strictly for internal use in the organization.
3.0 Managed Care Contracts
The psychiatrist\’s signature on a contract with a managed care company or provider network indicates that he or she agrees to abide by the terms of the contract. Reservations regarding terms of the contract should be negotiated, and the contract revised, before signing. Minor disagreements with parts of a contract can be addressed by crossing out offensive clauses or including substitute language, then initialing and dating the area.
By signing a document, a psychiatrist indicates that he or she understands and is willing to assume a number of important responsibilities associated with that document. The assumption of these responsibilities is part of the value of the services provided by psychiatrists. Psychiatrists must use care, discretion, and integrity when signing documents, to minimize vulnerability to liability, but more important, to preserve the meaning and authority of the psychiatrist\’s signature for the profession at large.
AMERICAN ACADEMY OF
CHILD & ADOLESCENT PSYCHIATRY
3615 Wisconsin Avenue, NW Washington, DC 20016-3007
202.966.7300 – FAX 202.966.2891
AMERICAN ACADEMY OF
CHILD & ADOLESCENT PSYCHIATRY
Prescribing Psychoactive Medications for Children and Adolescent
Adopted by the Council on June 16, 2000
Prescribing psychotropic medications for children and adolescents requires the judgments of a physician, such as a child and adolescent psychiatrist, with training and qualifications in the use of these medications in this age group. Certainly any consideration of such medication in a child or infant below the age of five should be very carefully evaluated by a clinician with special training and experience with this very young age group. Any child or adolescent for whom medication is a consideration requires an evaluation of the psychiatric disorder, including the symptoms, co-morbid conditions, any other medical conditions, family and psychosocial assessment and school record.
Most psychoactive medications prescribed for children under age 12 do not as yet have specific approval by the Federal Drug Administration (FDA); such approval requires research demonstration safety and efficacy. Such research so far lags behind the clinical use of these medications. Efforts to address this deficiency include the development of Research Units of Pediatric Psychopharmacology (RUPP) and recent federal regulations requiring increased studies of medications presented for children and adolescents. Long-term studies are needed to adequately determine the safety and efficacy of psychoactive medications.
In making decisions to prescribe such medications the physician – specifically the child and adolescent psychiatrist – should consider data from studies in adults in treating the target disorder and/or symptomatology, any clinical or anecdotal reports of use in child and adolescent patients, studies conducted outside the United States and the experience of colleagues.
The prescribing of multiple psychotropic medications (“combined treatment”–“polypharmacy”) in the pediatric population seems anecdotally on the increase. Little data exists to support advantageous efficacy for drug combinations, used primarily to treat co-morbid conditions. The current clinical ” state-of-the-art” supports judicious use of combined medications, keeping such use to clearly justifiable clinical circumstances. Ongoing medication management requires the informed consent of the parents or legal guardians and must address benefits vs. risks, side effects and the potential for drug interactions.
It is important to balance the increasing market pressures for efficiency in psychiatric treatment with the need for sufficient time to thoughtfully, and adequately, assess the need for, and the response to medication treatment. Monitoring on going prescribing of psychoactive medications requires sufficient time to assess clinical response, side effects and to answer questions of the child and family. AACAP opposes the use of brief medication visits (e.g. 15-minute medication checks) as the accepted standard of care by the insurance industry; health plans and managed care companies. The role of psychosocial interventions, including psychotherapy, must be evaluated, and such interventions must be included in the treatment plan.
T. J. Glenn, M.D., F.A.P.A., F.A.A.C.A.P.
Child, Adolescent, and Adult Psychiatrist
1922 Sherwood Dr.
Cape Girardeau, MO 63701
Fax # 573-335-7899
E-Mail [email protected]