Performance Measurement Network

Question: Documentation ofJustification for Multiple Antipsychotic Medications

If a patient is admitted on multiple antipsychotic medications is the attending physician responsible for documenting justification for multiple antipsychotic medications even if he was not the original prescriber?

Answer:

As the attending psychiatric clinician (even if they are not the original prescriber), they are responsible for ordering and managing the patient's medications during the hospital stay. If a patient is on more than one antipsychotic medication, a determination should be made as to why by questioning the patient, family or ambulatory provider or by reviewing past medical records to determine if there have been at least 3 failed trials of monotherapy. If this is the case, they must at a minimum document the names of the 3 failed medications. If a determination is made to cross-taper the medications, this is another justification that must be documented in the continuing care plan. The third justification would be when a second agent is added to augment Clozapine. Please refer to the FAQ that addresses appropriate justification for multiple antipsychotic medications and the supporting article posted with the answer in the database of FAQ's on this website for further information.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical, Related Manual - Data Quality Manual
Related documents: HBIPS,
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