New form facilitates mental status exam

Psychiatric patients present unique challenges for the EDs, not the least of which is ensuring that a mental status exam is performed and fully documented. St. Joseph’s Regional Health Center in Bryan, TX, has standardized the process with a specially designed form that ensures every patient is getting the same standard of care.

"Patients with mental health problems were not getting the mental status examination recorded on the chart," says Robert Patton, MD, FACEP, medical director of the emergency services department. "Whether it was being done or not is up for question, but we know that it wasn’t being documented. That would be like treating a heart patient without documenting the cardiac exam."

In addition to inadequate documentation, there were delays in patient care. "Previously, doing the medical screening exam had delayed treatment or placement of patients. We met with a psychiatrist from our hospital’s psychiatric facility, and we all felt this form was something we could benefit from," says Sheila Hejl, RN, the ED’s assistant director of nurses.

The form was developed by staff at the hospital’s psychiatric facility in an easy-to-use checklist format. It’s very quick and stays away from the DSM (Diagnostic and Statistical Manual of Mental Disorders) codes, Hejl explains. "The physicians can go through it very quickly and circle their responses, such as eye contact — good or poor." (See chart on p. 31.)

"When physicians see a psychiatric patient, they complete the form, which includes questions about appearance, mood, suicidal or homicidal impulses, thoughts, and justification for inpatient treatment. The form allows us to perform a mental status examination in less than five minutes," says Patton.

"The standardized language is helpful. It allows us to communicate with our psychiatric colleagues in their language, similar to the way we do with cardiologists or pulmonologists or whatever subspecialists we tend to consult," he says.

Form is easy to use

The ED sees approximately 25 psychiatric patients each month. "The mental health patient is not as common as some of the other patients we deal with, so the form serves as a reminder of how to do a mental status examination, what questions to ask," says Patton.

Because the form is so easy to use, staff training is minimal. "It’s a very simple form and self-explanatory. We took it to a departmental meeting, introduced it to the nursing staff so it could be put on the chart properly, and went over with the physicians which patients should be evaluated with the form," says Hejl.

The standardized mental status exam reduces risks, some of which result from the increasing number of psychiatric patients being treated in the ED. "Psychiatry over the past several years has gone much more toward outpatient treatment, and I think that’s put more of a burden on emergency departments," says Patton."We end up dealing with people who are chronically ill from mental health disease, psychiatric illness, and who, for whatever reason, have no access to care."

If a patient is committed involuntarily, the form can help justify the decision later. "Part of the form is a justification for inpatient treatment, with several check boxes giving the common reasons why people need emergency attention at a psychiatric facility, along with the admitting diagnosis," says Patton.

Screening violent patients

The standardized exam also ensures that potentially violent patients won’t slip through the cracks. "Part of our exam determines whether the patient has suicidal or homicidal ideation, which is a big issue in clearing these people for discharge home or placing them in an institution," says Patton. "That’s one risk factor that needs to be addressed in every patient who presents in the ED with mental health issues."

It’s a challenge to determine whether psychiatric symptoms are drug-induced, indicative of an organic brain disorder, or reflect a bona fide psychiatric illness. The standardized mental status exam helps the ED physicians differentiate among these conditions, says Patton. "It also standardizes our approach and gives us a record on every mental health patient regarding their status," he adds.

"The form ensures that a thorough exam is performed, which reduces the risk of a misdiagnosis. We check the alertness and ability to concentrate, which can help you distinguish between major psychotic conditions vs. [those] secondary to illness or drugs," says Patton.

Standardizing the exam can help protect against a future lawsuit. "If you have an adverse event regarding a mental health patient, documentation is one of your primary defenses against a misdiagnosis, improper treatment, or an improper disposition," says Patton.