Psychiatry residency program at psychiatric hospital

Dr/Zeinab El Nagar
Lecturer of Psychiatry
Ain Shams University
Psychiatry Residency Program at
psychiatric institute
(in patient resident duties)

We are excited to
have you as
a member of our
residency team

Our residency environment will provide you
with:
1.clinical case experience
2. didactic information
3. confidence to enter the practice of general psychiatry
as a competent, board-eligible physician.
4.You will learn the skills and information that will
enable you to diagnose and treat a diverse patient
population with a wide variety of disorders.

Program Mission
Our mission is to :
1. provide to psychiatric residents excellent and quality
healthcare to all, especially hospitalized patients .
2. provide a comprehensive learning experience to
meet the demands of psychiatric practice.
3. Acquired you by knowledge, skills, and
competencies predominantly through community-
based learning experiences.

Educational Requirements Didactics
Residents are required to sign in when they
arrive.
An attendance report is prepared for the program
director who provides feedback to residents
during the required semi-annual Resident
Reviews.

The program director is responsible to:
1. Review program policies.
2. Review rotation and didactic goals and objectives.
3. Assist with 6 month resident performance reviews.
4. Assist the chief resident in developing theActivity.

6. Encourage, monitor, and assist residents in
identifying and participating in appropriate scholarly
activities.
7. Attend the Residency Training Committee
Meetings each month.
8. Assist with recruitment and active participation in
the interview process of applicants for the residency
program.

Role of the Chief Resident
1. supports resident teaching activities such as:
• Grand Rounds
• weekly didactics
• Journal Club
• Clinical Case Conferences.

2. supervises the development and
modification of resident schedules,
including :
vacation requests
arranging back-up coverage for unplanned
absences.
3. Provide an avenue of communication to raise and
resolve issues without fear of intimidation or
retaliation.

4. ensure continuity of service and care for all Psychiatry
patients.
5. Assist residents with transitions to next clinical sites.
6. Ensure that the upper level residents are helping in
the education of medical students and lower level
residents, also in rotations of clinical services system

Role of the Chief
Resident
7. Share in teaching duties and clinical
information gathering and clinical basics.
8. Assist with student orientation.

Program Duty Hour Logging
Requirements
Failure to log duty hours for seven (7) or
more consecutive days WILL results in an
administrative day for the resident.

1. Shift/rotation—all schedule activities (including
lectures) associated with rotation
2. Clinic
3. Conference/workshops/lecture—
4. Didactics and Grand Rounds only
5. Back-up call in any time a resident is called in for
a shift as back-up, moonlighting.
6. Vacation
7. Holiday/Day off

Time Management and Administrative
Responsibilities
1.Documentation
2.duty hours
3.patient/procedure logs
4.participation in learning opportunities should met and
documented by the resident
5.Seventy (70%) attendance to Grand Rounds
and Didactics on a quarterly basis
6.set aside a minimum of 2-3 hours per weekday (or
10-15 hours per week) to complete these
administrative program requirements

Residents are discouraged from taking
vacation on timed rotations such as:
A.Inpatient Geriatrics Experience
B.Neurology
C.Child (outpatient and inpatient)
D.Forensic
Problems or Difficulties—What to Do?

When to Call for Help
For clinical help:
1. seek your supervising resident or chief resident
first.
2. If the situation is not resolved or if no
supervising resident is available, call
your(assistant lecturer)

Residents are responsible for completing
hospital, program, educational and
administrative assignments by given
deadlines
If personal problems arise:
you may discuss them with the program
director and/or you may contact
Human Resources ?

Work Hours
Unless otherwise specified by the clinical
supervisor:
•the work day generally begins at 8 a.m. and
continues until the end of the clinical work day for the
rotation.
•Ending times may vary from rotation to rotation, but
in general, ending time is usually between the hours
of 5 p.m. and 6 p.m.

Duty hours are defined as all clinical and
academic activities related to the program
including:
1. inpatient and outpatient patient care assignments
2. administrative duties
3. do not include reading and preparation time spent away
from the duty site.
Residents must adhere to all duty hour
restrictions and requirements as outlined below:
1. Continuous on-site duty must not exceed 16 consecutive
hours.
2. No new patients may be accepted after 24 hours of
continuous duty.

3. Duty hours must be limited to 80 hours/week,
averaged over a four weeks.
4. Residents must have one day in 7 free from all
educational and clinical responsibilities, over a four
weeks.
5. Residents should have 10 hours, must have 8 hours,
free between all daily duty periods and call
assignments.
6. In-house call must occur no more frequently than
every fourth night for psychiatry rotations,
averaged over a 4 week

7. Over time must not interfere with the ability of
the resident to achieve the goals/objectives of the
educational program nor interfere with duty hours.
8. Internal moonlighting is considered part of the duty
hour limitations.
9. conferences for the hours that extend beyond the 24
hour period.
10.Each resident must enter written Justification or
Cause in the event of a violation.

In all cases the program director should be informed of
the occurrence and nature of the situation in which the
respite rule of duty hour.
All duty hour violations are monitored, recorded
and automatically reported to the program director.
Residents may stay beyond that period for four
additional hours in order to carry out an effective
patient care transfer.
Beyond a 24-hour period of duty in the hospital the
resident must have at least 14 hours free from duty.

the resident is required to document the reasons for
remaining to care for the specific patient and submit
the information where he will be out of compliance
with the policy
This documentation will allow the program director
to discuss the resident’s schedule with the resident
with the goal of preventing future occurrences.
if the justification is acceptable, the program
director, chief resident(s), and resident meet to review
the cause for the violation and resolve future duty hour
violations.

PROTOCOL FOR
EPISODESWHEN
RESIDENTS REMAIN
ON DUTY BEYOND
SCHEDULED HOURS

In unusual circumstances
residents, may remain beyond their scheduled period of
duty to continue to provide care to a single severely ill
patient or unstable patient, academic importance of
the events transpiring, or humanistic attention to the
needs of a patient or family.
Under those circumstances, the resident must:
1. Appropriately hand over the care of all other patients to the
team responsible for their continuing care
2. Document the reasons

Program Goals
psychiatrists who are proficient:
1. in the details of medical management
2. sensitive and responsive to the special circumstances
3. Educational Competencies to begin the independent
practice of this specialty.
4. Medical Knowledge about established and evolving
biomedical, clinical, and epidemiological and social-
behavioral sciences and then apply it to patient care.
5. Residents are expected to demonstrate an investigatory and
analytic thinking approach to clinical situations.

First rotation (general psychiatric unit) (in
patient)
This is a transitional year during which residents: are
introduced to patient safety and quality improvement
curriculums and competency expectations.
Second rotation (special psychiatric units)
1. This year provides training and experience in outpatient
community psychiatry.
2. Experiences in child and adolescent psychiatry, addiction
psychiatry.
3. Residents participate in patient safety and quality
improvement activities/projects and begin work within
the different psychotherapy competencies.

Third rotation :
Residents will complete:
an emergency psychiatry rotation
consultation-liaison rotation
forensic rotation
Residents will continue care for long term supervised
psychotherapy cases and patient safety/quality
improvement projects

Interpersonal and Communication Skills
(groups with role-play during weekly meeting)
Residents are expected to:
1. Create and sustain a therapeutic and ethically-sound
relationship with patients.
2. Use effective listening skills as well as elicit and provide
information using effective nonverbal, explanatory,
questioning,and writing skills.
3. Work effectively with others as a member or leader of a
healthcare team or other professional group.
4. result in effective information exchange, and the ability to
team with patients, their patients’ families, and professional
associates.

Duties of junior resident
1. Writes admission orders
2. Examines every assigned patient (daily exam)
3. Performs the main write-up on every admitted
patient
4. Schedules tests; reviews lab data
5. Reports to resident at work rounds
6. Reports to Attending at Attending rounds (if no
student)
7. Supervises student on writing orders, collecting
labs, physical exam
8. Writes/supervises daily progress note

9. Performs procedures under supervision of resident
orAttending until proficient
10.Outpatient or subspecialty consult service
11.Takes history, examines patient, writes basic note
12.Reports to Attending
13.Ensures that all work is directly checked by
Attending
14. Writes prescriptions, lab/imaging orders
15.Reviews results with Attending
16.Communicates with referring physicians/other
consultants

17.Examines assigned patients (history, physical, and
psychiatric evaluation)
18.Reviews admission orders with Attending physician
19.Participates in team treatment planning and progress
meetings
20.Participates in patient conferences
21.Follows patients for medication management and
psychotherapy under supervision
22.Participates in family conferences
23.Presents patients in case conferences and grand
rounds

In patient Duties of sub- senior resident
1. Supervises junior and students
2. Organizes, directs ward team
3. Primary contact with Attending unless designated
to junior
4. Fills in when junior not adequate
5. Direct teaching and supervision of students
6. Reviews all student work-ups
7. Instructs students in physical and patient
management

8. Directs students to information resources
9. Provides outpatient/subspecialty consult service
10.Takes history/examines patient, writes note
11.Reports to Attending
12.Writes prescriptions, lab/imaging orders
13.Reviews results with Attending
14.Communicates with referring physicians/other
consultants

Out patient Duties of sub- senior resident
1. Performs psychiatric evaluations of patients including
substance abuse history and mental status examination
2. Plans and performs psychotherapy and psychopharmacologic
treatments under supervision
3. Participates in case conferences
4. Participates in group and family therapy
5. Participates in clinical out-patient research
6. Participates in evaluation treatment and management of
patients on the following services:
7. o Child psychiatry
8. o Psychosocial rehabilitation

Duties of senior resident
1. Evaluates acute psychiatric patients for in-patient
treatment including psychiatric evaluation, substance
abuse history and mental status examination
2. Plans and performs psychotherapy and
psychopharmacologic treatments under supervision
3. Participates in case conferences
4. Participates in group and family therapy
5. Evaluates acute/emergency psychiatric patients

Residents must provide patient care that is
appropriate for the treatment of health
problems and the promotion of health:
Communicate effectively and demonstrate caring and
respectful behaviors when interacting with patients and their
families.
Gather essential and accurate information about their
patients.
Make informed decisions about diagnostic and
therapeutic interventions based on patient information and
preferences, up-to-date scientific evidence, and clinical
judgment.

Develop and carry out patient management plans.
Counsel and educate patients and their families.
Perform competently all medical and invasive
procedures considered essential for the practice
of psychiatry.
Provide healthcare services aimed at preventing
health problems or at maintaining health.
provide patient-focused care.

Residents must be aware and responsiveness to the
larger context and system of healthcare
Have the ability to work effectively on system
resources to optimal provide care
Understand how their patient care and other
professional practices affect other healthcare
professionals, healthcare organization, society, and how
affect their own practice.

Identify how types of medical practice and
delivery systems differ from one another, including
methods of controlling healthcare costs and allocating
resources.
Practice cost-effective healthcare and resource
allocation that does not compromise the quality of
care.
Advocate for quality patient care and assist patients
in dealing with system complexities.

Patient Logs
Guidelines
and
Requirements

1. Residents should complete the log of their patients in new
Innovations.
2. The resident should update his or her patient log entries no
less than once per week.
3. The log entry should include: site where the patient
encounter occurred, the diagnosis and it’s code, patient
demographics, patient identification, selected a
treatment which available at hospital.
4. The patient logs are to be reviewed by the site supervisor
then by provisional staff for accuracy to verify
completion, broadness of exposure and to identify
deficiencies in experiences.

Patient Safety
/Quality
Improvement

Patient Safety
the delivery of healthcare in a manner that employs
safety methods and minimizes the incidence and
impact of adverse events while maximizing
recovery from such events.
Quality Improvement
a formal approach to assess the degree of services
provided by healthcare professionals for populations:
• increases the likelihood of the desired outcome
•evidence-based standards of care
•systematic effort to improve performance.

Discuss the historical background of Patient
Safety/Quality Improvement.
Define terminology pertaining to PS/QI
(including near miss and adverse events).
Define PS/QI problems specific to Psychiatry.
Demonstrate behaviors associated with effective
teamwork and interpersonal and communication

Core content to achieve PS/QI
1. Knowledge
a. History
b.Terminology
c. Root cause analysis
d. Error reporting
e. Safety culture:
• documentation of proper medication
•completion of suicide risk assessments
•use of seclusion and restraints

2. Skills
a. Root cause analysis
b. Formulate QI question
c. QI project
d. Identify types of medical errors
e. Proper handoff
f. Effective teamwork, interpersonal skills and
communication
3. Attitude Appreciation of patient safety
and quality improvement

Strategies
•Psychiatry orientation in June/December
•Quarterly didactics (every 3 months)
•Grand Rounds and Case Conferences
•Direct observation of hand-offs
•Weekly supervision
•Residents will prepare one case conference per year that
incorporates patient safety and quality
improvement issues. ?
•Residents should complete QI modules from
Institute for Healthcare Improvement.?
•Residents will design a QI project with the assistance
of a mentor (faculty).?

Transfer
of
Care and
Patient Sign-Out Policy

1. A transfer is a real time, active process of conveying the
responsibility for the care of a patient from one entity to
another.
2. It may involve the discharge with the patient’s medical and/or
psychiatric records.
3. “Sign-out” is the term that we use to refer to the verbal and
written patient hand-off communication that takes place
between the outgoing and on-coming teams at the change of
shift and in transferring care to another service.
4. The sign-out/hand off is a way to provide information to
facilitate continuity of care.
5. when contacting another physician when there is a change in the
patient’s condition.

POLICY:
• Caregivers involved in the sign-out/hand-off process
include, but are not limited to, physicians, nurses,
therapists, technicians, and transporters.
•Patient information related to current condition and
present treatment patient information will include at a
minimum:
Patient name, location, age/date of birth
Diagnosis
Allergies, Medical History, and Psychiatric History
Important current labs and vitals; pending tests and studies
which require follow-up

 Level and commitment status
Medications
Potential seclusion/restraint issues
•What to watch for or monitor during the next
interval of care:
important items planned between now and discharge
written transfer reports should be documented using the
templates developed at the unit or departmental level.
outpatient setting to the emergency receiving facility.
the name and contact number of the caregiver transferring
care will be included to facilitate the asking of questions.

PROCEDURE:
Caregivers will have at hand any supporting documentation
or tools, paper instructions, used to convey information and
immediate access to the patient record.
All communication and transfers of information will be
provided in a manner consistent with protecting patient
confidentiality.
If the contact is not made directly (face-to-face or by telephone,
or e-mail address) to provide opportunity for follow-up call or
inquiry.
The patient will be informed by the departing resident or
Attending of any transfer of responsibility even if temporary or
brief.

A resident must not leave the hospital until a hand-
off has occurred.
Verbal& Written Sign-out: This is the written
patient hand-off communication used to keep record of
patients admitted or cared for during the residents call.
These written communications are updated
throughout the shift as patients are admitted, have status
changes, or are discharged.
the written communication is printed for review.

4 Additional Procedures:
SBAR can be used to deliver or receive the
information:
Situation: What is the problem?
Background: Pertinent information to the
problem at hand
Assessment: Clinical staff’s assessment
Recommendation: What do you want done and/or
think needs to be done?

key information
to
sign-out
on
the patients

1. Reason for admission
2. Concerns for any monitoring
3. Any risky or concerning behaviors
4. Medication initiations or changes that could
cause problems
5. Restricted medications: are there medications
the patient should not receive?
6. F/U labs, imaging that may be important
7. Any medical conditions that may likely
become unstable

1. ensures safe ongoing patient care.
2. communicate essential knowledge to provider errors
are eliminated.
3. The ultimate goal of shift hand-off is to prevent
mistakes and potential errors that may be avoided.
4. there are two major hand-off periods:AM and PM.

Morning (AM) hand-off: weekdays
1. account for the patients that were seen
overnight.
2. understand the disposition for all of the
patients that were evaluated, arrange any
follow up that is appropriate, and to
highlight any systems issues.
3. if there are patient care concerns for the
next shift

1. On the weekend, there is one major sign-out period at
08:00 AM.
2. This should occur with the Attending of the
outgoing and incoming resident, a nursing
representative.
3. Hand off of week end should at the Administrative
meeting to the chief resident & at minimum a senior
resident .
4. During the sign-out, all relevant issues will be
communicated by both the verbal and written.

5. Any pending testing or evaluations will also be
communicated at this time, similar to the hand-off
during the week.
6. up-to-date information (patient’s care, treatment ,
services, condition, any recent or anticipated changes).
7. No Interruptions to minimize the possibility that
information would fail to be conveyed or forgotten.
8. verification of the received information, including
repeat-back or read-back.

PROCEDURES:
1. Shift changes
2. Meal breaks
3. Rest breaks
4. Changes in on-call status
5. When contacting another physician when there is a
change in the patient’s condition
6. Transfer of patient from one care setting to another
7. It must include an opportunity for the on-coming
physician to ask pertinent questions and request
information from the reporting physician.
8. Telephonic is not acceptable.

At minimum, specific information listed below (as
applicable):
1. Patient name, location, age
2. Patient diagnosis/problems, impression
3. Important past medical history
4. Identified allergies
5. Medications, fluids, diet
6. Important labs, vitals, cultures
7. Past and planned significant procedures for the next
24+ hours and between now and discharge
8. Specific protocols/resources/treatments in place
(DVT/GI prophylaxis, insulin, anticoagulation, restraint
use)

In addition, to SBAR
Situation:
What is the problem?
Background:
Pertinent information to problem at hand
Assessment:
Clinical staff’s assessment
Recommendation:
What do you want done and/or think needs to be
done?

1. A medical professional consistently demonstrates respect for
patients by his or her performance, behavior, attitude, and
appearance.
2. Also responsibilities and an adherence to ethical as the
following:
•Respect patient privacy and confidentiality.
•Knock on the door before entering a patient’s room.
•Appropriately drape a patient during an examination.
•Do not discuss patient information in public areas.
•Keep noise levels low, especially during sleeping.
•Respect patients’ autonomy and rights and his family to be
involved in care decisions.
•

•Introduce oneself to patient and family
•explain role in the patient’s care.
•Wear name tags (identify names and roles).
•Take time to ensure patient and family understanding
informed consent of medical decisions and progress.
•Ensure continuity of care after discharge by
documenting who will provide that care and how that
caregiver can be reached.
•Respond promptly to phone messages, pages, e-mail, and
other correspondence.
•Maintain and promote physician/patient boundaries.

•Respect individual patient concerns and perceptions.
•Comply with accepted standards of dress for each
hospital.
•Arrive promptly for patient appointments.
•Remain sensitive and responsive to a diverse patient
(gender, age, culture, race, religion, disabilities).
•Avoid write any data about any one of the patient.

Respect, compassion, and integrity
A responsiveness to the needs of patients and society
that supersedes self-interest
Accountability to patients, society, and the profession
A commitment to excellence and ongoing professional
development
A commitment to ethical principles withholding of
clinical care, confidentiality of patient information,
informed consent, and business practices
Sensitivity and responsiveness to the patient’s culture,
age, gender, and disabilities

EVALUATION OF
PSYCHIATRIC
PATIENTS IN
THE
EMERGENCY
DEPARTMENT
ED

problems facing psychiatric patients
in ED:
1. Evaluation of Psychiatric Patients in ED
2. Medical Clearance and management of
Psychiatric Patients in ED
3. Boarding of Psychiatric Patients in ED and
how to reduce it.
4. Disposition of Patients from ED
5. Community Resources for Emergency
Psychiatric Patients.

1. The first step—the initial assessment—is
performed to place the patient into one of
five categories with an emphasis on
identifying patients with delirium.
2. four other categories are considered to have a
psychiatric concern and require only a brief
medical evaluation to rule out acute
medical conditions.

MEDICAL CLEARANCE OF PSYCHIATRIC
PATIENTS INTHE ED
prior to the patient’s evaluation by a psychiatrist or
psychiatric liaison provider.
diagnostic evaluation should be directed by the
patient’s history and physical examination.
routine lab. of all patients is of very little benefit not
need to be performed as part of ED
“are costly and appear to be unnecessary.”

toxicology screens obtained in the ED should not
delay patient evaluation or transfer.
alcohol intoxication, the psychiatric assessment of the
patient should be based on the patient’s cognitive
abilities, not blood alcohol level.
use period of observation to determine if psychiatric
symptoms resolve when intoxication resolves .
Routine urine toxicology screens for drugs of abuse in
patients who are alert, awake, and cooperative do not
affect ED management

BOARDING OF PSYCHIATRIC PATIENTS IN
ED1. significantly worse problem: psychiatric patients remaining in
ED far longer than medical.
2. boarding negatively affects patient quality of hospital care
and the system’s finances.
3. Multiple factors contribute to long psychiatric boarding
times.
4. longer boarding times significantly correlate with lack of
public insurance, restraint use, positive alcohol abuse and
need for transfer to an outside facility.
5. lack of inpatient beds globally is big contributors to
boarding
6. Reductions and a mismatch between supply and demand.
7. Reductions in outpatient services.

Steps to alleviate boarding
1. Quantify and monitor the problem
2. Improve ED care of psychiatric patients
3. Make more efficient use of existing capacity
4. implement low-cost collaboration
5. Work with law enforcement actions
6. Invest in continuity of care
7. Psychiatry consultations live or via telemedicine.
8. Treatment protocols.
9. ED case management.
10. keep psychiatric patients in a quiet environment from the
chaotic environment of ED.
11. patients in a psychiatric crisis have worsened outcomes with
increased boarding times (crisis management
prevention).

MEDICAL MANAGEMENT OF
PSYCHIATRIC PATIENTS IN ED
1. Therapy includes both pharmacologic and physical
aspects
2. screening for suicide threat is urgently.
3. approaching an agitated patient:
• Psychotherapy is typically considered to be
the 1st step to be determined
• addressing underlying organic cause such as
toxicity , delirium, or medical disease.
• The use of restraint or seclusion is a
controversial aspect of dealing with the agitated ED
patient.

4. Prior to applying restraints or other interventions: you
should:
A. using verbal, non coercive de-escalation
B. decreasing physical stimuli (excessive noise)
negotiating with the patient.
C. observation and reevaluation
D. restrict the patient’s freedom of movement
concurrently with medications to calm agitated
patients.
E. The preferred route is oral, followed by IM,
followed by IV. The onset of effect is the inverse
order.

traditionally use 1ST generation such as haloperidol with
or without BZD (lorazepam).
2nd generation antipsychotics (oral).
Haloperidol is preferred in alcohol-induced
agitation.
BZD are useful in alcohol withdrawal but not for
agitation during intoxication.
avoid Antipsychotics with QT prolongation in cardiac pt.
1ST generation antipsychotics are associated with
extrapyramidal and anticholinergic effects (avoid pt with
history of urine retention).
Some reduce seizure threshold(avoid in epileptic pt.)

DISPOSITION OF PSYCHIATRIC PATIENTS
FROM ED
1. By using reasonable judgment on risk of harm to
him/herself or others, the pt. should be admitted for
psychiatric evaluation and treatment.
2. If the patient does not voluntarily consent to treatment,
involuntarily held.
3. The ED resident must be authorized to make this
determination without requiring approval by an outside
entity (police, court) or consultant.
4. This emergency hold should be for a minimum of 12 hours
and a maximum of 72 hours to allow psychiatric evaluation
and initial treatment to start.

5. The major determinant is psychiatric bed
availability, whether at the treating facility or for
transfer. ?
6. Patients who are uninsured and those who are
homeless tend to have longer disposition-to-
discharge/transfer times?
7. Ideally, this consists of scheduling outpatient
appointments prior to ED discharge(72 hours).
8. The ED resident should be held immune from civil
liability resulting from any involuntary hold.

The role of EDs in suicide prevention
1. Suicide Prevention is important by continuity of
care from the ED.
2. importance of screening for suicide risk and
providing an assessment to those who are at
risk.
3. treatment with written educational safety
planning and follow-up instructions.
4. early follow-up is recommended

Handover is essential for patient management and
safety and must be done.
Communication through one- or one improving
professionalism.
It is not just a favor but is essential.

What is important to include is:
1) All patients in ER that are admitted but are awaiting
paper work.
2) These patients are the on-call team’s responsibility
to manage when issues arise while in the ER and.
2) Number of beds available on wards.
3) Patients that have been expected to come for
assessment or admission.
4) Patients discharged home from the ER that may
likely be back the next day.

Roles of the Medical
Student,Junior
Resident,Senior
Resident,and Staff
Psychiatrist in ED

Medical students:
1. doing a rotation in psychiatry is on call on
weeknights and weekends until 11pm,
2. attend any emergency or ward presentations with the
resident.
3. A medical student should never be asked to assess a
patient alone
4. should never be asked to go to the other site alone
to assess a patient.
5. The primary teachers for the medical students on
call are the residents so they appreciate discussion and
supervision.
6. This is a good opportunity for recruitment.

Junior residents:
1. first call for any emergency assessments, ward calls,
emergency consultations to the medical wards and
any outside calls.
2. The junior resident should present and discuss the
case with the senior resident before discussing with
the staff psychiatrist.

Senior residents:
1. actively involved in assessment, supervision and
teaching of the junior resident and medical student.
2. actively involved in urgently ill patients and bed
management decisions.
3. present for each case, not just when there are several
patients referred and waiting to be seen.
4. It is not acceptable for the senior resident to provide
telephone supervision only unless it is very busy and
both residents are seeing patients at different sites.

5. When ER is not that busy, senior residents may
decide to observe junior residents interviewing
patients and provide feedback.
6. seeing the patient briefly after the junior has assessed
the patient.
7. The residents are expected to work as a team with
discussion of each case that presents.

staff psychiatrist:
1. must be easily accessible by phone and in town while
on call.
2. The staff supervises the residents by phone but is
3. supervise in person in the ER , if it must to be there.
This would be if many patients are waiting to be seen
(more than 4)
4. The staff psychiatrist is primarily responsible for
finding beds.
5. Please explain your decision making.

At shift
1. One of the residents is expected to check in
with the inpatient wards at night between 9-
11pm.
2. Physical contact with the wards constant
observation should be more regular ? if
there are patients in seclusion or restrained
, on or in withdrawal

Assessment of the Patient in the ER
There are times when psychiatry is consulted on more patients
than can be seen in a reasonable amount of time.
Mange patients in the ER based on the acuity of their problems and
the potential risks posed.
We have now moved to a two-resident system for
call?

Before you see the patient take a few
minutes to:
•review the referral and talk to the referral source if
possible.
•The police, friends, and family are particularly important
to talk with early in the process, as they can often leave
unexpectedly.
•Determine whether there is accompanying
documentation, for example a form 1, note from a
referring physician, suicide note, etc.

•Search through MYSIS for patient information.
•Ask yourself “What are the circumstances that led to the
patient’s presentation to the ER?”
•Review what was already done (assessment by the ER
staff, vitals, blood work, what meds have already been
given).
•Try to determine if there is someone else that you could
talk to for collateral information after you see the patient
•Collateral information is often more important in the
emergency psychiatry case than in any other specialty.
However, in an emergency situation we do not need
their consent

When you go in to see the patient:
you must remember safety first and, if in doubt, check with
your staff-person and have security present.
Just as one would quickly assess a medical patient by looking
at them and their vitals, then saying‘critical, sick, or stable’,
we often do a quick-look test, essentially a brief mental
status exam, prior to entering the room. Examine the patient
for appearance, agitation, psychomotor activity, disorganized
speech, dysthymia, level of intoxication.

•Then knock and enter the room, introducing yourself
as a resident physician who has already reviewed their
chart.
• Perform a brief ER-oriented psychiatric assessment.
•longitudinal history important in identifying
personality disorders, and is useful for identifying
trauma,ADHD and learning disabilities but
•This should last no longer than 20-30 minute

Your assessment should answer the
following questions:
1. Are there safety concerns at the time of the
presentation to the ER?
2. Is the patient certifiable (should Form 1 be
placed/continued) and on what basis?
3. Does the patient need admission and why?
4. If I discharge the patient, what would I need to ensure
adequate management?
5. Ask the patient for permission to talk to a family
member about the treatment plan,if appropriate.

Use the psychiatric
database form provided
in the ER to record the
data you may collect?

Medical Clearance
1. do a focused assessment physical and medical which
consider appropriate in their judgment.
2. They are not a physical exam or routine lab
investigation screening service.
3. It is important to remember that we are medical
doctors and psychiatric consultants to the emergency
doctors
4. If the psychiatric assessment indicates an organic
cause of the presentation such as delirium, brain
tumor take opinion with medical ER doc. to
complete recommended work up. ?

5. If there is a psychiatric diagnosis and need for admission
but the patient is medically unstable (Overdose, acute
medical problem, suspected delirium) , consult
actively with the medical ER doc. before admission.
6. Psych ER may order further investigations and
referrals, but care should be communicated and
coordinated.
7. The ER resident are always available and for any coming
consultation.
8. If patient requires routine investigations, then order
them in ER, but the patient will not have to stay in ER
until results are back.

Reviewing the CaseWith Staff
1. After the assessment, formulate the case and decide
on a presumptive diagnosis and a management
plan before you talk to your staff-person.
2. prepare brief presentation about the case in a
logical, cohesive way and demonstrate that you are
able to function as a medical expert, consultant and
health-advocate

A layout for the case presentation :
1.Always start with ID and reason for presentation
2.The patient was brought by …… and is / is not on a form
3. I spoke with the patient, ER staff, family member, social
worker, police etc.
4.The patient presents with symptoms indicating …...
5. Past psychiatric history is relevant for…..
6. Medical history is relevant for….
7. Family history is significant for…
8.The patient lives with …. .and …. .are the main supports
9. On mental status …. (Also indicate if the patient was a reliable
historian)
10. My diagnosis at this time is ...
11. I suggest the following treatment

If you and your staff make the decision to
admit an adult patient,you must do:
1. Contact with the ER nurse and determine which
psychiatric unit the patient will be admitted under their
supervision .
2. Give handover on the patient to nursing.
3. Physical exam, if not already done.
4. Fill out admission form (absolutely required for
admission)
5. Fill out admission orders (some suggestions TTT and
investigations).

6. Make sure to include blood work, urine toxicology
screen, regular meds they are already on and
agitation meds,as needed
7. Document recommendations about specific admission,
which you discuss with your staff person or referral senior
staff .
8. If the patient is to wait for a bed or admission paper
work in the ER for a lengthy period talk to the ER
nursing staff and inform your staff :
• you should assess the risk for suicide/escape
• provided the necessary treatment.
• Try to reassess the patient if necessary.

If you plan to discharge the patient consider document
your report to next shift resident and ask pt. for an early
appointment on next day at OPC.
Remember, that a further option for disposition is jail:
• Some of our patients have committed a crime and
assessment may indicate, no need hospitalization.
•Due to confidentiality, police cannot be contacted
unless homicide risk assessment indicates a breach of
confidentiality is required.

Management of Bed space (for full bed)
this is an important part of the manager role in
psychiatry
Handover will always include the number of beds available
it is necessary to check with nursing as to the bed situation
throughout the day.
communicate with your staff, who may have to phone to other
facilities to transfer patients and to ER nursing staff, who may have to
make accommodations if the patient is to stay in the ER overnight?
When the beds are full some decisions need to be made, always by
your staff-person.

Your staff may ask you for permission to use free
(connect to mange it).
If you decide to transfer someone, ensure the pt. is
medically stable and not unduly influenced by
substances.
We can facilitate smooth and appropriate transfer
with basic blood work to rule out a medical illness,
urine drug screen, and any other relevant
investigation
Reserve bed for pts. come overnight , may be used in
an emergency. ?

Assessing a
Child or
Adolescent in ER

Admission protocol for Suicidal children and
Adolescents in ER
these depending on time of day and whether it is during
working hours or night and weekend.
Note:
Usually we don’t admit pt. under 14 years old but if needed pt.
admitted with his parent after inform child staff unit.
a) Patients under age of 16 years DO NOT need to be
certified if parent or Guardian is agreeable to theirAdmission
c) BZD, are not necessary for children and adolescents as it
may cause disinhibition and acting out kids get more combative
.
We tend to Use Olanzapine if needed

Suicide Risk assessment of C and A
This is based on suicidal ideations as opposed to attempts.
 risk for attempts and completion higher in males >14
years.
high lethality behaviors with substance abuse
family histories of suicides
psychiatric disorders is a significant risk.
Females presenting with less intent lethality behaviors as
cutting are more suitable for urgent consult clinic?.
 But again if you deem them at risk for completion feel
free to admit.

Urgent Clinics /SocialWork?
1. These are very useful for pts. with psychosocial difficulties. do
not require urgent psych consults or admission.
2. Patient less than 18 yrs old need urgent appointments within 48
hours after presenting to ER (take contact no.).
3. Needs an Urgent PsychiatryAssessment within two weeks
4. Patient does not have a psychiatrist following up
5. Preferably does not have a chronic disorder.
6. Has not been recently discharged from the inpatient unit
(within the last month)

Requests for taking
a patient“Direct to
Psychiatry”

If the physician wishes to transfer a patient on a Form for
assessment
Always discuss with your staff person before accepting a patient
direct to psychiatry.
We only accept patients direct to psychiatry if the request is
made by a physician believes the patient is medically stable and
there is a bed available on the ward
Ask if they are medically stable and what additional care needs to
be set up.
If you are not convinced that they are medically stable, medical
issues require follow-up, or that another service may be more
appropriate,

The transferring physician always has responsibility that
the patient arrives for assessment.
ambulance or police are transferring the pt. they must
remember it is their responsibility( if an accident, suicide,
homicide, or elopement occurs along the way).
We do not give specific appointment times for emergency
assessment (Urgent clinic)

Do not accept a C&A patient for transfer without you or your
staff-person first
We will often get calls from physicians from specialties other
than Emergency.
Ask if the consultation is regarding an inpatient or a patient
already in medical ER department .
These cases are usually referred to consult-liaison psychiatry,
whose hours of seeing consults are ? and days ?. if there is an urgent
case that cannot be addressed in the morning, the resident should
discuss with their staff-person about appropriate advice and
whether that patient needs to be seen.
If the medical or surgical team identifies that the patient needs to
be seen urgently, you must without delay.

Sample admission
orders
These are suggestions to be
discussed with your staff-
person

Admit to unit …… or under supervision
of .. referred staff
Diagnosis Schizophrenia, Bipolar mania,
etc
Diet Regular, Diabetic , Cardiac, Renal, Soft
texture, etc.
 restrict to ward, etc.
voluntary or involuntary ?
Vitals routine (means once on admission),
specify more often if required…
Constant observation, every … minutes or hours
observation

Investigation required (CBC, diff,, Ca, Mg,
Phos, Crt, albumin, ALT, ALP, GGT, TSH, glucose,
HbA1C, prolactin, lipids)Drug levels (carbamazepine,
lithium,……) Urine (beta-HCG, drug screen)
ECG / CT head if required
In general, leave them on most general meds
that they came in on, unless increasing, starting, or
lowering psych drug or eliminating meds contributing to
the psychiatric condition or delirium.
Smoker? Don’t forget a patch or gum.
Agitation /Chemical Restraint/alcohol
withdrawal (special management)

II. Specific pt scenarios (Suicidal, Escaping ,
Agitated, Intoxicated)
A. Suicidal
please ensure they are in a secure
watched environment while in your care.
alert security sooner according to your judgment of
elopement/suicide risk
B. If pt. already escaped you should to
document this and notify police department
at your hospital.

C.Agitation
Always avoid actions that will cause agitation
escalate quickly, you should watch for signs .
Have security nearby when interviewing agitated/potentially
agitated patients.
Be aware that the patient may have weapons on their person.
Tie up pony-tails and loose articles of clothing that can
be grabbed.
 Do not carry into the room anything that could be used
as a weapon.
Try to remove chairs or any other potential weapons.
Panic buttons are available connected emergency desks.

If a patient is agitated offer some medication to
calm them, have nursing prepare an IM ready to be
used if necessary.
 Sit/stand close to the door, but not directly
between the door and the patient.
Do not turn your back.
If a patient is escalating, try turning your body
perpendicular to the patient and keep your hands free.
If concerned about your safety, and go by your gut
feelings, express this to the patient, pause the
interview, and discuss this with your staff-person.

D.Intoxication
Intoxicated patients can be difficult to deal with.
It is also next to impossible to do a psychiatric assessment
on such a patient.
It may be reasonable to ask the referring ER physician if
there is life saving conditions.

In an Emergency Situation It
is important to know the
screening centers in your
county.
What is a screening center?

Dealing with Security
Security guards are often utilized in the emergency
department and on the inpatient wards to watch patients
with difficult behaviours and help subdue agitated patients.
They are an important part of the hospital team, and it
is important to be comfortable dealing with them so
that they know what is expected of them.
It is important to recognize that they have no mental
health training.
When they watch a patient they are expected not to
communicate with the patient.

They do have training in restraining patients and
you do not. It is not the role of the psychiatrists to
physically restrain a patient.
You are the leader of the team response to the
agitated patient so communication is very important with
all team members for a coordinated response.
It is important to be aware that the presence of
security guards escalates many patients.
Sometimes it is helpful to ask security to be present
in ER but out of sight of a patient.

Inpatient Psychiatric Unit Admission
Criteria
How do you know when to hospitalize?
When behaviors present a danger to:
a. self
b. others
c. property.
d. Grave impairment Medical necessity

Important documents to be forwarded to
the admissions office:
 Power of attorney, advance directive
 Face sheet
 copies of insurance cards
 progress notes
 Psychiatric evaluation
 nursing assessment
 lab work
 immunization record?
 Medication Administration Record
 medications prescribed but ineffective.

 interventions that were discuss with the team
 established clinical information from
interdisciplinary assessments
 plan and treatment goals for the
hospitalization(which is to stabilize symptoms).
 the most important things they should know about
the patient to provide quality care.
 resident’s former profession/career
 discharge planning, which begins at the time of
admission
 food, activity, and environmental preferences?
 likes and dislikes ?

Discharge planning begins upon admission.
Hospitalization goal is to provide: necessary
care and symptom stabilization.
Discharge plans include:
follow-up treatment plans for continued
care.

Patient and family education are an important
part of the treatment plan.
Patients and families are encouraged to ask
questions about care and treatment.
Knowing what medications are being taken and
why is extremely important in transitioning back
to the assisted living or long-term care setting.
Family should know who is assigned resident.

Involuntary Medication Administration
patient is presenting a danger to self
refusing medications
A psychiatrist can utilize a three-step process to
provide the patient the needed treatment

In order for an individual to be admitted as a
voluntary patient into a psychiatric hospital, the
individual must
(1) have a mental disorder that is susceptible to
care or treatment
(2) understand the nature of his request for
admission
(3) be able to give continuous assent to retention
(4) be able to ask for release

The reasons given for voluntary admission
include:
1. it involves less stigma to the patient
2. it is less coercive
3. it allows the patient to acknowledge a desire
for help and treatment
4. it respects individual autonomy
5. it allows the patient the legal right to request
release
6. it increases patient involvement and personal
responsibility

The reasons against voluntary admission
include:
1. the potential for patient abuse exists
2. the patient is subject to coercion
3. the patient has fewer opportunities for
discharge;
4. the patient is admitted under the threat of
involuntary commitment
5. there is no adversarial process
6. there is no maximum length of stay
7. the patient is not free to leave

At the time a patient considers signing the
“voluntary” admission document, one
should look carefully at the patient’s
documented behavior as recorded by
the hospital staff.

involuntary admission
1. forces doctor and patient into an adversarial
relationship that undermines the therapeutic alliance
and adversely affects the patient’s participation in
treatment
2. the patient is more likely to succeed
3. there is a perception that the stay is shorter
4. the patient who voluntarily undertakes treatment is
more likely to be rehabilitated than an involuntary
patient
5. it is normalizing since it is very similar to other
medical admission

Patient’s initial arrival at psychiatric hospital is
involuntary and subsequently seeks inpatient psychiatric
hospitalization on voluntary basis.
Patient evaluated by psychiatrist to determine ability
to make an informed decision and communicate
choices.
Patient knowingly and voluntarily desires inpatient
treatment and care, capable of providing continuous
consent and capable of requesting discharge.
Further hospitalization would require resigning forms
subsequent to psychiatric evaluation, consultation

Progress reports written by
psychiatrist reflected condition upon
admission describing him as:
1. disoriented/ confused,
2. semi-mute
3. bizarre in appearance/ thought
4. uncooperative at the initial interview
extremely psychotic
5. apparently paranoid and hallucinating

psychiatric history and mental status
examination:
to obtain information relevant to decisions about
diagnosis and functional capacity.
pay particular attention to such areas as:
1. motor activity
2. form of talk
3. mood
4. belief (delusions)
5. perceptions (hallucinations)
6. cognition (ability to reason, remember and orient
oneself in time and space).

Brief Psychiatric Rating Scale
Mini-Mental State Exam
WeschlerAdult Intelligence Scale
Revised vocabulary subtest
?

Documentation of a medical record:
It is important to keep in mind who will read the
medical record. ?
In the event you are ever involved in a lawsuit
whether done on paper or electronically
 serves to promote patient safety
minimize error
improve the quality of patient care
must be maintained in a way that adheres to applicable
regulations, professional practice standards, and legal
standards.

The medical record is a legal document , It
may be:
•The only evidence available years later
•Used to reconstruct the care provided
•may likely be used as evidence of care provided or
not.
•Should paint actual picture of past events
•Professional credibility
•Judicial authority
Not documenting is unethical or confidential issues
(legal)

DO’S AND DON’TS
FORWRITTEN
DOCUMENTATION

The medical record should contain the
following types of information:
1. medical history
2. Relevant information regarding diagnosis and treatment
3. Assessment of suicide/violence
4. Medications prescribed along with dosages, side effects and
monitoring performed
5. Informed consent
6. TTT compliance/non-compliance(describe objectively)
7. Boundary issues
8. Termination / transfer to another place details
9. Relevant information to support practices
10. Formal consultations

DO
1. Write legibly in permanent ink
2. Put patient ID # on each page
3. Sign, initial and date (month, day, year, time), each
entry
4. Make entries as soon as possible (do not make entries
in advance and identify late entries as such)
5. Incorporate prior records into documentation
6. Include test results/consultations in record as well as
notes that you reviewed

DO
7. Document informed consent/refusal
8. Use specific, actual, objective language, and not
language that speculates, opinions, or is subjective in
nature
9. Document all facts relevant to an event, course of
treatment, patient condition, and response to
treatment
10.Document rationale for deviating from standard
treatment, when applicable
11.Each entry or paper documented with your signature
must be with a date/time/ stamp

What may not be documented in
psychiatry:
• Detailed account of sexuality
• Interpersonal conflicts
• Issues that may be embarrassing to the patient if
disclosed
•Third party names
But in some cases:
• Sexual behavior
• Criminal behavior/history

DON’T
• Don’t leave blank areas on a page
• Don’t squeeze in late entries
• Don’t use personal/non-standard abbreviations when
documenting
• Don’t include names of informal consults, nor should
informal consults document in the medical record
• Avoid using words like error, mistake, accident,
inadvertent, and malpractice
• Don’t erase/ block out entered information

Correcting medical record information:
At times it may be necessary to correct entries ,
when you should remember to:
 Draw a single line through entry errors (make sure
original entry is still legible handwriting)
Write “mistaken entry”
Write the correct entry as close as possible, but not
over it
Every entry should be date, time, author stamped
Document the correct entry

A symbol identifying new/additional entries should
be viewable
DO NOT alter the original entry, or “black it out”
The original entry should still be viewable, “strike
through” methods with author, date, time, commentary
Note the reason for the correction
If a hard copy is printed, the hard copy must also be
corrected

Psychotherapy notes are kept by the
psychiatrist during therapy session
This is pertain to the patient’s personal
life and the psychiatrist’s reactions.
These records are:
• Subject to more stringent
confidentiality standard
• Must be kept separate from the rest of
the medical record

Documentation in
Psychiatric
Nursing Practice

Problem Oriented Recording
Narrative recording
Process recording

Problem-Oriented Record (POR)
1. a method of patient care record focuses on specific health care
problems
2. a cooperative health care plan designed to cope with the
identified problems.
3. Progress Notes: document of observations, assessments,
nursing care plans , physician's orders, of all health care
personnel directly involved in the care of the patient.
4. A system of recording list of the patient's problems :
• relevant medical history /physical findings/lab. Data.
• medications are listed under the appropriate medical
problem.
• synonymous to intake interview

5. information required for each patient
regardless of diagnosis or presenting
problems:
•subjective data obtained from the patient and others
close to him
•objective data (observation, physical examination,
diagnostic investigation).
6. assessment of the patient's status:
•analysis of the problem, possible interaction of the
problems, and changes in the status of the problems

Narrative report
to describe something.
 told from a particular point of view.
 makes and supports a point.
 filled with precise detail.
Chronological, baseline charted every shift
Lengthy and time consuming
Source-oriented

Process recording
a system used for teaching nursing students to
understand and analyze verbal and nonverbal interaction.
The conversation between nurse and patient is written
on special forms or in a special format.

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