February 28, 2019
We are thinking of rolling out a patient questionnaire meant to gauge depression. Will this trigger an added documentation requirement? How much is enough?
Thanks, Dr. A
Very likely, yes. Information is power, and with power comes responsibility (we all know this). Here, you are getting more information direct from your patient - information that in today's world could potentially impact the safety of others. You will have a burden to process the information you are receiving. The way we process today is to document, document, document, with explicit mention of your consideration of the facts presented in your new survey as weighed during your patient assessment. Similar to how we show our consideration of the Prescription Monitoring Program (I-STOP) when we prescribe, or elect not to prescribe, so will your new survey require comment when you elect to admit, refer or release with no follow up. Be mindful. To be extra careful, you may wish to mention your roll out of this extra assessment tool to your malpractice carrier.
Since you did not specify your specialty, if you are not a trained mental health provider, consider bringing in a specialist to develop protocols for you before roll out.