Case Study
As part of routine health maintenance screening at their PCP’s office, a patient completed a Patient Health Questionnaire, PHQ-9, a validated tool for depression screening. The PCP interpreted the PHQ-9 results to be consistent with severe depression. Over the course of the visit, the PCP completed a relatively detailed review of systems and discussion in the mental health realm and learned that although not actively suicidal, the patient had significant suicidal ideation in the past. The rest of the ROS and exam were unrevealing. The PCP, in addition to ordering lab tests, made a referral to both a psychiatrist and a therapist. The next day, the patient called the PCP and stated the earliest that any of the five psychiatrist offices could get him in was eight weeks and the earliest a therapist could start working with him was in five weeks. The patient noted he was very frustrated with the long delay and asked if the PCP could start treatment immediately because the depression was having substantial impacts on his sleep, work performance, and relationships, and he was worried about becoming actively suicidal. The PCP was comfortable managing mild to moderate depression without a psychiatrist’s assistance, but was concerned that major depression with a history of suicidal ideation was too risky to manage without a psychiatrist’s help and that she would be held responsible if any adverse outcome occurred prior to the patient seeing a psychiatrist.
Analysis and Guidance
There is a nationwide shortage of mental health providers and often long delays from the time of referral to the time of available consultation. As a consequence, many PCPs and other providers are trying to help these patients that they would typically expect a psychiatrist to be managing and monitoring with medications. Simultaneously, the providers do not want to inadvertently expose themselves to allegations of negligence in the event of adverse outcomes.
Fortunately, best practices for these scenarios are relatively straightforward. As with all patient care conversations, shared decision making should be appropriately documented. This serves to reduce risk of allegations that a provider is “practicing outside of their usual scope” or “should have referred to a specialist.” Of course, no actions can guarantee against lawsuit risk, but the following ideas are helpful and important considerations:
- Care notes should be completed contemporaneously to the patient visit. Delayed completion of notes creates a time window for an adverse outcome to occur prior to documentation. If a note does not already contain information about the delayed availability of a specialist and the clinical judgment that was exercised in making the care plan, then adding this “after the fact” when a bad outcome has occurred may lack credibility to outside reviewers.
- Documentation should clearly state that your judgment was that a referral was indicated and that you made the referral. The means of communicating this to the patient should be included. If you or your staff call the specialist, then that should also be documented contemporaneously.
- If an AI tool or a scribe is used for documentation of the encounter, you should read the note to ensure that it accurately reflects your awareness of the importance of the diagnosis and efforts at referral. Additionally, documentation of patient management should include any medications, testing, and follow-up plans.
- Planning regular follow ups with the patient while waiting for the consultation and documenting this is helpful. This should include the follow-up schedule and the patient’s understanding.
- Suicide is an impulsive act and even an experienced psychiatrist has difficulty in predicting if/or when a patient will become suicidal. In a clinical scenario such as this one, it is important to perform and document appropriate suicidal ideation (SI) screening and to contract for safety with the patient where they agree that if SI occurs, they will immediately call appropriate resources, most likely you or 911.
The Substance Abuse and Mental Health Services Administration (SAMHSA) offers a printable safety plan template that includes references to the 988 system and links to helpful information for family members. Get it here: www.samhsa.gov/sites/default/files/988-safety-plan.pdf
Summary
Fortunately, although there is some risk in caring for patients with mental health issues prior to their establishing a relationship with a psychiatrist, you are not held to an impossible standard of instantaneous consultations. To protect yourself and your patients, best practices are to clearly and contemporaneously document the situation, why you are implementing a particular plan, and maintain a regular check in and reassessment of patients waiting for a specialist consultation.
The information provided herein does not, and is not intended to constitute legal, medical, or other professional advice; instead, this information is for general informational purposes only. The specifics of each state’s laws and the specifics of each circumstance may impact its accuracy and applicability, therefore, the information should not be relied upon for medical, legal, or financial decisions and you should consult an appropriate professional for specific advice that pertains to your situation.
Article originally published in Copic's 3Q25 Copiscope newsletter.
