CAPS

I.A POLICY AND PROCEDURE OVERVIEW AND MISSION STATEMENT

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Fri, 11/17/2017
Revised: 
Fri, 11/17/2017
Policy: 

Counseling and Psychological Services (CAPS) operates under the auspices of UCSC Student Health Services.  In most general manners, CAPS follows the policies and procedures stipulated in the Main Manual of the Student Health Center.  The policies and procedures delineated in this section represent those areas in which CAPS operates somewhat differently in its provision of mental health services to the students of UCSC.  CAPS clinical providers also are bound by their various professional codes of conduct (i.e.-American Psychological Association Code of Ethics) and applicable state laws. Throughout this manual, the use of the term students, clients, and patients should be viewed synonymously and are used interchangeably. Similarly, our Electronic Health Record may at times be referred to as an Electronic Medical Record or as our Electronic Health Record vendor, Point and Clink (PnC).

 

The mission of Counseling and Psychological Services (CAPS) is to support UCSC students, both graduate and undergraduate, in maintaining or improving their general well-being by providing a broad range of counseling, psychiatric services, consultation and outreach services and programs to the campus community.  It is also the mission of CAPS to maintain accreditation by the International Association for Counseling Services, Inc. (IACS), an accrediting association, for all its programs and services and to maintain APA accreditation for its internship program. CAPS' vision is to be part of the University’s endeavor to advance the education and development of all UCSC students by:

  • Addressing important mental health, psychosocial, academic, and personal issues that influence learning, achievement, and success in the university community and beyond.
  • Recruiting and retaining a highly trained multidisciplinary and multicultural staff.
  • Developing an inclusive, multicultural range of services to ensure student differences are respected and valued
  • Providing multiple points of entry so as many different students as possible can receive CAPS services
  • Providing high quality training and supervision to doctoral psychology interns and post-doctoral fellows

 

IV.D SUMMARY OF PSYCHIATRY SERVICES

Effective Date: 
Sun, 09/01/1996
Reviewed: 
Wed, 05/27/2015
Revised: 
Wed, 05/27/2015
Policy: 

Under the coordination of the Lead Psychiatrist, CAPS Psychiatric staff, which include psychiatrists and nurse practitioners, provide both evaluative and on-going care to UCSC students who are eligible for services in CAPS. Consultative services are available to CAPS and SHC clinicians as well as University administrators and other staff and faculty. Consultation and collaboration also occurs with clinicians outside the University. Psychiatry services can be reached by calling the main CAPS office at (831) 459-2628. Information regarding psychiatric service will be available in patient brochures, information and consent documents and on the CAPS website.

Procedure: 

HOURS

  • A credentialed psychiatrist or nurse practitioner with a psychiatrist serving in a consultative or supervisory role, as needed, onsite or electronically, provide psychiatric and consultative services in CAPS and the SHC . The service is open during regular CAPS hours, Monday through Friday 8 AM – 5 PM during the academic year. The service is closed on campus holidays, during campus closure, during evening and night hours as well as weekend days.

APPOINTMENTS

  • Psychiatric appointments are available on a priority or routine basis by referral from CAPS, SHC or off campus clinicians. In view of the need to extend access to all students, the number of appointments available to any one student may be limited. The Lead Campus Psychiatrist, in consultation with the CAPS Director, is responsible for determining how limited appointment times are utilized. Patients requiring more appointment time than is available in CAPS psychiatry or those students presenting with difficulties  that can not be safely managed on campus may be referred to off campus providers or mental health facilities. For services not available on campus an off campus referral will also be made. In the event a clinically relevant urgent situation should arise, a previously scheuled student appointment may be cancelled and rescheduled to accomodate the urgent matter.
  • Students requesting an appointment for ADHD evaluation or treatment will need to follow certain steps before a psychiatric appointment is scheduled. See CAPS Website for details
  • Students requesting transfer of their psychiatric care to a CAPS psychiatry staff will need to follow certain steps before a psychiatric appointment is scheduled. See CAPS Website for details

CONSULTATIONS

  • Psychiatric staff  are available to consult with staff and others who have contact with and responsibility for students. Consultations are provided with the understanding that patient confidentiality is respected.

EMERGENCIES OR NEED FOR IMMEDIATE SERVICE

  • During CAPS agency hours: One psychiatric staff member will be designated as the “doctor of the day” each weekday CAPS is open for service. In the event the designated “doctor of the day” is not available for service the Lead Psychiatrist or designee will serve in this capacity. Responsibilities will include consulting on emergency referrals; evaluating and developing an initial treatment plan on emergency referrals if clinically appropriate; addressing urgent telephone messages and refill requests ; and consulting with CAPS , SHC, University and other personnel for urgent matters requiring immediate attention. The “doctor of the day” will also review and address urgent items on each clinician’s provider task summary in the electronic medical record for whom they are providing covering service . The “doctor of the day” will be available onsite in CAPS or can be reached by electronic means for consultation.
  •  After Hours: There is no psychiatric staff member available to provide psychiatric emergency or routine service to students or refill medication requests during campus closures, campus holidays or during the evenings, nights or weekends when CAPS is closed. Students requiring service prior to the next available day CAPS is open, will be directed to contact the CAPS after hours ProtoCall Service for additional information on referral options. The ProtoCall service is available Monday-Friday between 5PM and 8AM, and 24 hours on weekends and holidays by calling (831) 459-2628.

IV.A DOCUMENTATION OF CLINICAL CARE

Effective Date: 
Mon, 08/01/2011
Reviewed: 
Thu, 05/28/2015
Revised: 
Thu, 05/28/2015
Policy: 

All clinical interactions with patients are documented by CAPS professional staff with a signed, contemporaneous note in the medical record in accordance with professional standards and regulatory guidelines.

Clinical documentation is accurate and completed in a timely manner.

Clinical records are maintained in an electronic medical record with security features that preserve privacy but allow timely viewing by health care practitioners with appropriate permissions.

Information that is shared with Primary Care Student Health Center staff can be found in the Sharing of CAPS Clinical Information with Student Health Center Policy.

The SOAP (subjective findings, objective findings, assessment and plan of care) format use is encouraged in all standard initial evaluation and follow-up clinical notes.

Procedure: 

1) Patient encounters or telephone encounters are completed soon after the clinical interaction and within two working days of the visit. The electronic record provides the time and date when notes are electronically signed. Notes written on a subsequent date are dated with the actual date of signature, even if referring to an earlier interaction. Dictation of complex visit types and initial psychiatric evaluation is available. Dictations are reviewed, edited and signed off by the responsible health care practitioner when they return from the transcriptionist.  Sign-off of dictation must occur within 3 working days of entry into the medical record.

2) Content Notes of clinical visits are done using templates and transcriptions in the electronic medical record utilizing the SOAP format when appropriate. Entries include, at minimum:

  • Date of service
  • Provider name and title
  • Chief complaint or nature of visit, with appropriate history
  • Objective clinical findings
  • Diagnosis, assessment or impression
  • Diagnostic testing ordered (lab, xray etc)
  • Treatment plan
  • Therapies administered or ordered, with discussion of necessity, risks, and alternatives as appropriate
  • Follow up instructions, if applicable
  • Practitioner’s electronic signature

An initial psychiatric evaluation intake note will include history of present illness, past history including psychiatric, medical and substance use problems, brief family history, mental status examination, DSM-5 diagnosis, assessment or impression and a treatment plan, including any medications prescribed. A re-intake evaluation should be completed if it has been more than one year since the last visit .At the clinician’s discretion, a re-intake note may be added to the chart when a student sees a new provider, or if there has been a significant lapse of time or change of condition since the last visit.

3) Psychotropic medication lists and allergies to medications are updated with each clinical visit.

4) Telephone contact with a patient is clearly identified as such in the medical record and content of the call is noted in the EMR, with appropriate clinician signature.

5) Entries made into the wrong patient record are reported by clinicians to the Medical Record Systems Administrator for correction.

6) If it necessary to correct or clarify an entry in a patient chart an addendum to the note is made by the clinician.

7) Lab results are sent by the ordering clinician to the patient using the secure message system or communicated to the patient by phone or in person.The chart note will reflect discussion of labs if a secure message is not utilized.  The secure message system has more stringent security features than campus email.  Campus email is not used for protected health information.

8) Security of Medical Records - Health practitioners lock the computer screen prior to leaving the exam room and screens automatically time out after 5 minutes if they inadvertently forget to lock the screen. Reminders to lock the screens are found on the work station. Paper protected health materials are collected throughout the day and locked up at the end of each day in the alarmed medical records office.

Key Points: 

1.  Documentation of clinical care occurs in the patient’s electronic medical record.

2. Documentation occurs in a timely manner, using standard clinical templates.

3. Documentation errors are corrected using addendums to the note unless the documentation was entered into the wrong patient's chart in which case follow the Medical Records Standards policy & procedure: XI. Corrections and Amendments to Records

4. Security features to assure the safety of protected health information include the lock-out features in the EMR and regular collection of paper materials for storage in the locked Medical Records office.

IV.B PEER REVIEW FOR PSYCHIATRY

Effective Date: 
Fri, 06/08/2007
Reviewed: 
Sat, 05/30/2015
Revised: 
Thu, 05/28/2015
Policy: 

Peer Review is an integral component of the Quality Management and Improvement Program and shall be conducted on a regular and ongoing basis by CAPS psychiatry staff.
Purpose of Peer Review:

  • Monitoring of indicators of clinical quality and conformity with UCSC CAPS Psychiatry Service and community standards of care. The focus of the review will include completeness of documentation, diagnostic assessments, and medication management.
  • Identifying opportunities for improvement in clinical care and providing feedback and educational opportunity for staff psychiatrists and nurse practitioners.
  • Providing information to the Lead Campus Psychiatrist, CAPS Director, and SHC Medical Director as one component of the clinical credentialing, privileging, and evaluation process.

 

Procedure: 

It is the responsibility of the Lead Psychiatrist, with the advice and consultation of the psychiatric and medical staff, to identify and address any problems or opportunities for improvement in the clinical care provided by members of the CAPS psychiatric staff.
Process:
1. Twice yearly, during the academic term, 5 charts of each clinician (psychiatrist or psychiatric nurse practitioner) will be randomly distributed to the other clinicians on the psychiatry staff for peer review. The reviewers will use a peer review form (see attached) to evaluate whether, in their judgment, clinical care and documentation met UCSC CAPS Psychiatry Service and community standards of care.
2. Charts will be reviewed in the electronic medical record.
3. In cases where the peer reviewer feels the care deviates significantly from the community and UCSC CAPS Psychiatry Service standards, the reviewer will indicate that further review is required.
4. Cases requiring further review will be reviewed a second time:

  • By the Lead Campus Psychiatrist, if the Lead Campus Psychiatrist was neither the first reviewer nor the psychiatrist under review.
  • By another staff psychiatrist or psychiatric nurse practitioner, if the Lead Campus Psychiatrist was the first reviewer or the psychiatrist under review. The second reviewer may request additional information on the care of the case from the treating psychiatrist. If the second reviewer also states that the management of the case was inadequate, the issue will be forwarded to the Lead Psychiatrist who will consult with CAPS management staff. If the Lead Campus Psychiatrist is under review, the issue will be forwarded to the CAPS Director, who will consult with the SHC Medical Director as needed. If the second reviewer states the care was adequate, both reviewers’ opinions will be included in a summary sheet, but no further action will be taken.

5. Psychiatrists and psychiatric nurse practitioners will receive a summary sheet detailing results of peer review, including results of second reviews, within thirty days of review. Any psychiatrist or psychiatric nurse practitioner disagreeing with or having concerns about a case review may respond directly or in writing to the Lead Campus Psychiatrist and/or the CAPS Director, who will make a written reply.
6. The Quality Management Committee will regularly receive a summary report on Peer Review of psychiatric staff. The Lead Campus Psychiatrist will regularly summarize peer review activities in psychiatry to the rest of the Quality Management Committee.
7. A CAPS administrative assistant will designate charts for review for each psychiatrist or psychiatric nurse practitioner by randomly selecting cases new to CAPS Psychiatry in the EMR from the two previous academic quarters under review. Documents to be reviewed will include clinical records, starting with the initial contact and going forward in the academic quarter under review. The CAPS administrative assistant, under the direction of the Lead Psychiatrist, will collate the reviews and produce a summary sheet detailing results of peer review for each clinician reviewed.
8. If necessary, training will be provided to the psychiatric staff on general themes and issues that arise from the peer review process.Peer Review is an integral component of the Quality Management and Improvement program, and shall be conducted on a regular and ongoing basis by CAPS psychiatric staff.

University of California, Santa Cruz                                      CAPS  Psychiatry Service
                                       PSYCHIATRY PEER REVIEW FORM 

IV.C REVIEWING DIAGNOSTIC TEST RESULTS

Effective Date: 
Sun, 09/01/1996
Reviewed: 
Tue, 06/30/2015
Revised: 
Mon, 06/01/2015
Policy: 

Incoming diagnostic test results (lab, radiology, EKG, etc.), clinical summaries from consultants, and other medical records are reviewed, addressed, initialed, and routed by licensed personnel in a timely fashion.

Procedure: 

Laboratory and x-ray results are downloaded into the EMR (PNC).  Laboratory results are directly loaded from Quest into the EMR with a patch program.  Radiology reports on imaging performed in the SHC is transmitted via a secure interface from the outside Radiology Medical Group directly into the EMR.

These results appear in a "folder" in the EMR called the Provider Task Summary.

Clinicians are responsible for reviewing contents of the Provider Task summary at least daily.  Part time and per diem clinicians have their lab and x-ray results reviewed by a career clinician assigned to cover them when they are not working on site.

Once diagnostic test results have been reviewed, the clinician clicks the "acknowledge" button below the result.  This creates a dated, electronic signature indicating that the clinician has reviewed the result.

Additional options for acknowledgement are available in the EMR.  These options allow the clinician to put a note on the lab or indicate that the clinician called or sent a secure email message to the patient regarding their results.  The clinicians are expected to review all lab results and notify the patient by secure message, phone contact or in person unless other arrangements have been made. For very common labs, a variety of pre-written text messages are available to clinicians to send to patients regarding test results.

Some diagnostic test results, letters from consultants, or copies of past medical records come to the Student Health Center by fax or mail.  These results are logged on arrival in Medical Records, date stamped, and each result placed in an individual red folder.

The CAPS administrative assistant reviews fax and paper results and delivers them to the clinician working with the patient.  If no clinician is identified then the result goes to the Psychiatric case manager.

Fax and paper results are initialed by the CAPS/Psychiatry clinician, returned to CAPS Medical Records, and then scanned into the EMR.  These results appear in the section of the EMR called Scanned Documents.  These results are not in the sections called Laboratory or Radiology.

To assure that no results are lost both lab and x-ray track tests from collection through to results.   Each department maintains a daily log of all tests done.  Each log entry is maintained as an active manifest until results for every test have been entered into the EMR.  This allows rapid identification of results which exceed the expected turnaround time and may have been delayed.  Labs sent out to reference laboratories which do not return within the expected turnaround time will be tracked by the UCSC SHC  lab staff.  The UCSC SHC Lead Clinical Lab Scientist or designee will contact the reference lab and expedite transmission of the final lab result.  In the case of a delay in the X-ray reports, the Lead Radiology Technician will contact the Radiology Medical Group administrator to expedite the final report if not received within one business day.

Key Points: 

 

  • All laboratory and radiology diagnostic test results drawn or performed in the SHC appear in the ordering provider’s inbox or provider task summary list.
  • The EMR allows the clinician to electronically acknowledge test results and generate secure email messages to notifying patients of their results.
  • Fax and paper reports are logged, date stamped, and sent to the appropriate clinician for review.  The clinician signs the paper report and returns it to Medical Records where it is scanned into the EMR.
  • Both lab and x-ray maintain daily logs which track all studies sent out from the Student Health Center and their status.  This prevents inadvertent delay of a lab or x-ray final report.

     

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CAPS Manual

Effective Date: 
Mon, 07/11/2011

I.5.

Management of referrals and transfers to and from the facility

I.6.

Cooperation with and coordination of medical care with behavioral health care

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