CAPS

II.B.i CRISIS PROCEDURES - AFTER HOURS SERVICES - PROTOCALL GUIDELINES *

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Thu, 05/17/2018
Revised: 
Mon, 04/18/2016
Policy: 

After business hours, during weekends and on holidays, ProtoCall (an off-site, privately contracted company) provides telephone crisis assessment, safety planning, and referrals for UCSC students. This service is accessed by phoning the CAPS Central Office at (831) 459-2628 and selecting the “After Hours Crisis Services” menu option. All members of the UCSC community (students, staff, faculty and parents) may utilize this service to obtain immediate, telephone-based consultation and support regarding a variety of crisis issues, and to facilitate transitions to CAPS daytime services. Each business day, CAPS staff review new ProtoCall contacts and respond accordingly.

If a critical incident occurs after business hours, a ProtoCall provider will contact the CAPS “back-up” person or other UCSC officials to mobilize campus and community resources. The “back-up” person is not “on-call,” but is “on-alert,” is generally available by cell, and is not required to be in a specific geographic location. If the back-up person is not available, ProtoCall will contact another member of the CAPS counseling staff and/or management.

Procedure: 

Criteria for when ProtoCall is to contact the CAPS back-up person:

1. The death of a student.

2. Disaster (i.e. earthquake, school shooting, etc).

3. In any situation involving Duty to Warn or reports of imminent danger due to suspected child or elder abuse or neglect per ProtoCall policies and procedures.

When contacted by ProtoCall, the CAPS back-up person is to:

1. Consult with ProtoCall and gather information about situation.

2. Assess the level of severity of the situation and determine the need for response.

            a. Consult with CAPS management if, in fact, ProtoCall is responding to one of the three criteria defined above, or as needed in other situations if the CAPS back-up person determines that consultation with CAPS management is needed.

            b. CAPS staff needs to provide direct service(s) that may include:

                        1. Consultation to staff, student, or administration.

                        2. A debriefing at the time of the incident and/or thereafter.

                        3. Resource information.

                        4. Coordination of local resources with ProtoCall staff (e.g., contacting campus or local law enforcement).

3. Follow-up the next working day.

            a. Provide follow-up/debriefing with CAPS management.

            b. Provide information to daytime Crisis staff.

            c. Determine any necessary follow-up beyond what the daytime Crisis staff are responsible for providing, including supplementing the documentation of daytime Crisis staff.

Daily procedures for new ProtoCall reports:

The Crisis Worker is responsible for checking the online ProtoCall Share Point drive for any Protocall reports  prior to 8:30 AM every morning and at the beginning of the afternoon shift and responding to the reports accordingly. Guidelines for following up on ProtoCall reports are outlined below.

Students who called and did not indicate imminent risk:

  • Check in PnC and/or with the front office to determine if the student has utilized CAPS services.
  • If the student is a current/recent CAPS client, call the clinician  and disclose report information or IM the ProtoCall report to the clinican.
  • No further follow-up is needed on the part of the crisis worker.

Students who called and indicated imminent risk:

  • Check in PnC and/or with the front office to determine if the student has utilized CAPS services.
  • If the student is a current/recent CAPS client, call the clinician and disclose report information.
  • If the student has an off-campus provider and there is a release of information, contact the provider to disclose report information if appropriate.
  • Collaborate with the CAPS or off-campus clinician to provide follow-up for the student.  The student should at least be called and offered assistance/resources either by the current clinician or the crisis worker.
  • If the student does not have an on or off-campus provider, please consult with your crisis team member regarding an appropriate follow-up plan.

Parents who called:

  • Check in PnC and/or with the front office to determine if the student has utilized CAPS services.
  • If the student is a current/recent CAPS client, call the clinician and disclose report information.
  • Check the student’s chart for pertinent releases of information.
  • Do not disclose student information to the parent unless there is a release of information and it is clinically indicated due to risk.  Make every attempt to consult with current/recent CAPS or off-campus provider prior to disclosing info.
  • Only if the parent indicates the student is at imminent risk, attempt to contact the off-campus provider with release of information to disclose report information.
  • Only if the parent indicates the student is at imminent risk and the parent might need continued support despite ProtoCall contact, call the parent to offer support and assistance.

Staff and faculty who called:

  • Check in PnC and/or with the front office to determine if the student has utilized CAPS services.
  • If the student is a current/recent CAPS client, call the clinician and disclose report information or IM the ProtoCall report to the clinician.
  • Check the student’s chart for pertinent releases of information.
  • Do not disclose student information to staff/faculty unless there is a release of information and it is clinically indicated due to risk.  Make every attempt to consult with current/recent CAPS or off-campus provider prior to disclosing info.
  • Only if the staff/faculty indicates the student is at imminent risk, attempt to contact the off-campus provider with release of information to disclose report information.
  • Always return calls from staff and faculty to offer support and assistance, regardless of level of risk.

Documentation:

If a student is an active or recent client of CAPS, document the ProtoCall contact in the student’s Electronic Health Record (EHR) using the Protocall template,  and note whether further follow-up is needed or recommended, and if any action was taken.

If a student is not a current or recent CAPS client, document the ProtoCall contact in the third party security division of the EHR and indicate that a ProtoCall report has been received.  Note whether further follow-up is needed or recommended, and if any action was taken.   See Third Party Contacts policy and procedures. 

II.B CRISIS PROCEDURES - OVERVIEW *

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Mon, 05/07/2018
Revised: 
Thu, 01/11/2018
Policy: 

Brief Risk Assessments:

All registered UCSC students who present to CAPS Central Office during normal business hours (Monday through Friday from 8 AM until 5 PM) and are perceived to be at risk or in an acute crisis are eligible for a same day, brief risk assessment at no charge. Brief risk assessments are designed to assist students who are confronting life-threatening circumstances, current or recent traumatic event(s), or serious mental illness. Examples of such issues include:

  • suicidal thoughts
  • the need to be hospitalized for mental health purposes
  • thoughts about harming another person
  • recent assault or abuse
  • concern about their safety or someone else’s safety
  • hallucinations or other “odd thinking”
  • recent death of a loved one
  • witnessing or experiencing a traumatic event
  • adverse drug reaction

Consultations:

CAPS provides in-person and telephone consultations to students, staff, faculty, and parents who are concerned about UCSC students who might be in emotional or psychological distress. See Third Party Contact/Consultations Policy

After Hours Crisis Service and ProtoCall:  

After business hours, during weekends and on holidays, ProtoCall (an off-site privately contracted company) provides telephone crisis assessment, safety planning, and referrals for UCSC students. This service is accessed by phoning the CAPS Central Office at (831) 459-2628 and selecting the “After Hours Crisis Services” menu option. All members of the UCSC community (students, staff, faculty and parents) may utilize this service to obtain immediate, telephone-based consultation and support regarding a variety of crisis issues, and to facilitate transitions to CAPS daytime services. Each business day, CAPS staff review new ProtoCall contacts and respond accordingly. See After Hours Service and ProtoCall Policy.

If needed, a ProtoCall provider may contact CAPS clinician(s) or other UCSC officials to mobilize campus and community resources. The primary CAPS clinician on-alert for ProtoCall contacts is generally available by cell, and is not required to be in a specific geographic location while on-alert. If the primary CAPS clinician on-alert is not available, ProtoCall will contact another member of the CAPS counseling staff and/or management.

Procedure: 

Students who are referred, or self-refer, to crisis services need to complete the crisis triage form (Appendix A).

Positive Crisis Triage Form:

Students who endorse one of the questions on the crisis triage form are given the next available crisis appointment.

For students who complete the crisis triage form and endorse the item, “I am having a severe reaction to a psychiatric medication,” only (i.e., no other items on the crisis triage form are endorsed), front desk personnel will inform students they may utilize one of three options: (1) schedule a same day crisis appointment, (2) present to the SHC’s Same Day Clinic, (3) schedule an Initial Assessment appointment.

For students who complete the crisis triage form and endorse the item, "I attempted suicide within the last 24 hours," all other preliminary steps are bypassed and the student is seen immediately by the crisis staff or management backup.  If the student had recently ingested a toxic substance, or is otherwise in immenent physical risk, UCSC police dispatch will be contacted immediately and, if indicated, student will be taken to the local emergency room.  If there is a delay, the Medical Director (or designee) can be contacted for their assistance.

For students who endorse one of the questions on the crisis triage form yet decline a crisis appointment, or who express a desire to leave prior to their crisis appointment, the front desk personnel will encourage the student to attend a crisis appointment. Additionally, whenever possible, the front desk personnel will inform a CAPS clinician of the student’s imminent departure or disinterest in an appointment. If a student continues to decline an appointment, the student will be given the CAPS Walk-Out Letter (Appendix B) and be invited to contact CAPS for a crisis appointment. As needed, following the student’s departure, the CAPS clinician will consult with additional CAPS providers to determine appropriate courses of action aimed at minimizing the risk of harm or injury.  

Negative Crisis Triage Form:

Students who do not endorse a question on the crisis triage form are offered the next available Initial Assessment appointment.

Students who do not endorse questions on the crisis triage form yet express a strong urgency to meet with a crisis counselor for a same day appointment will meet with a CAPS clinician for a “brief consultation.” During the “brief consultation,” the CAPS clinician will ascertain and inform front desk staff whether the student’s concern(s) warrant a same day crisis appointment or an Initial Assessment appointment.

Brief Risk Assessment:

For same day crisis appointments and “brief consultations:” Prior to meeting with a CAPS clinician, front desk personnel will provide students with: (a) the Informed Consent and Notice of Privacy Practices Form –(Appendix C), (b)  the “Same-day Crisis Assessment and Consultations” informational sheet (purple paper) (Appendix E). Additionally, for same day crisis appointment, students will compete the Student Questionnaire form (Appendix F), and the CCAPS.

Upon meeting with a CAPS clinician: The CAPS clinician will inform the student of the limitations of confidentiality and conduct a brief risk assessment.  Following the risk assessment, the clinician will provide an appropriate level of crisis management and intervention services. In collaboration with the student (and/or other Student Health Services providers—CAPS; primary care), the clinician will identify an appropriate treatment and service plan (e.g., CAPS first follow-up appointment;  hospitalization; on- and/or off-campus referral services; personal action plan). See relevant subsections of the CAPS Policies and Procedures Manual for additional information on the aforementioned clinical, counseling and psychiatric services. Guidelines specific to crisis follow-up(s) are outlined below.

All crisis assessment, management, and intervention services are delivered in accordance with professional standards and regulatory guidelines, and follow usual and customary care practices.

Crisis Follow-up Appointments:

Crisis appointments can serve as a replacement for an Initial Assessment as much of the same information is gathered.  As is the case with Initial Assessments, if a student is appropriate for brief therapy on campus, the crisis worker will conduct the First Follow-up and subsequent sessions, if possible.  If this is not possible (due to the clinical demands of the case or scheduling issues), the case should be brought for disposition.  Each  follow-up appointment should involve a risk assessment and check-in regarding the treatment and service plan documented during the previous crisis contact.

For information on managing and documenting missed crisis follow-up appointments, see the Missed Appointments section of the CAPS Policy and Procedures Manual. 

Documentation:

All crisis service related forms and clinical interactions with students are documented in students’ Electronic Health Record (EHR). Crisis Assessments are to be completed within 1 business day by licensed staff. Crisis assessments completed by unlicensed staff must be reviewed and signed by a licensed CAPS clinician within 2 business days. See section II M, Documentation of Clinical Care

II.A ELIGIBILITY AND ACCESS TO SERVICES *

Effective Date: 
Tue, 09/06/2011
Reviewed: 
Mon, 05/07/2018
Revised: 
Thu, 01/11/2018
Policy: 

 

  1. All currently enrolled students at the University of California, Santa Cruz, are eligible for services.  These services include crisis consultations and assessments, time-limited individual, couples,  and group counseling, and psychiatric services, based on the client's appropriateness for the services provided by CAPS.
  2. Primary point of entry is through a scheduled in-person Initial Assessment, although students can also walk in.
  3. Each student utilizing the services of CAPS is required to have an initial assessment each year, even if the student was a CAPS client previously.
  4. All students must show a valid student ID at their initial assessment appointment or provide proof of current enrollment on request.
  5. New, incoming students, who have registered for classes, may be seen prior to classes beginning, at management's discretion.
     

 

 

 

I.B SCOPE OF SERVICES *

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Mon, 05/07/2018
Revised: 
Tue, 11/21/2017
Policy: 

Counseling and Psychological Services (CAPS) offers services to all currently enrolled students at the University of California, Santa Cruz.  As mental health practitioners, our scope of services consists of providing or facilitating access to counseling and mental health services.  CAPS provides both psychotherapy and psychopharmalogical treatment.  Our psychotherapy generally follows a brief therapy model that consist of providing a handful of sessions around a specifically identified issue or helping a student transition to longer term treatment. Our psychiatric service can provide on-going medication treatment if appropriate.  We collaborate with other UCSC campus  services (housing, academic advisors, disability resource center, etc.) to ensure students get the resources they need. If we have an established treatment relationship with a student, we will complete forms to support students working with these other services or offer an opinion regarding the student’s request. CAPS is committed to meeting the diverse needs of each student and considers their sociocultural context when making treatment recommendations.  We seek to identify underserved populations and outreach to provide culturally sensitive services.

Limitations on Treatment:
When students have been assessed to require a higher level of care than can be provided at CAPS (e.g.- long-term therapy, Intensive  Outpatient treatment, substance abuse detoxification and intensive treatment, complex psychopharmological treatment), we work with them to find appropriate off-campus referrals and treatment.  If such services are refused, we reserve the right to administratively discharge them from our services.  In no event (other than presenting a clear danger to staff) would we refuse to provide a crisis evaluation (as defined in policy II.B.).

In order to ensure that we maximize the number of students who benefit from our services we generally do not provide long term, on-going therapy. We will often work with off-campus partners to address those needs.

The following are brief summaries of the services offered:

  • Brief Therapy:  CAPS utilizes a brief therapy model in the provision of individual, couples, and family counseling to address personal, academic, social, or family concerns.  Following an Initial Assessment, each student’s needs are assessed on an individual basis for the appropriateness of a brief treatment approach.  Students whose needs might be met best from a longer term model may be referred off-campus.
  • Psychiatry Services: Psychiatry services are offered by referral from other CAPS staff, the UCSC Student Health Center, or an off-campus medical or counseling professional.  Psychiatry staff conduct diagnostic evaluations and prescribe medications to address mental health disorders such as depression and anxiety. CAPS staff psychiatrists also offer follow up services, medication management and on-going care. Prescription refill requests will be processed only during regular CAPS hours.
  • Counseling Groups:  Counseling groups are available throughout the academic year and are advertised each quarter. Groups provide opportunities for students to explore personal issues with peers in order to develop awareness, increase their emotional support and interpersonal skills.  Specialized groups may be offered on a variety of issues, such as life transitions, eating awareness, depression, anxiety, sexual abuse survivors, and groups for students of color.
  • Crisis Services   Students who are in need of emergency crisis services may call 831-459-2628 for a crisis consultation or can be seen for a crisis assessment at the CAPS central office.  A risk assessment is conducted and treatment recommendations are made by CAPS counseling staff.  The CAPS Central Office is open Monday through Friday from 8 am to 5 pm.
  • Phone Triages   Students who are only interested in off-campus referrals are given a half hour time slot to call in to one of our clinicians.  During this time a risk assessment is conducted, the presenting problem is discussed and a plan for ongoing services is determined.
  • After Hours Crisis Service:  An off-site mental health phone service is available evenings and weekends. The service is accessed by contacting the CAPS central phone number (459-2628) and selecting the menu option of After Hours Crisis Services. The service is available to all members of the UCSC community (students, staff and faculty) and provides telephone-based risk assessment, crisis triage, and safety planning. The off-site provider can offer immediate consultation and support by phone regarding a variety of issues and can facilitate the transition to CAPS daytime services. As needed, the after-hours provider will contact CAPS or other UCSC officials to mobilize campus and community resources in case of an emergency.
  • Referral Services:  CAPS offers referral services to off-campus providers when appropriate for longer term treatment or treatment that is outside our scope of service or expertise.
  • Let's Talk: CAPS offers a drop-in program in different locations on campus where students can stop by for a brief, confidential converstation with a counselor to receive consultation, support, referrals, and advice. See Appendix
  • Consultation Services: Consultation is available to staff, faculty, administrators and family members who are concerned about a student who may be at-risk of harm or in need of counseling services.  Upon contacting the CAPS central office, these third party consultation calls are referred directly to the crisis counselor on call. The CAPS Central Office is open Monday through Friday from 8 am to 5 pm.  For non-emergency consultation, staff, faculty, students and residential communities can also contact CAPS staff directly for consultation.
  • Outreach Services:  CAPS offers a variety of outreach services, including workshops addressing students' developmental, situational, and lifelong concerns. Workshops can include academic skill topics such as time and stress management, study skills, and test anxiety. Workshops may also be offered on a broad range of psychological issues such as interpersonal communication, sexuality, and parenting.
  • Curriculum:  From time to time, CAPS staff offer courses sponsored by colleges in areas such as multiculturalism and academic success.

I.A POLICY AND PROCEDURE OVERVIEW AND MISSION STATEMENT *

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Thu, 04/19/2018
Revised: 
Thu, 04/19/2018
Policy: 

Counseling and Psychological Services (CAPS) operates under the auspices of UCSC Student Health Services (SHS).  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).  All CAPS clinical services provided are approved by the governing body of SHS as stipulated in the individual provider's privileging form.  The CAPS Director is responsible for oversight of the resources and activities of CAPS counseling services, as well as the administration of procedures related to the provision of supervision, crisis/emergency management, quality, and evaluation of services provided.  The Director of Psychiatry has similar oversight of psychiatric services.

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: 
Mon, 02/05/2018
Revised: 
Mon, 02/05/2018
Policy: 

Under the coordination of the Director of Psychiatry, 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 central 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 Director of Psychiatry 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 services that can provide the frequency and level of safety required. For services not available on campus an off-campus referral will also be made. In the event an urgent clinical situation should arise, a previously scheduled 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 Director of Psychiatry 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 emergency or routine psychiatric service to students or to refill medication requests during the evenings, nights, weekends, campus closures, or campus holidays 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: 
Mon, 02/05/2018
Revised: 
Tue, 05/01/2018
Policy: 

All clinical interactions with patients are documented by CAPS and Psychiatry 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 24 hours 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 24 hours 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: 
Mon, 02/05/2018
Revised: 
Mon, 02/05/2018
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 Director of Psychiatry, CAPS Director, and SHC Medical Director as one component of the clinical credentialing, privileging, and evaluation process.

 

Procedure: 

It is the responsibility of the Director of Psychiatriy, 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 Director of Psychiatry, if the Director of Psychiatry was neither the first reviewer nor the psychiatrist under review.
  • By another staff psychiatrist or psychiatric nurse practitioner, if the Director of Psychiatry 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 Director of Psychiatry who will consult with CAPS management staff. If the Director of Psychiatry 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 Director of Psychiatry 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 Director of Psychiatry 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 Director of Psychiatry, 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 

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