Documentation of Psychotropic Drug Management
| Nanette Lavoie-Vaughan, M.S.N., APN |
Purpose:
What is agitation?
How to describe agitation:
Yelling Scratching
Screaming Spitting
Cursing Throwing
Howling Insomnia *(treated differently)
Biting Fidgeting
Crying Repetitive vocals
Pacing Threats
Restlessness Attention seeking
Hitting
Environmental factors:
Documentation guidelines for anti-psychotics:
Acceptable diagnoses:
Document non-pharmacological interventions:
CMS Guidelines for use of anti-psychotics:
Documentation for other psychotropic medications:
- To document appropriate use of psychotropic drugs especially anti-
psychotics.
What is agitation?
- Those inappropriate behaviors whether verbal, vocal or motor that
create significant stress for the resident, caregiver and/or medical
staff.
How to describe agitation:
Yelling Scratching
Screaming Spitting
Cursing Throwing
Howling Insomnia *(treated differently)
Biting Fidgeting
Crying Repetitive vocals
Pacing Threats
Restlessness Attention seeking
Hitting
Environmental factors:
- Noise
- Light
- Other residents
- Approach of caregivers
- Toileting/Showers
- Hunger
- Temperature
- Pain
Documentation guidelines for anti-psychotics:
- Always include the diagnosis and/or target symptoms in orders and
notes. Use the descriptive symptoms of agitation, paranoia, delusions
and hallucinations as the reason for the medication or the adjustment. - Do not use wandering, elopement, taking others belongings, going
into other resident rooms or symptoms of anxiety and depression as
reason for use.
Acceptable diagnoses:
- 290.20/290.42 - senile dementia/vascular dementia with delusions
- 290.3/290.41 - senile dementia/vascular dementia with delirium
- 295 - Schizophrenia
- 294.11 - Dementia with behavioral disturbance
- 297.0 - Paranoid state, simple
- 297.1 - Delusional disorder
- 296 - Bipolar with mania
Document non-pharmacological interventions:
- redirection, structured activity, dementia supplies, food,
aromatherapy, music, videos, wander-guard, exercise, toileting
schedule, reduce stimuli, individual care plan for staff - Document plan for dose titration and/or reduction when appropriate.
- Document efficacy and any adverse effect
CMS Guidelines for use of anti-psychotics:
- Symptoms are due to mania/psychosis
- Symptoms endanger themselves or others
- Symptoms result in inconsolable and/or persistent distress, a
significant decline in function or difficulty receiving appropriate care - Plan should include: adequate time frame, discontinue or cross taper
of failed trial before start of another, symptomatic treatment, weigh
potency versus safety.
Documentation for other psychotropic medications:
- Depression - focus should be on mood, absence of crying, sad
affect, weight loss, anger and involvement in facility activities. - Anxiety - focus on behavior displayed and level of distress. Behavior
may be very similar to agitation descriptions. - Sedative/hypnotics - must have diagnosis of insomnia and show
that other methods have been tried and unsuccessful: environmental
approaches, low dose benzos or if depressed, an anti-depressant that
has the side effect of drowsiness (e.g. Trazodone). Always show
titration to lowest effective dose and drug holiday. - Off label use of drugs - need to clearly document symptoms and
behaviors that are being treated and what has been used and failed.
(Remeron, Depakote). - Combination therapy - always show that you have maxed the dose
of one drug before starting a second in the same category. Really
have to justify the use of 2 medications in the same category.
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