Preparing for appointments

Page posted: 3/6/24

Being prepared for appointments can help improve communication with licensed practitioners and support optimal health outcomes for people who take psychotropic medications. This page covers the following topics:

· What to expect at an appointment.

· Important information to understand before going to an appointment.

· What to bring to an appointment.

· Optional forms to help people prepare for appointments.

What to expect at an appointment

Licensed practitioners often discuss the following topics at appointments for psychotropic medications:

1. Medical history, such as:

· Mental health diagnosis (DSM-V).

· History of illness.

· Psychiatric/mental health history or hospitalizations.

· Applicable social or family history.

2. Mental and physical health symptoms.

3. Mental status.

4. Quality-of-life issues and desired or undesired changes in the person’s life.

5. Summaries of person-centered tools (refer to Psychotropic Medication Manual – Person-centered tools to support medication management).

6. Data on targeted behaviors and symptoms, and whether the person’s behaviors are increasing, decreasing or stable.

7. Data on side effects or a discussion about how to identify when the person is experiencing side effects.

8. PRN (i.e., as needed) medication use.

9. Current medication(s), supplements, treatment or laboratory orders.

10. Rationale for any medications prescribed.

11. Alternative options.

12. Future appointments, plans or referrals and the date of the next appointment(s).

In some cases, the person might be unable to provide history or current symptoms of their mental health condition. This is one reason it is important for support teams to use or request copies of the tools referenced throughout this manual before any appointments with the licensed practitioner (e.g., Psychotropic Medication Manual – Diagnostic assessments and medical evaluations, Psychotropic Medication Manual – Functional behavior assessments (FBA), Psychotropic Medication Manual – Quality-of-life assessments).

Important information to understand before going to an appointment

The 245D service provider can better support a person by learning about the following topics before attending an appointment:

· Plans to monitor medication effectiveness.

· Plans to monitor side effects.

· Roles and responsibilities of support team members.

· PRN medications.

· Chemical restraint.

Plans to monitor medication effectiveness

The 245D service provider can help monitor the effectiveness of a person’s medications. They should ask the licensed practitioner for tools to track effectiveness and symptoms. It is consistent with leading practices for providers to collect and report to the practitioner symptom-related data for all psychotropic medications.

The 245D service provider also might need to help a person schedule appointments for therapeutic drug monitoring (TDM) or other laboratory tests. TDM measures the amount of certain medications in a person’s blood. For most medications, people can be prescribed the optimal dose without special testing. However, for certain medications, measuring the level of medication in a person’s blood helps minimize risk and optimize effectiveness. Ultimately, TDM can help the practitioner determine if the person is taking the best dose of medication. For more information, refer to Medline Plus – TDM.

Plans to monitor side effects

Although medications can positively affect a person’s life, they also might have side effects. The goal of pharmacotherapy is to produce optimal therapeutic effects while minimizing side effects.

Side effects can occur when a person starts, decreases, increases or stops a medication. They can range from being mild to warranting immediate medical attention. They also can vary between people. When medication side effects are severe, the practitioner might need to adjust the dosage, prescribe a second medication or stop the medication. Lifestyle or dietary changes also might help minimize side effects.

It is important for the person and their support team to be familiar with both the short-term and long-term side effects of medications and know how to assess for potential concerns. The licensed practitioner is a valuable resource who can provide information and educate the person and their team about medication side effects.

Early identification and intervention are very important. Some side effects might be alarming but easily treatable before they become severe. During appointments, DHS strongly encourages the support team to ask the licensed practitioner about side effect monitoring forms.

Detection

Side effects might not always be immediately noticeable, so it is important for the licensed practitioner to develop a plan to track any side effects in collaboration with the person and their support team. Ideally, this monitoring starts before the person starts a medication.

For people with intellectual disabilities, side effects can manifest in unique ways. For example:

· A person might have a dry mouth, constantly ask for beverages and engage in challenging behaviors if their team denies their access to liquids.

· An intellectual disability might mimic or obscure certain side effects, such as changes in speech or gait.

· A person with speech or communication impairments might have difficulty verbally reporting side effects, but they might be able to report these side effects through their behavior.

Roles and responsibilities to discuss medication effectiveness and side effects with the licensed practitioner

All members of support teams are responsible to monitor effectiveness and side effects (including both positive and negative side effects). However, specific roles might vary. The following table provides information about specific responsibilities.

When	Responsibilities
Before the appointment	Depending on the type and frequency of services provided, 245D service providers often are responsible to: · Collect and summarize effectiveness and side effect data. · Report that information to the licensed practitioner. Sometimes the person taking the medications, a family member or someone the person trusts can complete these tasks.
During the appointment	The licensed practitioner is responsible to: · Educate the person and their support team about effectiveness and potential side effects. · Identify concerning side effects. · Determine which symptoms and side effects need to be monitored, what information needs to be recorded and when/how frequently it should be reported. The licensed practitioner should conduct a side effect review at each appointment and review side effects more thoroughly every six months. The person or their support team might need to discuss with the practitioner the possibility of conducting side effect assessments more frequently if the person: · Is in a high-risk group. · Undergoes multiple lifestyle changes. · Has a history of experiencing side effects.
After the appointment	The person and their support team should: · Be familiar with both short-term and long-term side effects of medications and how to assess for potential concerns. · Speak up if they observe a side effect of concern or a change in mental health symptoms compared to the person’s baseline presentation. · Notify the licensed practitioner as soon as possible about any changes in a person’s ability to function. Early identification of changes in behaviors, movement, communication, etc., can help determine possible side effects of medications. The 245D service provider might be responsible to collect and report data (depending on the person’s support needs). They should note regular data reviews in the person’s support plan, as described on CBSM – Support planning for long-term services and supports (LTSS).

PRN medications

Sometimes, the 245D service provider must ask the licensed practitioner to clarify prescription orders or give plain language examples of when to administer PRN medications. For example, the practitioner should clarify the term “depression” with examples specific to the person. The symptoms of depression for one person differ from the symptoms of depression for another person.

Definition of PRN medications

Many people take certain psychotropic medications as needed (i.e., as a PRN), instead of on a regular schedule. PRN stands for “pro re nata,” which is a Latin phrase meaning “as the circumstance arises.”

Most people are familiar with PRN medications, but they might not know them by the term “PRN.” For example, if a person has allergies, the practitioner might write them a prescription for an allergy medication to take as needed. It is likely that the person and practitioner determined symptoms that indicate when to take the PRN allergy medication. When these symptoms occur, the person knows it is time to take their medication. If they wait too long and develop a sinus headache or more severe symptoms, the PRN medication may not be as effective, or they might need to take a stronger dose to treat the more intense symptoms. People use these types of PRN medications similar to the way people receiving services use PRN medications. Planning how to use PRN psychotropic medications is important to ensure optimal effectiveness.

Appropriate use of PRN psychotropic medication

In the following examples of appropriate use, staff give Lee his PRN medication for specific symptoms he experiences when he is anxious. His medication administration record lists the symptoms as excessive sweating, restlessness, breathing rapidly/hyperventilation, trembling and reporting of gastrointestinal problems related to heightened stress. Lee either accepts or requests the medication, and staff give the medication in compliance with the 245D service provider’s procedures.

Examples:

· Appropriate use example #1: Lee decides to attend a local community dance. On the day of the dance, he begins thinking about what other people will say when they see him dance. He worries they will make fun of him, so he starts feeling anxious and paces around his room. He notices he is beginning to sweat and starts worrying about that, too. He finds a staff member and tells them how he feels. He asks his staff for his PRN medication. He has a diagnosis of an anxiety disorder, and one of his target symptoms is profuse sweating in social situations. The staff member provides his medication as requested, documents the administration in Lee’s record and notes the outcome (reduced sweating and slowed breathing).

· Appropriate use example #2: Lee does not request his PRN medication. He continues to pace and sweat in his bedroom. His staff person asks if he wants to join his roommates for dinner. Lee raises his voice and says, “No, leave me alone.” The staff person approaches him and says, “I see you might be worrying about going to the dance tonight. Do you want your med that helps you calm down?” He says, “Yes,” and the staff member gives him the medication. The staff member documents the administration in Lee’s record and notes the outcome (discontinues pacing and talks calmly with his roommate while eating).

Inappropriate use of PRN psychotropic medications

In the first example of inappropriate PRN use, staff force Lee to take the medication even though he refused. In the second example, staff give him the medication for a symptom that is not consistent with the licensed practitioner’s prescription guidelines.

Examples:

· Inappropriate use example #1: Lee is pacing and sweating in his bedroom. When staff ask him if he needs his PRN medication, his response is, “No, go away,” and then he lunges toward his staff to hit them. The staff person responds by telling him that he must take his medication because he is very upset. Lee complies because he does not feel he has a choice. The staff member documents the administration in Lee’s record and notes the outcome (discontinued aggression).

· Inappropriate use example #2: Lee does not demonstrate any of the symptoms listed in his medication administration record. However, right before his household leaves for the dance, he starts yelling at his peers and hitting them. A staff member approaches him and says, “You need to calm down. Do you want to take your PRN med?” Lee takes the medication offered by staff. The staff member documents the administration in Lee’s record and notes the outcome (continued to argue with his peers, increased aggression and emergency manual restraint).

Chemical restraint

The 245D service provider should be cautious about unintentional use of chemical restraint. As defined in Minn. Stat. §245D.02, subd. 3b, chemical restraint means the administration of a drug or medication to control the person’s behavior or restrict the person’s freedom of movement, and it is not a standard treatment or dosage for the person’s medical or psychological condition. In the inappropriate use example #2, staff gave the medication to control Lee’s behavior, but the symptoms he displayed were not listed in his treatment protocols within his medication administration record. This is an example of chemical restraint.

If there are any discrepancies or confusion between the prescription guidelines and the situations in which staff administer a medication, the support team should consult the licensed practitioner quickly for clarification and guidance. Keep in mind that the APA – Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) typically does not list behaviors such as hitting or running away as symptoms, so the team should work with the licensed practitioner to outline prescription guidelines that are consistent with best practices. If symptom terms such as “anxiety” or “aggression” are part of the prescription guidelines, the team and the licensed practitioner should work together to develop observable and measurable definitions for those terms that are person-specific. The team should give special attention to behaviors that might indicate the need for a medication before a situation escalates to aggression or self-injury.

Lack of clarity and precision in the prescription guidelines might result in additional reporting requirements. The 245D service provider should keep in mind the reporting requirements under Minn. R. 9544.0110: “License holders must use the Behavioral Intervention Report Form to report the use of PRN medication to intervene in a behavioral situation. This does not include the use of a psychotropic medication prescribed to treat a medical symptom or a symptom of a mental illness or to treat a child with severe emotional disturbance.”

What to bring to an appointment

Assessment and discovery information and/or other data need to be collected, analyzed and briefly summarized by the 245D service provider before meetings with a licensed practitioner. Licensed practitioners often have 15-minute appointments, so it is important that any team member taking a person to a medical appointment be familiar with the summarized information and be able to present that information to the licensed practitioner in a concise manner.

Benefits of collecting data before appointments

Having data on the person’s current condition is helpful because the licensed practitioner can compare it to future data to determine if there have been reductions in symptoms or changes in the person’s overall quality of life. Often, the licensed practitioner asks for the person’s impressions of the effects of medication at an appointment. Just asking the person or a team member about their impressions may lead to an incomplete or biased response.

The person-centered tools mentioned on Psychotropic Medication Manual – Person-centered tools to support medication management overview can help a team share their impressions with a licensed practitioner in a systematic way. The benefits of collecting accurate and thorough data and other information before appointments might include:

· Better understanding of the nature and extent of the person’s health needs.

· Indication of whether medications are effective.

· Context for support and crisis prevention planning.

· Opportunity for support team members to talk about ideas proactively instead of reactively.

· Increased likelihood of positive health outcomes for the person.

· Decreased risk for toxicity, negative side effects or inappropriate use of medications.

What to bring to appointments

The person and their support team should ask the licensed practitioner what information to bring to appointments. The team might consider bringing:

· List of all current prescribed medications, over-the-counter medications and supplements, as well as the diagnosis or purpose, dose, start date and comments.

· Summarized information from the assessments and discovery tools for person-centered practices.

· Data from the Medication and Treatment Administration Packet (.doc).

· Brief health history since the last appointment.

· Medication history (e.g., past medication trials, previous doses and outcomes, names of previous doctors or clinics).

· Description of the current target symptoms or behaviors.

· Data on the frequency and intensity of current target symptoms or behaviors.

· Notes or data on any observed side effects since the last appointment.

· Any other information that might help determine the desired outcomes for the person.

Optional forms

The following forms include optional tools to help people prepare for appointments.

· Effects on quality of life and person-centered summary, DHS-8479B-ENG.

· Background information and support team observations, DHS-8479A-ENG.

Additional resources

Psychotropic Medication Manual
Psychotropic Medication Manual – Appointments
Psychotropic Medication Manual – Attending appointments