How can I see a patient in 15 minutes and provide
quality care?
How to Maximize your 15-minute Medication Review
Dr. Kelly Gardiner PhD, PMHNP, CNS, BC
This chapter helps you:
-- Make the most of your time with the patient
--Make a fast connection with the patient
--Do thorough documentation, so that you know what you are treating,
from visit to visit
It may seem as if there is a lot in this chapter, that is because it also
provides some tips and tricks, for situations you will encounter in your
career. Yes, you can do a thorough medication review in 15-minutes
using the techniques outlined in this chapter. Rest assured, if you are
doing 15-minute visits, you likely work at a Community Mental Health
Clinic and can see the person more often. If you get 30 minutes per
visit, it may actually be 15 minutes if you have to set up your own
follow-up appointments or take payment yourself.
I recommend seeing the patient every 4 weeks until stable then,
every 8-12 weeks thereafter. (Remember that it takes about a week for
any medications to get into the system, another few weeks for the
person to know if the medication is working, or not. If you see the
person too soon, then you may try to add medications resulting in
polypharmacy, which we want to avoid. Usually, these people have a
Therapist and/or Case Manager who can oversee care, in conjunction
with your visits.)
Note that I primarily work at inner-city Community Mental Health
agencies therefore, not all of the following would apply to your practice
setting and clientele. These people have experienced extreme trauma,
poverty, illiteracy, and many are homeless.
MAKE The PERSON FEEL SPECIAL thus Creating a Connection
“That storm is awful out there, I am so happy that you made it in
today.”
“It is good to see you. I was worried because you haven’t been here in
several months. Please call the office if you cannot keep your
appointments so that I know you are ok. If you ever cannot make it in, I
will make sure that you don’t run out of your medications.”
“You look really nice today, are you going somewhere special?”
**Usually everyone gets a compliment, even if the person has terrible
body odor and dirty clothing, I find some way, to say something nice
because it means more than you think. After a while, you begin to truly
see the beauty in all your patients, and not keep it to yourself.
Here is a very wise quote from Audrey Hepburn:
For beautiful eyes, look for the good in others; for
beautiful lips, speak only words of kindness; and for
poise, walk with the knowledge that you are never
alone.
IT’S NOT REALLY SMALL TALK
Sometimes, I ask about the person’s pets, children, or other topics of
interest. This way I get to watch for the following:
--asymmetry in the face (stroke, oral dyskinesia, rotten teeth, etc.)
--psychomotor restlessness (can be a sign of crack withdrawal, but also
may be a side effect of older psychiatric medications called Akathisia or
Tardive Dyskinesia)
--evidence of other side effects from medications (rocking back and
forth, dry mouth, drooling)
--affect
--laughs/smiles appropriately
--follows the train of thought or has delayed response time
--clear speech or dysarthria (dental care, stroke, Tardive Dyskinesia???)
--I observe the person walking to my office (“no arm swing” may
indicate some parkinsonism and other abnormal gaits may indicate
cerebellar issues which call for a neurological evaluation).
-- Is the person up to date on current events?
--What is the body language between people who come with the
person to the appointment?
IF a caregiver comes with the person to the
appointment, I always spend a few minutes, asking that
person how he or she is doing.
I joke with some male patients, “Please forgive me but,
your sister and I need to have some “girl talk” before my
visit with you begins.”
Some loved ones have little money and work part-time to provide
caregiving services due to the severity of the mental illness. (Is this
person getting chore provider payment from Medicaid? If not, you can
facilitate this by completing the form, having the person take it to the
DHS office, and the process will begin. The following website is for
Michigan but other states have the same program with different
names: https://www.michigan.gov/documents/dhs/DHS-PUB0815_198252_7.pdf ) If help is needed due to a medical problem, I
print out the form for the caregiver to take to the Primary Care
Provider, to fill out (sometimes I fill it out for him or her). If the
caregiver is also disabled, I let them know that someone from the
Department of Human Services will send someone to the home to help
with appointments, medical care, and so forth. OR, a family member,
who is not disabled, can get the money instead, for providing the
services.
BODY ODOR/POOR HYGIENE
For these people, at the end of the visit, I usually say, “Jim, next time I
see you, I want you to give yourself a beauty treatment.” (patient
usually laughs especially if male) This way the person isn’t too
offended. I then stress the importance of self-care. Of course, I talk to
the Case Manager, if there is one, to try to help the person in case he or
she might need laundry detergent, new clothing from the Goodwill,
help with buying a shaver, or whatever else is needed for hygiene.
Sometimes, I find out that the person is living in various abandoned
homes without running water. This requires an emergency Case
Management referral if the person doesn’t have one so that adequate
housing can be secured.
Females might need some nice smelling soap, or a trip to the beauty
school for a low-cost facial or hair care, with help from the Case
Manager, Group Home staff, or whoever is there to lend support.
(These people are not lazy but the mental illness often affects the
frontal lobe of the brain which, results in a lack of motivation and an
inability to follow through on tasks. See Frontal Lobe: Unmotivated
Type chapter) Sometimes lack of hot water and money for hygiene
supplies is the problem. It is your job to figure it out THEN refer the
person to a Case Manager who can help coordinate medical care, get
housing, and so forth. Some Insurance Companies have Case Managers
available upon request.
How can I do a good assessment, typing on a computer,
while the person is talking to me?
I have the patient sit next to me instead of in front of my desk (if able
to do so in a small office). I face one way toward my screen, they sit in
a chair, at the side of my desk, facing me (so they don’t see the
computer screen). I usually have lotions and hand sanitizer on the table
for him or her to use while I type or look over information from past
visits. (i.e. peppermint lotion and I tell them if they are really sad or
having sinus congestion, try this lotion but don’t get it in your eyes,
hard to be sad when you smell like peppermint candy OR lavender for
calming if nervous or upset… you get the idea). THEN, you can watch to
see if the person puts it all over his or her body, underarms, etc., or
mixes scents altogether. Patients feel more engaged sitting this way so
that you are more personal, have better eye contact, and more like a
“visit with someone” as opposed to an “appointment”.
Remember to stick to essential oil lotions (lavender, lemon, cinnamon,
peppermint which are common scents in the world) and food-type
lotions only (chocolate, mango, watermelon). After a while, patients
will be looking forward to trying the various lotions, when they arrive.
One patient nicknamed me, “the lotion lady”.
Some people get offended by perfume odors, and I personally get
asthma from various “plug-ins”, fabric softeners, and citronella oils.
The use of common scents in the world or kitchen which cuts down on
the risk of a complaint. These are also gender-neutral.
Once one person complains to management, someone puts out a
notice that no more scents are allowed. This will end your therapeutic
aromatherapy patient education. Yet, the office is not perfume-free
(which always puzzles me) reeks of cleaning solutions that make you
feel ill, dirty vents with an inch of dust in them, etc. Sticking to food or
common real scents can help lower the risk of being told not to do
this.
This process can keep the person occupied while you review the chart.
I usually set up my note ahead of time but sometimes need to review a
few things first or fill in some checkboxes.
SAFETY: First a few words about a very important topic.
You should have the easiest access to the exit route in case you need to
escape your office.
You should be trained in “physical management and non-violent crisis
intervention” and, review it in your mind regularly (or have a friend sit
where the patient sits and try to choke you, grab your arm, stab you
with a pen, etc. and work on escape and de-escalation plans). Keep
dangerous potential weapons away from patients (staplers, scissors, 3hole punch devices, heavy objects such as lamps/vases, etc.).
Make sure that there is a panic button on or near your desk and that it
works. (Send a note to administration if these aren’t present in your
office because others might not be as safety conscious as you are and
could end up getting harmed.) Does the staff know what to do when
the panic alarm is pressed by a staff member? You might also suggest
that your agency have professional training for active shooters in or
around your building (one office I worked at had everyone line up in
one unsecured area, like sitting ducks, the training was NOT done by a
law enforcement professional!!!) I personally review in my mind
strategies, in case an active shooter, enters my place of work.
Make sure that your door doesn’t lock when closed so that others can
enter easily if needed. Don’t let the patient block your exit, arrange the
furniture accordingly.
Years ago, staff always listened for people raising voices, yelling,
furniture moving, etc. but nowadays, people are laughing loudly, not
paying attention to what is going on, and so forth. Cleaning people in
the building are not trained in watching for potential dangers and may
even be listening to music via earbuds, and staff (not with patients)
keep office doors closed. I cannot tell you how many times I ran out of
my office to help someone, only to find out that staff was joking around
or just talking loudly. Sometimes, the lobby has screaming or gunshots
going on from a movie on the TV. ALL staff needs to be cognizant of
others around them but, you really need to protect yourself and,
know how to help others, in a crisis situation.
Starting Your Note (why is the person here?)
Your note should start with a brief summary of the last visit i.e. what
was the plan from the last visit or what symptoms were listed at that
visit so you can compare them. I cut and paste from the last note and
start it as follows:
EXAMPLE #1 “LAST SEEN 8/19/2021: Pt. reports crying spells 5x a week
without triggers, sleeping 2 hours a night every 2-3 weeks that last for
3-4 days with increased energy and feeling good, angry outbursts 2x a
week with yelling at people, yelled at the boss and got fired after going
2 days without sleep, no SI/HI, no gun access, hearing voices when not
sleeping for 2 days that are mumbled…..” PLAN: “take your Seroquel XR
300mg four hours before bedtime (set your phone to remind you while
here with me in the office), get an appointment with your dentist for a
cleaning, call the office if any problems with medication, start smoking
patch when ready (remember you can smoke the first day only), keep
up the good work!”
I then write in large letters (so the reader isn’t confused): “TODAY: Pt is
taking Seroquel nightly at 7 pm falls asleep at 11 pm, gets up at 7 am,
saw a dentist for a cleaning a week ago, not ready to start the “quit
smoking patches but has them at home and remembers how to use
them”, no SE to medication. Current symptoms include: ….(I compare
them with the symptoms from the last visit and usually they are much
better).
EXAMPLE #2
“LAST SEEN 8/19/2021: Patient reported the following symptoms:
crying spells 2x a day due to death of best friend 6 months ago,
irritability, sadness, no SI/HI, no access to guns, anhedonia (used to
bowl twice a week), no A, V, T, O hallucinations, eating once a day due
to poor appetite, and thinking too much about bad things. PLAN: “take
Vitamin D3 2000 IU daily to get rid of muscle spasms and help your
mood and immune system, take the B complex for your nervous system
and brain (helps hair skin, and nails, too) take the Lexapro
(escitalopram) 10mg once a day, remember that it will take about a
week to start feeling better so be patient, call the office if any problems
with medication or symptoms get worse, I’ll see you back in 4 weeks,
that will give us time to see if you are feeling better by then.”
At the next visit fill in symptoms and plan from the first visit then
write in big letters, “TODAY”: (review checklist and compare symptoms
for relief or not) then check to see if the plan was followed (maybe
vitamins not covered, didn’t quit smoking or smoking with the patch
on—dangerous, etc.)
THE CHECKLIST
I use a quantitative tool that I developed (available for your use in this
chapter) for several reasons:
--you can get the patient-focused (as well as yourself)
--you can track symptoms from visit to visit (patients may say, “I don’t
think the medication is working” then they list about 3 symptoms from
the checklist. I go back and read all 10 of the symptoms the person
reported at the first visit and the person usually says, “Gee, I guess it is
working after all.” Then, I kindly remind the person that feeling better
occurs so slowly that you often forget how awful you felt in the past.
Then, you adjust medications and dosing according to symptoms.
What about professional Depression/Anxiety and other scales given
to the patient?:
I have tried using various official questionnaires however, I find that if I
give out the Depression form to the patient to complete, and the
person is depressed, I will need to put all of the positive answers into
my note so that I know what I am treating, visit to visit (as opposed to
just a score). A score doesn’t tell me what symptoms I am treating.
This takes too much time and further inquiry is missing.
By using the following checklist, the person reads to me, symptoms and
I can get more information if needed i.e. crying spells (I ask how many
times a week/day/month, what makes you cry, if for no reason it might
be pseudobulbar affect, if normal grief….). You get the idea.
Remember, you cannot bill for non-face-to-face time. When you are
booked every 15-20 minutes, you don’t have time to read the scales
that patients completed in the lobby, record positive answers in your
note, and so forth.
I DO use certain checklists when needed such as the one for
pseudobulbar affect (PBA), trichotillomania, kleptomania, and
ADD/ADHD, so that I can have it in the chart, to justify diagnosis and
treatment. Insurance companies usually want the PBA form to cover
the medication available for this condition. If prescribing stimulants
and/or giving an ADD/ADHD diagnosis, you should have a scale to back
up and confirm your diagnosis. I try to get psychological testing done
but usually, there is no one to do it and I don’t have time to call
Medicaid to find out who I can refer the person to, for testing. If I
suspect ADHD plus one of the Bipolar conditions, psychiatric testing is
needed by a psychologist. If the person is responsible, you can ask him
or her to call the insurance company and get a referral for psychological
testing (be sure to give him or her an RX of what you want tested i.e.
ADD/ADHD, Definitive diagnosis Bipolar vs ADHD, etc. with
recommendations.)
NOW THE CHECKLIST
(a CLEAN copy is at the end of this chapter, feel free to adapt it to
your needs, the following has additional information next to it)
Please read the symptoms that you have had, for the past month, out
loud. Or, I can read the checklist to you. I type these in the note while
the person is talking under the first section of the note i.e. why the
person is here. (I usually ask, if the person has any problems reading
and offer to read the list to them, I make a remark about not being able
to read without my glasses very well either, as not to embarrass
someone who cannot read). Some patients are ok telling you that they
cannot read. (If that is the case, put it in the chart in a place where
others know about it, too!!!) Here I am explaining follow-up questions
for each section.
Severe changes in mood (happy, silly, irritable, angry, agitated,
aggressive, or violent) if violent/aggressive find out behavior, how
often, triggers, and so forth, to clarify. If angry or violent outbursts, I
request a neurological evaluation to check for temporal lobe issues
especially if there is a history of brain injury from a stroke, neurological
condition, or head injury of some sort. “Aggressive? What do you mean
by aggression? Do you ever hit people or punch walls? When was the
last time this happened? How often does it occur? What age did this
start?”
Increase in energy with the ability to go without sleep for several days
Ask: How often does this occur in a month, last time it happened, how
does the person feel when this happens i.e., awful or happy which can
hint at bipolar I or II. Find out if the person was on drugs/alcohol at the
time, which would change your diagnosis.
Not sleeping enough Always record bedtime, wake-up time, and
whether or not naps are taken. If getting up a lot during the night, is it
because of need to urinate (men with prostate problems, medicationinduced i.e. taking a water pill at bedtime by mistake? Sleep apnea
symptoms?) Send a note to the PCP about your concerns for further
medical workups/care.
I find a lot of patients say they cannot sleep but it is because he or she
wants to go to bed at 11 pm but sleeps in until 10 am the day before
HENCE, you will not be sleepy until 2 am the next night so don’t expect
to go to bed at 10 pm. Some parents also indicate that he or she gets
up at 6 am to get the kids off to school but upon further questioning,
they go back to bed for a 2-hour nap until 10 am and expect to get
sleepy at 10 or 11 pm that night which won’t happen, see sleep chapter
for details and how to help and educate these people.
Sleeping too much (same as above but find out what the person does
during the daytime i.e., bored, ill, or not sleeping as much as they think)
Increase in talking
Distractibility, poor concentration, and focus (Any hx of ADD/ADHD in
childhood?)
High-risk behavior (drugs, sex, alcohol, reckless driving….) find out
about birth control here and safe sex practices
Depressed mood
Persistent sadness (always sad)
Crying spells how often, triggers, (if for no reason, it might be
pseudobulbar affect). Did the person have a TBI or stroke in the past?
Thoughts of death or suicide (access to guns/weapons, plan, intent, ask
what keeps the person from ending his or her life, may need to petition
the person if the plan, means, and/or intent are present.) If of harm to
someone else, you have a “duty to warn” which should be done with 2
staff members present but not the patient. This would also require a
petition for a commitment evaluation in the ER. You may have to
request that the person remove any weapons from the home to be on
the safe side due to depression and/or a suicide history. ALWAYS make
sure that weapons are stored appropriately i.e. in a locked area so that
others in the home (teens) cannot access them.
Loss of enjoyment in favorite activities I usually ask what the person
stopped doing that used to be fun and reasons for such (maybe
financial or time-related as opposed to psych issues). When the person
resumes formerly forgotten activities and they re-emerge, that is a
good sign.
Complaints of physical illnesses (legit or not?)
Low energy
Jumping from topic to topic
Major change in eating (too little or too much)
Feeling guilty all the time (see Angels on the Planet chapter)
Overly sensitive i.e., hurt feelings
Thinking too much about bad things
Picking or harming your skin or excessive tattoos/piercings (see
excessive tattoos/piercings/skin picking chapter) be sure to document
what you see on the skin, watch for pox marks on the skin and ask
about them, last time it occurred, then give the person the patient
handout on this topic and explain it to him or her)
Panic Attacks Ask how often, what are the symptoms, triggers, how
long does it last, does it happen during sleep and wake the person up)
see “mimickers of anxiety/panic attacks” chapter
THEN I ASK about PSYCHOSIS? *** Find out if hallucinations occur
when the person is half asleep, waking up, or falling asleep as this could
be hypnagogic or other phenomena of sleep as opposed to a psychosis.
Is it a bug on the floor that turns out to be a spot of dirt which could be
Charles Bonnet Syndrome instead of psychosis. **See mimickers of
psychosis chapter***
--Do you ever see things other people don’t? (visual)) If it is a loved
one who died and comforting, I usually don’t count this as psychosis
since it is so common and doesn’t bother the person.
--Do you ever hear things other people do not? (auditory) IF hearing
voices, ask if they are mean/happy/both, is it an intrusive thought or
hearing them as if in the room, how often, triggers that increase them,
ways to stop them? Hearing someone call your name is normal!!!
Some people may still hear voices while on antipsychotic medications
and it doesn’t bother them. I ask the person to promise to tell me if the
voices ever get mean or bothersome so we can take care of it. There is
no need to increase the antipsychotic medication if the person is ok
with the condition. See Coping with Voices chapter for patient
handouts.
--Do you ever feel things touching you? (tactile)
--Do you smell things other people do not? (olfactory) A neurological
referral is indicated here to rule out seizures and other pathology.
--Do you ever wet the bed or lose control of your bowel or bladder
while awake? This is a very important question because psychosis
could be seizures or other brain pathology needing a neurological
referral.
I usually ask for a neuro referral due to psychosis. This way we get an
MRI and EEG to assess mimickers of psychosis such as tumors or
seizures. Make sure rationale is on the referral such as, visual
hallucinations, so the focus can be on various parts of the brain
regulating these areas. An ENT evaluation might be needed if hearing
issues. Olfactory is particularly worrisome where neurological
mimickers are concerned.
TRAUMA: If doing an initial assessment only NOT the 15-minute med
review, I make sure I have a section listing traumas. I say, “I don’t want
to upset you or have you go into detail but I need to get a list of
traumas you have had.” When you were a child or younger, were you
ever molested, or did anything else bad happen to you? How about
when you were in your 20’s, 30’s, etc. This really helps me understand
the person, make a good diagnosis, and make sure that therapy is there
for support. You can ask about post-traumatic stress disorder (PTSD)
symptoms here as well i.e., if they saw someone murdered do they still
get flashbacks, nightmares, think about it a lot, have hypervigilance and
so forth? If they were molested, I always ask if the person was put in jail
(sadly a lot of people were not believed as children). Again, I don’t
want anyone going into detail, just the facts and showing empathy, this
needs to be recorded for therapy recommendations, others to be
aware that this is a person who experienced trauma.
PROBLEMS YOU MAY ENCOUNTER DURING YOUR MEDICATION
REVIEWS (for newer people in the field, tips and tricks for dealing with
these situations)
Covert Substance abuse or other issues you find out about: I often use
a maternal approach (you can use a brotherly or fatherly approach if
male) with clients of various ages i.e. when I ask, “Are you using any
drugs, alcohol, cannabis/weed? If the answer is “no” and I smell skunk
weed, I give the person a motherly look and say, “Come on, weed?”
and the person cracks (we both laugh a bit). Then rationale for a
trusting relationship is provided. “Jim, how often do you use? You
cannot come here high anymore because we don’t have much time
together and I want you to be clean when you visit me. What do you
get out of using…..do you feel anxious all of the time……?” You get the
idea.
Rude person to you: (one-liners that usually work)
--“I want to help you but, you seem really irritable, are you angry with
me?”
--“What can I do to help you?”
--“Is anyone harming you at home? Are you safe where you live?” (yes,
they are surprised by this, I even ask the meanest toughest looking
people this question and they then see me as a concerned person—
sometimes)
--“I’m going to give you a few minutes to calm down because I want to
help you, you seem so upset but sad too.” (The word sad often has
people bursting into tears then the maternal loving and caring
approach ensues).
Drug Seeker Tricks: people who want controlled substances are always
in a hurry and want to rush you, i.e. “I have to pick the kids up from
school” or some other urgent matter. Do not let anyone rush you.
If the person remains disrespectful, (nasty remarks to assessment
questions, etc.) I tell the person that I really want to help but he or she
will have to return when able to treat me with respect, get up and open
the door for him or her to leave. **Try to get suicide/homicidal
ideations prior to this in case you need a commitment, weapons in the
home, all people and situations are different so use your judgment,
these are approaches that worked well for me**
I had one patient that I told to leave, threatening to kill me as she
walked out of the clinic. The front office staff was concerned when she
came back the next week for another appointment with me. When she
came to the office, I used my usual connection techniques and she
treated me with respect such as “yes ma’am” much to my surprise.
Some people respond well to someone who will not be disrespected.
Do not engage people who try to debate or argue with you. “I’m not
here to argue with you or engage in a debate with you. You can ask at
the front desk to see someone else who might be a better match for
you.”
Always get the person set up with someone else. “Let’s get you in
with another provider who might be a better match for you.”
TYPING
If you don’t know how to type, I suggest you take a class through adult
education or another venue. This will save a ton of time. I keep
letterhead on my desk and often type a fast letter to a medical
provider, requesting a neurological evaluation or other concerns and
just print it out without having to leave the room. Keep a copy in the
chart of the letter and document that it was sent in your current note. I
cut and paste the letter in the body of my note under the PLAN section.
This way it isn’t lost in the abyss of uploaded documents no one looks
at. I also add my concerns to the diagnosis page so it is there every visit
and others can see it as well i.e., 2/10/2021 letter sent to PCP re
request for a sleep study to r/o apnea.
Here is the form itself for you to use, feel free to add to it as you
deem appropriate
Please read the symptoms that you have had, for the past few
months, out loud.
Severe changes in mood (happy, silly, irritable, angry, agitated, violent)
Increase in energy with the ability to go without sleep for several days
Sleeping too little
Sleeping too much
Panic Attacks
Increase in talking
Distractibility and poor concentration and focus
High-risk behavior (drugs, sex, alcohol, reckless driving….)
Depressed mood
Persistent sadness
Crying spells (how often?)
Thoughts of death or suicide
Thoughts of harming others
Loss of enjoyment in favorite activities
Complaints of physical illnesses
Low energy
Jumping from topic to topic
Major change in eating (too little or too much)
Feeling guilty all the time
Overly sensitive i.e. hurt feelings
Thinking too much about bad things
Picking or harming your skin
Access to guns/weapons
**Now ask the psychosis questions as above and re-ask the
suicidal/homicidal questions if the person skipped over that section.
Remember to document auditory, tactile olfactory, and visual, plus
incontinence/bedwetting and birth control.***
It makes me happy when a patient, who had almost
everything on the checklist at our first visit together,
returns and hands me the list back with a smile saying,
“none of these now, I’m fine”.
Here is a second scale that I use when I suspect the
diagnosis is Bipolar Depression (not anxiety with
depression or PTSD):
Do you have problems relaxing and just feeling calm?
Do you ever get about 4 hours of sleep, yet you can still function, even though
you feel exhausted and tired?
Do little things bother you or, do you get angrier than you should, over silly
things?
Have you been on a bunch of antidepressants, that work for a while, and then
stop working?
If you get 8 hours of sleep, do you still feel tired and irritable or depressed?
No matter what medications you take, do you still feel depressed, irritable, and
tired?
Of course, you can go through the DSM criteria and find scales yourself, these are
just some of the main questions that I ask. Then, BINGO the person realizes that
you “get” him or her and know how they are feeling.
Chances are that the person has Bipolar II.
You CAN do a 15-minute visit if you cut and paste your
list of symptoms and your plan from the last visit into
your note.
Then you can follow up on the plan from the last visit
(success or lack thereof), compare symptoms between
visits via the checklist, and make changes accordingly.
Book the person every 4 weeks until stable then, every 8
weeks.
Using the information in this chapter allows you to be
an evidence-based diagnostician and prescriber.