Psychiatry consultation-liaison service

Psychiatry Consultation-Liaison Service
Saint Francis Hospital/Laureate
Resident Objectives:
1. Gain an understanding of the special issues involved in the diagnosis and treatment of
psychiatric illnesses in the medically ill. 2. Improve your understanding of suicide risk assessment, delirium, dementia, somatoform disorders, mood and anxiety disorders and other problems encountered in the med/surg population. 3. Strengthen psychiatric interviewing, diagnostic and presentation skills. 4. Perform a concise, organized case presentation and maintain accurate daily notes that 5. Demonstrate appropriate use of ancillary information, i.e. lab/radiology results, outside informants and past medical records. 6. Gain confidence and skill in managing psychiatric problems in the medically ill, including the use psychotropic medications, psychosocial treatments and effective communication with the attending physicians, nurses and family members.
1. Evaluate new consults and verbally present the case to the supervising psychiatrist in
an organized format. When you present the case, you will be expected to have your Differential Diagnosis and treatment recommendations ready for discussion/approval. (See example.) 2. Follow patients who are being seen by the consult service and make recommendations for management of psychiatric problems while they are hospitalized; including arranging for psychiatric outpatient treatment, if indicated. You will be expected to know the current status of each patient you are following. (E.g. “Mrs. Jones is the 68 year old female who is s/p CABG that we diagnosed with delirium. She was agitated yesterday and required 2mg of prn Haldol. On MSE she was …… I would like to start routine Risperdal 1mg q HS.”) 3. Maintain an updated patient list for the consult service. 4. Document initial consult in the electronic medical record. 5. Communicate our recommendations to the treating physician with a phone call following the consult, and note this communication in your documentation. 6. Write daily progress notes (using SOAP format) on patients you are following, currently being documented in the paper chart. 7. Demonstrate knowledge of the conditions we are seeing and treatments we are recommending through active reading and discussion in morning report. (E.g. “Last night I read about secondary mania and learned that mania can result from multiple sclerosis…”) Resident C-L Consult Rotation Orientation.doc4/01/05 Schedule:
You are assigned to the consult service at SFH M-F, 8:00 am – 5:00 pm. Your pager must be on during these times. You will be excused for Wednesday afernoon lectures and for your clinic half-day. Should you be called to do a consult during these times, you should ask if the consult needs to be done urgently, in which case you should tell the caller to page the Laureate psychiatrist on-call to see the patient. In most cases, the consult will not be urgent and you can plan to see them the following day. In both cases, please record the name and room number of the patient so that we can ensure that the consult was done. The consult team meets for morning report in the Redbud conference room or in the Residents’ Lounge. You should have printed a patient list for each member of the consult team and be prepared to report on the status of the patients we are following at that time, including knowledge of current medications and disposition plans. Tips:
1. Remember that the consultation service has two customers: the referring physician
and the patient. The consultation service is Psychiatry’s face to Saint Francis Hospital
and to other physicians.

2. Begin your day by using computer to determine which patients have been discharged
and which ones remain hospitalized and print the lists.
3. Set your priorities. New consults generally take first priority.
4. Know the consult question! Is this a request for transfer to Laureate?
5. It is best to speak with the referring physician before and after the consultation.
6. All consultations must have a written order on the chart from the referring physician.
This is a reimbursement issue. Please check the chart for this order. If it is not there,
please inform the physician verbally and in writing on the purple communication sheet in
the front of the chart.
7. Carefully review all information on Ulticare and in the chart, as well as information
from nursing staff and family when necessary. In the long run, this will make your job
easier and you we will provide a better consultation.
8. After obtaining the consult request and reviewing the chart, come up with a
differential diagnosis and review the DSM-IV criteria for each so you know what
questions to ask when interviewing the patient and/or family member. *Believe me, this
will make your job easier! Much time is wasted interviewing a delirious patient who is
providing inaccurate history that could have been more accurately and efficiently gleaned
from other sources.
Resident C-L Consult Rotation Orientation.doc4/01/05 9. In your write up and presentation, demonstrate evidence (patient’s report of symptoms or others observations of symptoms) supporting or ruling out disorders you are considering in your differential. New diagnoses to consider in your differential are likely to emerge as you interview the patient and others. Do your best to rule these in or out. 10. Make specific recommendations and provide contingency plans ‰ Further diagnostic testing ‰ Psychopharmacologic treatment-start dose, schedule ‰ Utilization of ancillary services – Social Work, Physical Therapy, Occupational Therapy, CD Counselor, Pastoral Counseling, Patient Representative, Psychiatric Nursing (can make recommendations to floor nurses for managing difficult patients). ‰ What kind of follow-up will be necessary and who will do it. 11. Remember that we are the consultants, not the patient’s doctor. The referring physician can take or leave or recommendations; we should not be critical of the referring physician to the patient. Also realize that the referring physician may not read your note; therefore you should always page the physician to briefly inform him/her of your diagnosis and treatment recommendations. 12. Read up on the psychiatric presentation/condition and medical condition of each patient you are assigned. Plan to share this information with the consult team. This approach will markedly increase your learning. 13. Ask questions! Remember, the only bad question is the one that wasn’t asked. Finally, C-L psychiatry is fun! The clinical problems we deal with are different than those in general psychiatry clinics inpatient psychiatry services. While on C-L psychiatry, you have the opportunity to work closely with physicians of other specialties and understand the impact psychiatric conditions have on medical illnesses, and the impact medical illnesses have on psychiatric conditions. Resident C-L Consult Rotation Orientation.doc4/01/05



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