As we know, there is currently an intense focus during TJC surveys on compliance with the CMS CoP for Special Medical Records Requirements for Psychiatric Hospitals (B Tags.) During surveys of psychiatric hospitals, there is a session designated for review of a sample of medical records for compliance with the specific requirements listed in B Tags 113 and 116. One area that is frequently found noncompliant is documentation of the mental status exam. Specifically, we see numerous survey findings related to the documentation of intellectual functioning, memory functioning, orientation, insight, and judgement. A common surveyor finding is that the mental status exam does not document how these elements were tested or, said another way, there is no “supporting evidence” for how these elements were assessed.

Many psychiatric hospitals have found it helpful to build prompts and structured questions into the format for their mental status exam to assist practitioners with completion of the required documentation. Toward that end, we are providing some prompts that can be incorporated into the mental status exam to help facilitate documentation of how the examiner arrived at his/her conclusions: (Note: From the sample prompts and questions below, your medical staff should determine which ones they see as most suitable for your patient population.)

Intellectual Functioning

Rate as Average, Below Average, or Above Average

Supporting Evidence:

  • Educational attainment
  • Occupational functioning
  • Fund of general knowledge
  • Ability to engage in abstract thinking

 

Memory Functioning

Rate as Intact or Impaired

Supporting Evidence: Responses to the following questions:

Recent Memory:

  • What is my name?
  • What medications did you take today?
  • What time was your appointment with me today?

Remote Memory:

  • What is your Social Security number?
  • What was the date of your graduation from high school?
  • When and where did you get married?
  • Where were you when President Kennedy was shot? (for patients over 40)

Immediate Memory:

Recall of three words (color, object, animal – e.g., blue, table, horse) after 5 minutes

Instructions: I’m going to ask you to remember three words and I will ask you to repeat them to me in 5 minutes. Please repeat them now after me: blue, table, horse. (5 minutes elapses.) What were those 3 words I asked you to remember?

Orientation

Person, place, date, situation

Supporting Evidence: Responses to the following questions:

  • What is your full name?
  • Where are we right now? (city, state, building)
  • What is the full date today? (date, month, year) and season of the year?
  • How would you describe the situation we are in?

Insight

Rate as Full, Partial, or Limited understanding of illness

Supporting Evidence: Responses to the following questions:

  • What has brought you here today?
  • What do you think is the problem?
  • What do you think is causing your problems?
  • How would you describe your role in this situation?
  • Do you think there is anything that will help you feel better?

Judgement

Rate as Good (able to anticipate outcomes); Adequate (able to use feedback to learn from mistakes); Fair (able to learn from some experiences); Poor (difficulty predicting results of choices)

Supporting Evidence: Responses to the following questions:

  • If you found a stamped, addressed envelope on the street, what would you do with it?
  • If you were in a movie theatre and smelled smoke, what would you do?
  • What would you do if you saw a train coming toward you on the track?

Hopefully, these prompts will make it easier and more efficient for the medical staff to document their mental status exams in a way that meets regulatory requirments. As with any type of clinical documentation, this takes teamwork between the medical staff and the PI Department that audits the records. This is a worthwhile effort nowadays since lack of compliance can cause a Condition level finding and a Follow-up Medicare Deficiency Survey within 45 days; something everyone wants to avoid.


Changes to the Behavioral Health Manual Coming in 2018