Prescribing for patients you haven’t examined

[Animal Mother]

When is this legal/appropriate?

Colleague is on vacation for 2 weeks and patient calls in requesting Effexor refill? How about benzo that they’ve been on for years?

New patient is discharged from the hospital with a 30 day script for an antipsychotic but can’t get into the clinic until day 45. CM calls right before he runs out to ask for a bridge until his appointment. How about if it’s not an antipsychotic but a high dose benzo for catatonia?

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[wolfvgang22]

I generally will renew the medication one time. If the patient no-shows, I won't renew until they see me. I won't prescribe anything outrageous or not supported by discharge papers or evidence.

 

[clausewitz2]

When is this legal/appropriate?

Colleague is on vacation for 2 weeks and patient calls in requesting Effexor refill? How about benzo that they’ve been on for years?

New patient is discharged from the hospital with a 30 day script for an antipsychotic but can’t get into the clinic until day 45. CM calls right before he runs out to ask for a bridge until his appointment. How about if it’s not an antipsychotic but a high dose benzo for catatonia?

Do your colleague's notes and the PDMP (for the benzo if your state does that) suggest that the patient should be running out of these meds during this time frame? If the answer is clearly yes, that's when that script should be up, then I don't see an issue. If they were both filled last week and now they want a refill, that's different and I think you have to ask a lot more questions.

Can the CM provide any documentation from the hospitalization? If the notes actually support catatonia you really ought to be bridging until you examine the patient to figure out how best to taper, just cutting them off has a high risk of causing a relapse. now if they conveniently don't appear for your appointment and want another bridge that is another story. If the neuroleptic is not Seroquel i don't think I'd hesitate and would just document my reasoning about risks of abrupt discontinuation and that I confirmed this was their dose at discharge.

My two cents, anyhow.

 

[VA Hopeful Dr]

If nothing is concerning re: early refills then I'd do 1 month of whatever med it is and have them go ahead and set up an appointment with their usual doctor.

 

[Animal Mother]

Law seems to vary by state. Some states seem to be stricter than others. I found this exemption for examination in California law, which seems to answer my original question:

The licensee was a designated practitioner serving in the absence of the patient’s physician and surgeon or podiatrist, as the case may be, and was in possession of or had utilized the patient’s records and ordered the renewal of a medically indicated prescription for an amount not exceeding the original prescription in strength or amount or for more than one refill.

 

[hamstergang]

If a patient I never met yet was discharged from the hospital with an inadequate supply of meds to make it to my appointment, I tell them to contact the hospital as it's, in my opinion, still that psychiatrist's responsibility. I feel it to be irresponsible to treat someone who has not yet become a patient at my office.

 

[clausewitz2]

If a patient I never met yet was discharged from the hospital with an inadequate supply of meds to make it to my appointment, I tell them to contact the hospital as it's, in my opinion, still that psychiatrist's responsibility. I feel it to be irresponsible to treat someone who has not yet become a patient at my office.

On reflection that is probably the better approach if the patient is new to you. I guess I assumed without good reason that this is a patient known to the clinic somehow and so is not a rando you have no experience treating.

 

[Sushirolls]

Colleague coverage for same medical group its customary to refill with no dose changes, for 30 days. However, there are times you simply refill until they get back from vacation with a message sent to the colleague to further address upon return. On occasion I've done a 90 script for the stable patient on SSRI with the annoying pharmacy by mail companies.

A patient after hospital discharge who doesn't have follow up in 30 days is a discharge planning failure. I don't cover further prescriptions past the original discharge prescription. That runs the risk of establishing a doctor patient relationship. The patient should have had a walk in appointment outlined, or even a Family Medicine appointment schedule to bridge their prescription needs. The risk of what can, and does happen is why go the follow up when all you have to do is call in, or have your CM call in to get you another Rx?

After hours do a 1-2 to day Rx if you must, get the patient in to further evaluate and then more aptly document/justify the Rx and risk benefits. Or you simply say this can wait for the urgent appointment tomorrow, the next day, etc. After hours Rx run the risk of being a new permanent Rx. One way to head this off is pre-document with the patient the possibility to call in for Rx ABC, then if they need to you've already done your documenting leg work in advance.

What was a stable patient calls in midway thru their follow up duration, schedule is packed, don't know when you'll fit them in, best try. Need to get them in to appropriately document and evaluate and justify that Rx. Otherwise bad outcome XYZ happens, "I was never informed of these side effects!" "Dr, why did you give X when patient was later determined to have Y? Why didn't you assess your patient?"

Prescribing for family or friend. Some states forbid it and is a fast to get medical board sanction. Another common pitfall to this is not maintaining a chart for your spouse, friend, child, etc. Medical boards do sanction for failure to appropriately document and maintain a chart. So much easier just to say no across the board for family and friends.