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Mental health professionals are too often pressured by time and money constraints to do what they consider a thorough job. The American Academy of Child Psychiatry in 1997 appointed a Task Force on Psychiatrists' Signatures, chaired by Dr. Alan Axelson, which offered recommendations on what a psychiatrist's signature should mean, and when it should be given.

Also on this page are guidelines on the prescribing of medicine for children.

We provide these excerpts so you can have knowledge to be a better parent and consumer of mental health services for your child, if you should need it.

Task Force on Psychiatrists' Signatures

Policy Statement

The Assembly was mindful of the often erratically changing practice climate of the last several years, and of the strains that these changing conditions place on psychiatrists' ability to practice in the best interests of patients and in professionally sound ways. Previously unforeseen clinical, financial and administrative relationships among and between psychiatrists, patients, and administrative and business entities have developed, and continue to evolve in a dizzying way.

1.0 General Principles

In signing a document, a psychiatrist assumes a number of legal and ethical responsibilities associated with that document. Signing documents therefore, should be done thoughtfully and in accordance with legal and ethical principles.

1.1.0 Role Implications

Unless otherwise specified, the signature of a psychiatrist on a clinical document implies that he or she has prepared the document personally, has had personal contact with the patient, and takes responsibility for the content of the document.

Psychiatrists may endorse documents ethically in other situations, for example, when they are functioning in adjunct roles. Appropriate other roles may include administrative or clinical supervisor; treatment team member and collaborating psychiatrist or consultant (Appelbaum, 1991). The psychiatrist's role should be explained either in the body of the document or near the signature. When the psychiatrist is providing supervision, the supervisee's name and role should also appear in the document (California Psychiatric Association, 1995a, 1995b). The same procedures should be followed in collaborating relationships.

1.2.0 Use of Colleagues' Names

A colleague's name on a document may imply co-authorship or shared responsibility for the document. This principle may apply to the use of colleagues' names in a description of an informal consultation concerning a patient's treatment. Colleagues' names, therefore, should be included in documents only with their permission.

1.3.0 Use of Dates

A date is a component of the authentication of a document. A date near a signature ordinarily indicates when the document was signed. If the document is a summary of an evaluation performed on another date, a statement should be made to that effect.

The date on a prescription order must coincide with the date the order was written. It is fraudulent and unethical to post-date or otherwise incorrectly date a prescription, and those doing so may be subject to prosecution by the Drug Enforcement Agency. For Schedule II substances, including stimulants, it is also unlawful to include a refill order in a prescription.

1.4.0 on-Call Responsibilities

Physicians frequently provide coverage for medical colleagues who are not available. The on-call coverage relationship should be pre-established in an oral or written formal agreement. Afterward, it is appropriate for a covering psychiatrist to use his or her signature or telephone authorization to manage treatment prescribed by the patient's psychiatrist.

2.1.0 Disability Documents

A psychiatrist's signature on a document to determine eligibility for disability or other benefits indicates that the psychiatrist has objectively assessed the medical condition of the patient, and has not based the determination solely on a patient's request, a family need, or other social factors.

2.2.0 Forensics Documents

In forensic evaluations, such as those to determine custody or responsibility for criminal behavior, the psychiatrist's signature indicates that he or she has evaluated the patient and accurately answered the questions asked. The psychiatrist's role as an agent of the court should be indicated in the document so that this role is not confused with the usual psychiatrist-patient relationship.

2.3.0 Treatment Plans

The signature of a psychiatrist on a treatment plan does not necessarily signify that he or she has examined the patient, but it does indicate that the psychiatrist has reviewed written or verbal clinical material sufficient to support the diagnosis and treatment plan. A psychiatrist may sign a treatment plan in this manner as part of his or her role as attending psychiatrist, treatment team leader, treatment team member, supervisor, or consultant. The role should be indicated with the signature or in appropriate administrative policies (American Psychiatric Association, 1989).

Although a treatment plan may be based on the assessment of others, by signing, the psychiatrist accepts responsibility for the treatment plan consistent with his or her specified role. Therefore, psychiatrists should allow for sufficient time for the review and completion of documentation before signing a treatment plan.

2.4.0 Administrative Reviews

Signatures on documents related to quality assurance review, or other administrative review of clinical records indicate that the psychiatrist has executed his or her responsibility as established by the guidelines of the facility. By signing a quality assurance or review document, the psychiatrist is indicating that to the best of his or her knowledge, the guidelines under which he or she is working comply with professional, ethical, and legal standards. When involved in administrative or quality review, therefore, psychiatrists assume considerable responsibility for the quality of the treatment process. The nature of the psychiatrist's involvement should be indicated in the document or in appropriate administrative policies.

A psychiatrist's signature on a prescription is a statement that he or she has seen and evaluated a patient and selected an appropriate medication. An accurate evaluation can be made only when the psychiatrist has spent sufficient time in clinical interviews and evaluation of collateral information or diagnostic testing. Signatures on subsequent prescriptions imply that the psychiatrist is reevaluating the patient's continuing need for the medication at intervals consistent with the patient's condition.

When the prescription is written for a patient who is receiving psychotherapy from a non-physician therapist, the prescribing psychiatrist risks being held legally responsible for not only the medication management but also the treatment being provided by the non-physician therapist.

2.5.1 Prescription Privilege

The prescription of psychotropic medications for the treatment of complex psychiatric illnesses is an intervention to be made only by an appropriately trained psychiatrist. In no case should a psychiatrist prescribe medications

Solely at the direction of a non-psychiatrist, which would enable another clinician to assume a role outside the scope of his or her license.

Signing blank prescriptions is unethical and illegal. There may be situations, such as medication monitoring of a stable patient, where nurse practitioners or physician assistants, operating within their scope of practice, may prescribe under the supervision of psychiatrists.

Psychiatrists in the role of "physician" may use their signatures to support the prescribing activities of resident physicians practicing under a limited license.

2.5.2 Telephone Transmissions of Prescriptions

Telephone contact or facsimile transmission to a pharmacist by a psychiatrist may be substituted for a signed prescription. Delegation of a verbal order for a prescription, however, should be made only to registered nurses or other professionals who are licensed to accept it. In certain jurisdictions a telephone or fax prescription may require authentication with an original signature.

2.6.0 Billing Documents

Psychiatrists' signatures commonly authorize insurance or other billing documents. The psychiatrist's signature indicates responsibility for the integrity of the billing information, including accurate identification of the treatment provider and the nature of the treatment provided (American Psychiatric Association, 1991).

It is illegal and unethical to submit a bill or to have a bill submitted on a psychiatrist's behalf for treatment not provided by that individual. If the bill is for treatment provided by a professional working under a psychiatrist's supervision, the relationship must be specified and the treating professional's degree identified on the bill.

The psychiatrist is responsible for the uses of his or her name and signature on billing documents prepared by administrative support staff. This includes the uses of the psychiatrist's signature stamp. Psychiatrists must be certain that the procedures followed by support staff are ethical, legal, and accurate to the payer's requirements.

2.7.0 Treatment Authorizations

When psychiatrists, by signature or name, request treatment authorization from a managed care company or other agent, an accurate description of the patient's condition and treatment needs should be provided. Using an incorrect diagnosis to gain insurance coverage, or misrepresenting treatment modalities in order to gain authorization is unethical, even when motivated by concern for patients. This principle reflects the Code of Ethics, Principle XVII (American Academy of Child & Adolescent Psychiatry, 1980).

2.8.0 Authorization Reviews

When a psychiatrist, as the agent of a managed care organization, makes a determination regarding the authorization of treatment, his or her signature indicates that he or she has made a medical judgment determining that the treatment meets or does not meet the utilization criteria of the organization. Furthermore, the psychiatrist's signature affirms by implication that the utilization criteria being followed comply with professional, ethical, and legal standards, and that the psychiatrist subscribes to these criteria. This principle applies even when the documents are intended strictly for internal use in the organization.

3.0 Managed Care Contracts

The psychiatrist's signature on a contract with a managed care company or provider network indicates that he or she agrees to abide by the terms of the contract. Reservations regarding terms of the contract should be negotiated, and the contract revised, before signing. Minor disagreements with parts of a contract can be addressed by crossing out offensive clauses or including substitute language, then initialing and dating the area.

4.0 Conclusion

By signing a document, a psychiatrist indicates that he or she understands and is willing to assume a number of important responsibilities associated with that document. The assumption of these responsibilities is part of the value of the services provided by psychiatrists. Psychiatrists must use care, discretion, and integrity when signing documents, to minimize vulnerability to liability, but more important, to preserve the meaning and authority of the psychiatrist's signature for the profession at large.

AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
3615 Wisconsin Avenue, NW Washington, DC 20016-3007
202.966.7300 - FAX 202.966.2891

American Academy of Child & Adolescent Psychiatry

Policy Statement

Prescribing Psychoactive Medications for Children and Adolescent

Adopted by the Council on June 16, 2000

Prescribing psychotropic medications for children and adolescents requires the judgments of a physician, such as a child and adolescent psychiatrist, with training and qualifications in the use of these medications in this age group. Certainly any consideration of such medication in a child or infant below the age of five should be very carefully evaluated by a clinician with special training and experience with this very young age group. Any child or adolescent for whom medication is a consideration requires an evaluation of the psychiatric disorder, including the symptoms, co-morbid conditions, any other medical conditions, family and psychosocial assessment and school record.

Most psychoactive medications prescribed for children under age 12 do not as yet have specific approval by the Federal Drug Administration (FDA); such approval requires research demonstration safety and efficacy. Such research so far lags behind the clinical use of these medications. Efforts to address this deficiency include the development of Research Units of Pediatric Psychopharmacology (RUPP) and recent federal regulations requiring increased studies of medications presented for children and adolescents. Long-term studies are needed to adequately determine the safety and efficacy of psychoactive medications.

In making decisions to prescribe such medications the physician - specifically the child and adolescent psychiatrist - should consider data from studies in adults in treating the target disorder and/or symptomatology, any clinical or anecdotal reports of use in child and adolescent patients, studies conducted outside the United States and the experience of colleagues.

The prescribing of multiple psychotropic medications ("combined treatment"--"polypharmacy") in the pediatric population seems anecdotally on the increase. Little data exists to support advantageous efficacy for drug combinations, used primarily to treat co-morbid conditions. The current clinical " state-of-the-art" supports judicious use of combined medications, keeping such use to clearly justifiable clinical circumstances. ongoing medication management requires the informed consent of the parents or legal guardians and must address benefits vs. risks, side effects and the potential for drug interactions.

It is important to balance the increasing market pressures for efficiency in psychiatric treatment with the need for sufficient time to thoughtfully, and adequately, assess the need for, and the response to medication treatment. Monitoring on going prescribing of psychoactive medications requires sufficient time to assess clinical response, side effects and to answer questions of the child and family.

AACAP opposes the use of brief medication visits (e.g. 15-minute medication checks) as the accepted standard of care by the insurance industry; health plans and managed care companies. The role of psychosocial interventions, including psychotherapy, must be evaluated, and such interventions must be included in the treatment plan.

This site is a supplement, not a substitute, for professional help.

T. J. Glenn, M.D., F.A.P.A., F.A.A.C.A.P.
20450 Huebner Rd. #203
San Antonio TX 78258
E-mail - tglennmd@familymentalhealth.com
Fax - 210-495-5436