The tables in this section are from Simon RI: Concise Guide to Psychiatry and Law for Clinicians, 3rd ed. Washington, DC, American Psychiatric Publishing, 2001. Copyright 2001 American Psychiatric Publishing, Inc.
Table 1. The Four Ds of a Malpractice ClaimA doctor-patient relationship must be present, creating the following: |
DUTY of care. |
DEVIATION from the standard of care must have occurred. |
DAMAGE to the patient must have occurred. |
The damage must have occurred DIRECTLY as a result of the deviation from the standard of care. |
Table 2. Actions by Therapists That May Create a Doctor-Patient RelationshipGiving advice to prospective patients, friends, and neighbors |
Making psychological interpretations during an independent evaluation |
Writing a prescription or providing sample medications |
Supervising treatment by a nonmedical therapist |
Having a lengthy phone conversation with a prospective patient |
Treating an unseen person by mail |
Giving a prospective patient an appointment |
Telling walk-in prospective patients that they will be seen |
Acting as a substitute therapist |
Providing treatment during an evaluation |
Table 2. Actions by Therapists That May Create a Doctor-Patient RelationshipEnlarge table Table 3. Suggested Guidelines for Termination of Patient Treatment1. | Thoroughly discuss treatment termination with patient. | 2. | Indicate the following in a letter of termination: | b.a. | Fact of discussion of termination | | b.b. | Reason for termination | | b.c. | Termination date | | b.d. | Availability for emergencies only until date of termination | | b.e. | Willingness to provide names of other appropriate therapists | | b.f. | Willingness to provide medical records to subsequent therapist | | b.g. | A statement of the need for additional treatment, if appropriate |
| 3. | Allow the patient reasonable time to find another therapist (length of time depends on availability of other therapists). | 4. | Provide the patient’s records to the new therapist upon proper authorization by the patient. | 5. | If the patient requires further treatment, provide the names of other psychiatrists or refer the patient to a local or state psychiatric society for further assistance. | 6. | If the need for further treatment is recommended, a statement about the potential consequences of not obtaining further treatment should be provided. | 7. | Send the termination letter certified or restricted registered mail, return receipt requested. |
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Table 3. Suggested Guidelines for Termination of Patient TreatmentEnlarge table Table 4. Examples of Statutory Disclosure RequirementsEvidence of child abuse |
Initiation of involuntary hospitalization |
“Duty to warn” endangered third parties or law enforcement agencies |
Commission of a past treasonous act |
Intention to commit a future crime |
Human immunodeficiency virus (HIV) infectiona |
Table 4. Examples of Statutory Disclosure RequirementsEnlarge table Table 5. Informed Consent: Reasonable Information to Be DisclosedAlthough there exists no consistently accepted set of information to be disclosed for any given medical or psychiatric situation, as a rule of thumb, five areas of information are generally provided: |
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1. | Diagnosis: description of the condition or problem | 2. | Treatment: nature and purpose of proposed treatment | 3. | Consequences: risks and benefits of the proposed treatment | 4. | Alternatives: viable alternatives to the proposed treatment, including risks and benefits | 5. | Prognosis: projected outcome with and without treatment |
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Table 5. Informed Consent: Reasonable Information to Be DisclosedEnlarge table Table 6. Indications for Seclusion and RestraintTo prevent clear, imminent harm to the patient or others |
To prevent significant disruption to treatment program or physical surroundings |
To assist in treatment as part of ongoing behavior therapy |
To decrease sensory overstimulationa |
To comply with patient's voluntary reasonable requestb |
Table 7. Contraindications to Seclusion and RestraintFor extremely unstable medical and psychiatric conditionsa |
For patients with delirium or dementia who are unable to tolerate decreased stimulationa |
For overtly suicidal patientsa |
For patients with severe drug reactions, those with overdoses, or those requiring close monitoring of drug dosagesa |
For punishment of the patient or convenience of staff |
Table 7. Contraindications to Seclusion and RestraintEnlarge table Table 8. Demonstration of a Rapid, Competent Suicide Risk AssessmentRisk Factor | Facilitating Suicide | Inhibiting |
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Anxiety | M | |
Loss of pleasure and interest in child | H | |
Depressive turmoil | M | |
Diminished concentration | L | |
Therapeutic alliance | | H |
Family relations | | M |
Hopelessness | L | |
Psychiatric diagnosis | M | |
Prior attempts | O | O |
Current attempt (lethality) | H | |
Specific plan | O | O |
Living situation | | H |
Employment | | L |
Availability of gun | M | |
Suicidal ideation/intent | L (passive) | |
Family history | H | |
Impulsivity | M–H | |
Drug/alcohol | O | |
Depression/postpartum | M | |
Religion | | L–M |
Insomnia | L | |
Other children | | H |
Physical condition | | M |
Cognition/competence | | M–H |
Marital relationship | | M–H |
Table 8. Demonstration of a Rapid, Competent Suicide Risk AssessmentEnlarge table Table 9. Clinical Risk Factors Associated With ViolenceThe stated desire to hurt or kill another |
History of violence |
Alcohol and substance abuse |
Inability to control anger |
Impulsivity (e.g., previous violence toward others or self, reckless driving, unrestrained spending, sexual promiscuity) |
Paranoid ideation, thought insertion or control, fear of harm |
Command hallucinations |
Psychosis |
Personality disorders: antisocial, borderline, and organic personality disorder (explosive type) |
“Soft” neurological signs |
Substance abuse |
Low intelligence |
Table 9. Clinical Risk Factors Associated With ViolenceEnlarge table Table 10. Demonstration of a Rapid, Competent Violence Risk AssessmentRisk Factor | Facilitating Violence | Inhibiting Violence |
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Specific person threatened | O (in hospital) | O |
Past violence | H (stabbed cousin) | |
Accessible victim | H (mother) | |
Therapeutic alliance | | L–M (with staff) |
Psychiatric diagnosis | H | |
Command hallucinations | O (in hospital) | O |
Employment | | L |
Specific plan | O | O |
Treatment response | | H |
Medication compliance | | H (in hospital) |
Structured environment | | H |
Alcohol dependence | H | |
Substance abuse | O | O |
History of impulsivity | H | |
Guns | | L (none at home) |
Compliance with aftercare | H | |
Relationships | M–H (loner) | |
Table 10. Demonstration of a Rapid, Competent Violence Risk AssessmentEnlarge table