In most situations, a separate, signed “Medication Consent” document is no longer required. Consents for medications can be captured/documented in the prescriber’s progress note. These recommendations are specific to consents for medications and not general informed consent/consent to treat.
To review the CalMHSA protocol and memo by Manatt, click here. You can also find the vetted templates and suggested use cases.
To document in the psych medical note template that you obtained the medication consent, you can choose to use your own consent template, or there is a vetted CalMHSA’s medication consent under Favorite Key Phrases. (Click here to learn how to make your own or use Key Phrases).
- Begin writing your note as normal.
- Click to place your curser in the desired textbox in Psych/Medical Note.
- Click the Select Action icon in the upper right-hand corner.
- Select Favorite Phrases from the menu.
- A pop-up will appear named Use Key Phrases on the left side of your screen. Click the Agency tab.
- Click the Category drop-down.
- Select CalMHSA Key Phrases.
- Click the Use hyperlink under the appropriate phrase to insert into your note. (see table below for verbage).
***For CalMHSA Rx users only***: you may need to add or modify the medication manually, or you select the medication to be copied and pasted from the CalMHSA Rx’s medication list.
You will want to add which side/adverse effects were discussed with the client, who gave the verbal consent, and any additional comments
Additional Documentation
If you are using the Psych Medical Note template, verbal or written consent can be captured for certain medications by using the checkbox next to the medication name.
Note: Ensure that the medication has been ordered in Medication Rx to pull into the note.
This document will be generated automatically when the checkmark is placed (whenever the document has been “Saved” or “Signed”). This will save in Documents (Client) titled “Medication Consent – [Drug Name]. There is no need to sign this blank document, but it is simply a Date/Time stamp.
This will change the icon for that specific medication within Medication Rx from a yellow warning to a green checkmark and add to the Medication Consent History if your county is using this screen.