Document behaviors and the pharmacologic/non-pharmacologic response over time:
Target behaviors with frequency, intensity, and triggers (behavior monitoring), and the non-pharmacologic interventions tried and their effect.
For each psychotropic: the documented indication and diagnosis, the target symptoms, the monitoring parameters, and consent.
GDR attempts and outcomes, or the documented clinical contraindication to reducing; PRN psychotropic use against the time limits.
MDS-supportive data
Psychotropic medication days (antipsychotic, antianxiety, antidepressant, hypnotic) are coded in MDS Section N; behaviors in Section E; mood (PHQ) in Section D; cognition (BIMS) in Section C. The record must support each — the behavior data and the medication indication must be findable (F641, and the antipsychotic quality measure).
