Prescribing Without a Available Collaborator
Dr. Elena Alvarez is a licensed psychologist in Las Cruces and holds the Board's prescribing psychologist authorization. Her new patient, Mr. R, is 42, has major depressive disorder (PHQ-9 = 19), insomnia, and no suicidal ideation. He also has hypertension treated with lisinopril, BMI 34, and has not seen a primary care clinician in two years. Dr. Alvarez has a signed collaborative agreement with a local family physician, but that physician is on leave and unavailable for consultation. Mr. R asks her to "just start sertraline today" because he cannot take time off work for a medical appointment. Dr. Alvarez has not obtained vital signs or baseline labs, and she has not reviewed the risks of SSRIs with him in writing. She has a full schedule and is considering prescribing now and arranging the medical visit later.
1. Identify the regulatory and clinical steps Dr. Alvarez must complete before prescribing, and explain why the collaborative agreement matters.
Read the worked answer
Dr. Alvarez should first confirm that her prescribing authorization is current and that the collaborative relationship required by the Board's prescribing rules is actually available. A signed agreement with a physician who is on leave does not provide the consultation the rules contemplate. She must obtain a medical history, vital signs, and any indicated baseline studies; refer Mr. R for a physical evaluation or arrange a warm handoff to a covering physician; and document the rationale for any delay. The collaborative relationship is not a formality: it supplies medical oversight for comorbidities such as hypertension, helps identify contraindications, and supports coordination with primary care. She must also obtain informed consent covering risks, benefits, alternatives, and the limits of her prescribing role. Prescribing "now" and arranging medical care later reverses the required sequence and creates avoidable risk. If no collaborator is available, she should not prescribe solely because the patient requests it; she should continue psychotherapy, address safety and sleep, and facilitate medical referral.
2. If Mr. R refuses the medical referral, how should Dr. Alvarez respond?
Read the worked answer
She should not abandon him or simply accede to the request. She should explain in plain language why the referral matters, offer practical options such as a telehealth medical visit, a covering physician, or a same-week appointment, and document the discussion. If he still refuses, she may decline to prescribe until the evaluation occurs, continue nonpharmacologic treatment and safety planning, and make a referral if his depression worsens. If he becomes acutely suicidal or medically unstable, she must act to protect him. The record should show the refusal, the alternatives offered, the risk-benefit reasoning, and the follow-up plan. Coercion is inappropriate, but so is prescribing without the information needed to do so safely.
3. What should be documented in the record before and after this decision?
Read the worked answer
The record should show her prescribing authorization, the status of the collaborative agreement and attempts to reach a covering physician, the medical history and hypertension, vital signs or the reason they were not obtained, the referral and Mr. R's response, informed consent including risks and alternatives, the treatment plan, any prescription decision and rationale, and coordination with the physician. If she declines to prescribe, she should document why, what she offered instead, and the follow-up interval. Good documentation demonstrates that the decision was clinically and regulatorily reasoned, not merely a response to patient pressure.