Name: Martin, Anthony MR #7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall Mental Health Assessment Date: Monday Time of Assessment: 1115 Location of Assessment: Medical unit

Consultation Requested By: Dr. James Gordon, MD, called to have me assess patient at bedside in the inpatient medical unit. Patient attempted suicide last week with Tylenol and prescribed medication overdose. Patient manifesting depressive symptoms with psychotic features.

Suicide Assessment (X where applicable)

Any suicide thoughts, attempts, gestures __X_yes _ no Comment:___________

Is the means readily available? ____yes _X___no_____N/A

If yes, Does patient have a plan? __X__yes _____no

History of previous suicide attempts? __X__yes ____ no

If patient has a plan, what is it? If yes, explain:

Suicide Risk Factors Present: X Ages 15-24 X Prior suicide gesture or attempt ___White male 65 year or older ___Newly homeless ___African American Male 15-19 ___Living away from family X Hopelessness ___Axis II current substance use disorder ___Lives Alone ___Axis III Diagnoses: DM, Cardiac, Cancer, AIDS

Suicide Protective Factors: ___Future orientation: patient states he wants to finish college and be a mathematician. ___Strong sense of obligation to others ___Less than 18 living alone

Psychosocial History – place an “x” where applicable

Income Source X Employment __Public Assistance _ Other: scholarship X Family __ None

Academic History __ No Education __Declining Grades __Special Education X Failing Grades __Learning Disability __Expelled

Other: enrolled in college

Spiritual: __Requests Chaplain __No Spiritual Orientation X Other: Stated “no comment” __Receives Meaning Strength __Current Spiritual Distress

Legal : __CPS/APS involvement __Child Custody Issues __Current Legal Problems __Probation/Parole __Past Legal Problems X Other: Denies Problems

Environmental Problems __Homeless X No environmental problems __Inadequate Housing

__Exposure to Drugs/Alcohol X Feels isolated from community __Other:

Name: Martin, Anthony MR #7695914310

Health Care Problems __Acute/chronic physical illness X Lack of services mental illness __Lack of services for Addiction Other: Denies health problems

Financial Problems __Poverty __Inadequate Housing X Other: Denies __Lack of Transportation __Inadequate Clothing

__Issues with blended/extended __Acting out in family Family Problems X Health Problems in family __Abusive Home Atmosphere __Lack of family support X Other: states “there is a lot of

stress in my family”

History of Trauma ___Abuse ___Rape ___Exposure to traumatic events ___Neglect ___Flashbacks X Other: Denies trauma history ___Nightmares ___Sexual abuse

Social History – place an “x” where applicable

X Withdrawn/Isolative X Poor peer relationships ___Other: X Problems with others ___No relationship problems

Mental Status Exam

Appearance: sitting in bed, hospital gown Thought process: loose associations, unable to pay attention Behavior: quiet, withdrawn Thought content: ideas of reference, suicidal ideation Orientation: alert, oriented x four Intellect/Memory: normal to above intelligence Mood/Affect: depressed mood, flat affect Speech: slow, fragmented

Insight/Judgment: impaired judgment, poor insight Sleep/Appetite: states he doesn’t eat sometimes because “poison”, sleeping 6 hours night

Recommendation: Recommend admission to psychiatric unit; Dr. Jacobe notified at 1145 and agrees to admission. Patient agrees (voluntary) admission. Called report to R. Sibaya RN in inpatient psychiatric unit to notify of admission.

Diagnosis:

Axis I: Depressive with Psychotic Features, Paranoid Schizoprhenia

Axis IV: family, social, academic, access to health care

Axis II: deferred Axis V: 20 Axis III: deferred

Legal Status on Admission: x voluntary involuntary legal charges pending

Provider Signature: Louise Ralston, RN, CNS

Name: Martin, Anthony       MR #7695914310 

NNeeiigghhbboorrhhoooodd HHoossppiittaall Admission History and Physical

Admission date: Monday

Identifying data

Patient is an 18-year old male with a history of paranoid schizophrenia. He was transferred today from the medical unit after being treated in the ICU for an overdose of Tylenol and other prescribed medications (olanzapine and seroquel). Patient currently has suicidal ideation and is manifesting depressive symptoms with psychotic features.

Sources of collateral

Report from inpatient medical unit, old psychiatric charts, interview with patient and mother (with patient permission).

History of present illness:

The patient was bought to the NBH ED after an ambulance was called to his home per his mother. The mother found the patient in a stupor after he took Tylenol (amount unknown) and prescription medications. The patient was transported to the ED per ambulance; he was admitted to the ICU and treated for a drug overdose.

Past psychiatric history

Patient has a history of two psychiatric inpatient hospitalizations prior to this one, both of which were in the last several months. The first admission he was treated for Psychotic Disorder NOS; the second admission he was treated for Schizophrenia: Paranoid Type. Patient currently is being treated/managed per outpatient psychiatry.

Past medical history

Patient denies.

Suicidality and risk assessment

Patient has suicidal ideation. He denies plan and/or a means.

Social history Patient lives with his parents, three siblings, his nephew and grandmother. He was enrolled in the local college in the last year but failed all of his classes as a result of psychotic episodes and subsequent treatment. He currently is not enrolled in school. His brother was recently in a car accident and incurred a spinal cord injury which is contributing to excess stress in the family. Patient is socially isolative, and works as a bagger at the local grocery store.

Legal Patient denies any recent legal problems. Family psychiatric history/suicide history

Patient’s mother has repeated anxiety and panic attacks. No other reported family psychiatric/suicide history.

Substance abuse history

Patient denies.

Current medications

Patient is on quetiapine (Seroquel). Will discontinue and start patient on risperidone (Risperdal) and citalopram (Celexa).

Allergies NKA Mental Status Examination

Speech: mumbles; motor activity: depressed; mood: depressed; affect: flat; auditory hallucinations; thought content includes: ideas of reference, suicidal ideation, loose associations, thought insertion, thought broadcasting, paranoia; concentration: unable to pay attention; intelligence normal or above; judgment: impaired; memory: poor recent.

Physical Examination

General: agitated, sitting in hospital bed, poor grooming and hygiene, alert and oriented x 4. Lungs: lungs clear to auscultation in all fields, respirations even, non-labored. Abdomen: abdomen flat, soft, non-tender, bowel sounds all quadrants x 4. Neurological: cranial nerves grossly intact, PERRLA. HEENT: Head: normocephalic, facial features symmetrical, nose/ears intact, no drainage. Cardiovascular: Apical pulse regular at 72, S1 and S2 auscultator; no murmur or extra heart sounds, no edema, well perused. Extremities: moves all extremities, denies numbness and tingling. Pain 0/10.

Name: Martin, Anthony       MR #7695914310 

Assessment The patient is an 18-year old with a history of paranoid schizophrenia. Patient at risk injury self due to recent suicide attempt, current suicidal ideation and psychosis.

Axis I Depression with Psychotic Features; Schizophrenia: Paranoid Type. II Deferred III Deferred IV Social, family, academic, access to health care V GAF = 20 Initial treatment plan: 1. Admit voluntary to Psychiatric Unit.2. Suicide precautions.2. Citalopram (Celexa) 20 mg po q day for depression.3. Risperidone (Risperdal) 1 mg bid psychotic symptoms.4. MSW to assist with Medicaid, discharge planning.

Date and Signature:: Monday Jacobe MD

Name: Martin, Anthony MR #7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaallPhysician Order Sheet

Drug Allergies: NKA Patient: Anthony Martin

Date Time Order Monday 1215 Admit to psychiatric unit

Line of sight for suicide precautions

citalopram (Celexa) 20 mg qd, start today

risperidone (Risperdal) 1 mg bid, start now

Vital signs q 4 hours

Regular diet

MSW: Medicaid application, discharge planning, referral for patient to county department of mental health for outpatient services

Health care provider signature: Jacobe MD Print Name: Jacobe MD

Date Time Order Tuesday 0800 Discontinue line of sight and suicide precautions.

Change vital signs to q 8 hours

Health care provider signature: Jacobe MD Print Name: Jacobe MD

Date Time Order Monday 1020 Discharge patient from inpatient services

Follow up with mental health clinic on Wednesday

Discharge medications: citalopram (Celexa) 20 mg qd; risperidone (Risperdal) 1 mg bid

Health care provider signature: Jocobe MD Print Name: Jacobe MD

Name: Martin, Anthony MR#7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall

Physician/Provider Progress Notes Date Time Notations

Monday 1245

Patient admitted to inpatient psychiatric unit secondary to Major Depression with Psychotic features. Patient has a history of paranoid schizophrenia. See admission history and physical. Jacobe MD

Monday 1430

Stopped in to see patient. Patient evaluated per Dr. Jacobe earlier today. Sat with patient. He was very quiet. Thanked me for visiting him. Louise Ralston RN, CNS.

Tuesday 0730

Speech: mumbles; motor activity: depressed; mood: depressed; affect: flat; auditory hallucinations; thought content includes: ideas of reference, loose associations, thought insertion, paranoia; concentration: unable to pay attention; intelligence normal or above; judgment: impaired; memory: poor recent. Patient denies suicidal ideation and/or plan. Discontinue line of sight and suicide precautions. Jacobe MD

Wednesday 1030

Speech: mumbles; motor activity: depressed; mood: depressed; affect: flat; auditory hallucinations; thought content includes: ideas of reference, loose associations, thought insertion, paranoia; concentration: improving. intelligence normal or above; judgment: impaired; memory: poor recent. Patient denies suicidal ideation and/or plan. Patient attended multidisciplinary treatment plan. Patient agrees to plan. Spoke with social worker; he is working on Medicaid application work and discharge planning. Continue medications. Jacobe MD

Thursday 0810

Speech: mumbles; motor activity: depressed; mood: depressed; affect: flat; auditory hallucinations; thought content includes: ideas of reference, loose associations, thought insertion, paranoia; concentration: improving. intelligence normal or above; judgment: impaired; memory: poor recent. Patient denies suicidal ideation and/or plan. Continue medications for depression and psychosis Patient attending groups: goals, psychoeducation, spirituality and occupational therapy. Plan discharge in 3-4 days. Jacobe MD

Friday 0845

Speech: mumbles; motor activity: depressed; mood: depressed; affect: flat; auditory hallucinations; thought content includes: paranoia; concentration: improving. intelligence normal or above; judgment: impaired; memory: poor recent. Patient denies suicidal ideation and/or plan. Patient states the auditory hallucinations are clearing up. Patient attending groups: goals and psychoeducation. Plan discharge in 2-3 days. Jacobe MD

Saturday 0800

Speech: mumbles; motor activity: depressed; mood: depressed; affect: flat; auditory hallucinations; thought content includes: paranoia; concentration: improving. intelligence normal or above; judgment: impaired; memory: poor recent. Patient denies suicidal ideation and/or plan. Continue medications for depression and psychosis. Patient states the auditory hallucinations are clearing up. Patient attending groups: goals, psychoeducation, spirituality and occupational therapy. Plan discharge in 2-3 days. Jacobe MD

Sunday 0715

Speech: mumbles; motor activity: depressed; mood: normal; affect: flat; auditory hallucinations; thought content includes: paranoia; concentration: improving. intelligence normal or above; judgment: impaired; memory: within normal limits. Patient denies suicidal ideation and/or plan. Continue medications for depression and psychosis. Decreased auditory hallucinations Patient attending groups: goals, psychoeducation, spirituality and occupational therapy. Plan discharge tomorrow. Jacobe MD

Name: Martin, Anthony MR#7695914310

Monday 1010

Discharge patient to home today; patient to be cared for by parents. Medicaid applications competed per social working. Patient to follow up with psychiatrist on Wednesday. Discharge medications: citalopram (Celexa) 20 mg qd; risperidone (Risperdal) 1 mg bid. Jacobe MD

Name: Martin, Anthony MR #7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall Nursing Psychiatric Assessment Date: Monday Time: 1330 Name: Anthony Martin Collateral: none

Age: 18

Vital Signs: T: 98.2 RR: 18 HR: 66 BP: 110/70 O2 Sat: 96% RA Pain: 0/10

Gender: Male

Diagnosis: Axis I: Major Depression with Psychotic Features, Schizophrenia, Paranoid Type Axis II: deferred Axis III: deferred Axis IV: family, social, academic, access to health care Axis V: GAF = 20

Marital Status: Single

Occupation: Works full time as a courtesy clerk at the grocery store.

Ht: 6’0Wt: 170 lb

LMP: N/A Pregnant: N/A Allergies: NKALanguage: English Education: Recently failed all classes in college, does not plan to go Ethnicity: Hispanic Race: White back to school

Referral source: Louise Ralston, CNS Legal status: Voluntary Medications: was on seroquel prior to overdose Reason for Seeking Care: Patient has a history of Paranoid Schizophrenia, depressed recently and overdosed approximately one week ago. Treated for overdose. The patient is currently depressed with psychotic features.

Past Psychiatric History: Hospitalized x 2 in inpatient psychiatric unit in the last few months: 1st hospitalization was Psychotic Disorder NOS, 2nd hospitalization was Paranoid Schizophrenia. Currently is treated per outpatient psychiatry.

Is there a psychiatric history in the family? Mother has panic attacks and anxiety.

Daily Living Situation:

How does patient spend time each day/weekday? (hobbies, work, school, interests): He works as a grocery clerk. He says he has no hobbies or current interests. The patient states “the medications make me feel sedated and I'm depressed and want to die”. The patient states he used to enjoy college especially mathematics and science but he failed out of school last semester.

Where and with whom does patient live? The patient lives in his parents’ house with his mother, father, sister, step sister, step brother, nephew and grandmother. He says his brother currently is not living at home because “he was in a bad car accident”.

What are patient’s responsibilities at home? Has the patient’s performance changed at work or home? Has to keep his room clean. Also helps in the yard sometimes and cleans the garage when his father asks him to. He recently dropped out of school due to illness and failing grades. He works full time as a bagger at the grocery store and states “it is an OK job”.

Any history of abuse or neglect? Explain. Currently denies.

Suicidal/Homicidal ideation: The patient denies homicidal ideation. The patient states that “I want to just die.” The patient denies a current plan

Has the patient had any thoughts of hurting self? Describe. See above

Ha thoughts of hurting others? Describe. Denies homicidal ideation.

Name: Martin, Anthony MR #7695914310 Are there any problems at home? The patient feels it is “a big mess at home”. He states that his mother is nice but an anxious “worrywart”, his father is “angry lately”, his sisters “always fight”, his brother is injured, and the house is crowded.

Social Functioning:

What kind of future does the patient see for himself/herself? He sees no future. He says he will “never be able to go back to school”. He wants to “end it all”.

What is the patient’s identified strengths/limitations? The patient has a history of high academic performance, and a supportive family. He states he is limited in everything now that he has schizophrenia.

Describe the patient’s relationships. How does the patient relate to others? The patient states he has a no friends, but prefers to be alone. His states the only one he can relate to is his grandmother.

Has the patient noticed any change in his/her sexual interest/function? Patient agitated when this question addressed. Deferred.

Coping Resources and Discharge Planning:

Is the patient able to provide for basic needs of food, safety, healthcare, clothing, shelter, money and transportation? The patient currently lives with his parents who provide him with the food, safety, and clothing necessary. He recently applied for Medicaid. Currently he has no outpatient psychiatric coverage on his insurance.

Is the patient able to anticipate his/her own needs? No.

Can patient make decisions in his/her own best interest? No. Currently patient has a poor appetite. He also thinks the neighbors are spying on him and people are trying to poison him. The patient is currently hopeless and has suicidal ideation.

Can patient manage own treatment regime? If no, explain: No, prior to this hospitalization patient refused to take medications. He also overdosed on his own prescription medications.

Is patient motivated for treatment? Patient says he will take the prescribed medications. He is admitted per voluntary status.

Substance Abuse Assessment: Amount Frequency Duration of use Last Used

Caffeine denies Tobacco denies Alcohol denies Marijuana denies Barbiturates denies Sleeping Pills denies PCP denies Hallucinogens denies Heroin denies Methamphetamines denies Pain Medications denies Glue, aerosols denies

Drug screen: not ordered

Name: Martin, Anthony MR #7695914310 Physical Data: Is there a history of serious physical illness? Denies history. Are there any problems with bowel/bladder elimination? Denies pain and burning on urination. Last BM yesterday. Does patient require assistance with any activities of daily living? Needs assistance with hygiene. Describe the patients sleep pattern. Sleeps 6-7 hours per night. Describe the patients eating pattern. He states he has a recent decrease in appetite. Sometimes refuses food secondary to thinking he is being poisoned. Eats 2-3 times per day. Family Medical history: Diabetes: denies Kidney disease: denies Hypertension: denies Heart disease: denies Alcohol: denies Drug Abuse: denies Arthritis: denies Stroke: denies Epilepsy: denies Cancer: paternal grandfather Tuberculosis : denies Other: Mother: gallbladder disease, anxiety Father: chronic back pain Review of Systems: History and Physical Are there any problems with physical health? (check all that apply- explain when necessary) Head/Neck: normocephalic, facial features symmetrical Respiratory: lungs clear to auscultation in all fields, respirations

even, non-labored

Mouth/Throat: intact Neurological: awake, alert, PERRLA, grips/pushes strong, equal

Nose/Ears: intact, no drainage Gastrointestinal: abdomen flat, soft, non-tender, bowel sounds all quadrants x 4

Eyes: moves eyes lateral and to center Musculoskeletal: denies numbness and tingling, moves all extremities

Skin: Color: pinkish tones, even color Moisture: dry Temp: warm

Cardiovascular: apical pulse regular at 85, S1 and S2 auscultated; no murmur or extra heart sounds no edema

Integumentary (note bruises and scars): No scars or bruises

Genital-urinal/reproductive: denies pain or burning on urination

Name: Martin, Anthony MR #7695914310

Mental status assessment: place an “x” near all that apply

Appearance: Motor activity: Hallucinations: Thought process x unkempt x lethargic x auditory circumstantial inappropriate dress tense, rigid olfactory flight of ideas neat, clean, appropriate restless visual x loose associations x minimal eye contact agitated command tangential appears older than age tics tactile thought-blocking appears younger than age grimaces gustatory perseveration Speech: tremors N/A logical, coherent rapid normal Thought content: Concentration/calculation x slow Mood: obsessions x distractible neologisms x depressed magical thinking unable to pay attention loud anxious phobias unable to do simple math soft angry x ideas of reference normal pressured euphoric homicidal Information/intelligence mute euthymic x suicidal illiterate stuttering Affect: hypochondriasis learning disabled slurring elated no problems retardation whispering x flat Delusions: Judgmentx mumbles blunted religious mildly impaired normal x inappropriate grandiose x significantly impaired Level of Consciousness: Memory: somatic normal confused poor remote x thought broadcasting Knowledge Deficits sedated poor recent x paranoia x understanding of illness disoriented to _________ poor immediate thought insertion x precipitating stressors stuporous confabulation Insight x coping skills x alert, oriented x 4 x intact denial of illness x accessing resources

blames illness on outside x medications normal other: _________________

Nurse’s signature: Ruby Sibaya Date and Time: Monday, 1415

Name: Martin, Anthony MR#7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall Date: Monday

Medication Administration Record Scheduled Medications Order Date

Medication Dose, Route, & Frequency Sched Times

Administered

Monday Celexa 20 mg po q day 0800 RS (started at 1230) Risperidone 1 mg po bid 0900

2100

RS (started at 1230)DH

Non-Scheduled and One Time Medications Order Date

Medication Dose, Route, & Frequency Administered

Diagnosis: Depression with Psychotic features, Schizophrenia: Paranoid Type

Signature Initial

Admission Date Monday

Ruby Sibaya RN RS

Physician: Jacobe

Douglas Herb RN, BSN DH

Allergies: NKA

Name: Martin, Anthony MR#7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall Date: Tuesday

Medication Administration Record Scheduled Medications Order Date

Medication Dose, Route, & Frequency Sched Times

Administered

Tuesday Celexa 20 mg po q day 0800 RS Risperidone 1 mg po bid 0900

2100

RS DH

Non-Scheduled and One Time Medications Order Date

Medication Dose, Route, & Frequency Administered

Diagnosis: Depression with Psychotic features, Schizophrenia: Paranoid Type

Signature Initial

Admission Date Monday

Ruby Sibaya RN RS

Physician: Jacobe

Douglas Herb RN, BSN DH

Allergies: NKA

Name: Martin, Anthony MR#7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall Date: Wednesday

Medication Administration Record Scheduled Medications Order Date

Medication Dose, Route, & Frequency Sched Times

Administered

Wednesday Celexa 20 mg po q day 0800 RS

Risperidone 1 mg po bid 0900

2100

RS DH

Non-Scheduled and One Time Medications Order Date

Medication Dose, Route, & Frequency Administered

Diagnosis: Depression with Psychotic features, Schizophrenia: Paranoid Type

Signature Initial

Admission Date Monday

Ruby Sibaya RN RS

Physician: Jacobe

Douglas Herb RN, BSN DH

Allergies: NKA

Name: Martin, Anthony MR#7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall Date: Thursday

Medication Administration Record Scheduled Medications Order Date

Medication Dose, Route, & Frequency Sched Times

Administered

Thursday Celexa 20 mg po q day 0800 RS Risperidone 1 mg po bid 0900

2100

RS DH

Non-Scheduled and One Time Medications Order Date

Medication Dose, Route, & Frequency Administered

Diagnosis: Depression with Psychotic features, Schizophrenia: Paranoid Type

Signature Initial

Admission Date Monday

Ruby Sibaya RN RS

Physician: Jacobe

Douglas Herb RN, BSN DH

Allergies: NKA

Name: Martin, Anthony MR#7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall Date: Friday

Medication Administration Record Scheduled Medications Order Date

Medication Dose, Route, & Frequency Sched Times

Administered

Friday Celexa 20 mg po q day 0800 RS Risperidone 1 mg po bid 0900

2100

RS DH

Non-Scheduled and One Time Medications Order Date

Medication Dose, Route, & Frequency Administered

Diagnosis: Depression with Psychotic features, Schizophrenia: Paranoid Type

Signature Initial

Admission Date Monday

Ruby Sibaya RN RS

Physician: Jacobe

Douglas Herb RN, BSN DH

Allergies: NKA

Name: Martin, Anthony MR#7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall Date: Saturday

Medication Administration Record Scheduled Medications Order Date

Medication Dose, Route, & Frequency Sched Times

Administered

Saturday Celexa 20 mg po q day 0800 MS Risperidone 1 mg po bid 0900

2100

MS HS

Non-Scheduled and One Time Medications Order Date

Medication Dose, Route, & Frequency Administered

Diagnosis: Depression with Psychotic features, Schizophrenia: Paranoid Type

Signature Initial

Admission Date Monday

Maria Sanchez RN, BSN RS

Physician: Jacobe

Harry School RN HS

Allergies: NKA

Name: Martin, Anthony MR#7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall

Date: Sunday

Medication Administration Record Scheduled Medications Order Date

Medication Dose, Route, & Frequency Sched Times

Administered

Saturday Celexa 20 mg po q day 0800 MS Risperidone 1 mg po bid 0900

2100

MS HS

Non-Scheduled and One Time Medications Order Date

Medication Dose, Route, & Frequency Administered

Diagnosis: Depression with Psychotic features, Schizophrenia: Paranoid Type

Signature Initial

Admission Date Monday

Maria Sanchez RN, BSN RS

Physician: Jacobe

Harry School RN HS

Allergies: NKA

Name: Martin, Anthony MR#7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall Date: Monday

Medication Administration Record Scheduled Medications Order Date

Medication Dose, Route, & Frequency Sched Times

Administered

Monday Celexa 20 mg po q day 0800 RS Risperidone 1 mg po bid 0900 RS

Non-Scheduled and One Time Medications Order Date

Medication Dose, Route, & Frequency Administered

Diagnosis: Depression with Psychotic features, Schizophrenia: Paranoid Type

Signature Initial

Admission Date Monday

Ruby Sibaya RN RS

Physician: Jacobe Allergies: NKA

Name: Martin, Anthony MR#7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall Multidisciplinary Progress Notes

Date and time Sign all entries with name and title Monday 1145

Received report via telephone from Louise Ralston RN, CNS. Patient will be transferred from medical unit room 147 within next hour secondary to major depression with psychotic features and suicidal ideation. Patient has a history of paranoid schizophrenia. Ruby Sibaya RN

Monday 1210

Patient on unit. Placed on one-on-one and suicide precautions. Psych tech notified. Ruby Sibaya RN

Monday 1215

Dr. Jacobe in to see patient. Ruby Sibaya RN

Monday 1415

Nursing psychiatric assessment completed. See form. Ruby Sibaya RN

Monday 1430

Louise Ralston RN, CNS visiting with patient. Ruby Sibaya RN

Monday 1800

When asked if patient wants to hurt himself. Patient states “I want to die”. When asked if patient has a plan. Patient states “no”. When asked if patient feels safe, he says "yes". Patient has hands over ears. When asked if he is hearing voices he says “yes”. Douglas Herb RN, BSN

Monday 2100

When asked if patient wants to hurt himself. Patient states “no, I feel safe here”. When asked if patient has a plan. Patient states “no”. Douglas Herb RN, BSN

Tuesday 0810

Physician discontinued line of sight and suicide precautions. Patient and tech notified. Patient notified to seek help of tech or nurse if suicidal ideation occurs. Patient stated “OK”. Ruby Sibaya RN

Tuesday 0930

Patient attended am goal group. Did not state goal for today. Ruby Sibaya RN

Tuesday 1045

Mrs. Martin visited patient in hospital. Met with patient’s mother and patient to assist with application for Medicaid. Discussed outpatient support groups for patient: schizophrenia. Also suggested patient’s mother and her family attend NAMI and/or seek resources on the internet. Martin Vauk MSW

Tuesday 1900

When asked if patient wants to hurt himself. Patient states “no”. Disheveled, alert, oriented x 4; speech mumbled, affect blunted; mood: depressed; thought process circumstantial; delusions, paranoid; impaired cognition; poor insight; poor judgment; auditory hallucinations. Douglas Herb, RN BSN

Wednesday 0900

Patient attended goal group. Patient states his goal is to continue taking his medication and to be discharged. When asked if patient wants to hurt himself. Patient states “no, I feel better”. When asked patient if he feels safe here, he replies “yes”. Ruby Sibaya RN

Wednesday 1030

Patient attended multidisciplinary treatment plan and agrees to plan. Ruby Sibaya RN

Wednesday 1920

Patient does not respond when asked how he is doing. When asked if patient wants to hurt himself. Patient states “no”. Patient does nod his head “yes” when asked if he

Name: Martin, Anthony MR#7695914310

feels safe. Sitting in dining room. Disheveled, alert, oriented x 4; speech neologisms; affect flat; mood: depressed; thought process circumstantial; delusions, paranoid. Douglas Herb RN BSN

Thursday 0900

Patient attended am goal group. Did not state goal for today. Patient does nod his head “yes” when asked if he feels safe. Patient states he denies thoughts of hurting himself. Disheveled, alert, oriented x 4; speech slow; affect flat; mood: depressed; thought process circumstantial; delusions, paranoid; impaired cognition; poor insight; poor judgment, auditory hallucinations. Ruby Sibaya RN

Thursday 1530

Patient attended group psychotherapy. Participated. Arrangements made for outpatient mental health appointment with county. Martin Vauk MSW

Thursday 1800

Patient states he is feeling OK. He says he wants to “go home”. Patient says “yes” when asked if he feels safe. Disheveled, alert, oriented x 4; speech mumbled no neologisms; affect blunted; mood: flat; thought process circumstantial; delusions, paranoid; impaired cognition; poor insight; poor judgment; denies hearing voices. Douglas Herb RN, BSN

Friday 0915

Patient attended am goal group. Patient states his goal today is “to do whatever it takes to go home. When patient asked if he feels safe he says “yes”. Patient denies thoughts of hurting self. Disheveled; alert, oriented x 4; speech mumbled; affect blunted; mood: depressed; thought process: delusions, paranoid; impaired cognition; fair insight; fair judgment, denies hearing voices.

Friday 1815

Patient states he is feeling better. He says he wants to “go home”. Patient says “yes” when asked if he feels safe. Disheveled, alert, oriented x 4; speech mumbled, no neologisms; affect blunted; mood: depressed; thought process circumstantial; delusions, paranoid; impaired cognition; poor insight; poor judgment; denies hearing voices. Douglas Herb RN, BSN

Saturday 0900

Patient attended nursing group on psycho education and psychopharmacology. Patient did ask a few questions during group. This nurse instructed him on the use of, and potential side effects of risperidone and citalopram. Patient nodded “yes” when asked if he understands information taught. Maria Sanchez RN, BSN

Saturday 1810

When asked if patient feels safe he says “yes”. When asked if he has thoughts of hurting himself he says “no.” Disheveled, alert, oriented x 4; speech mumbled, no neologisms; affect blunted; mood: fair; thought process circumstantial; delusions, paranoid; impaired cognition; poor insight; poor judgment; denies hearing voices. Harry School, RN

Sunday 0900

Patient attended spirituality group led by pastor. Patent states he cannot wait to go home. When asked if he has thoughts of hurting himself patient says “no”. When asked if patient feels safe he nods his head “yes”. Maria Sanchez RN, BSN

Sunday 1800

Disheveled, alert, oriented x 4; speech mumbled, no neologisms; affect blunted; mood: normal; thought process circumstantial; delusions, paranoid; impaired cognition; poor insight; poor judgment; denies hearing voices. Harry School, RN.

Monday 1045

Patient and his mother given prescriptions: risperidone and citalopram Instructed on use, action, and potential untoward side effects of medications. Patient and his mother instructed on need for patient to follow up in mental health clinic next Tuesday at 1000. Gave patient/mother the phone number at the clinic. Patients discharged home per car with mother.

Name: Martin, Anthony MR #7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall Multidisciplinary Treatment Plan

Patient Agreement

Admission Date: Monday Date of Plan: Wednesday

DIAGNOSIS: Axis I: Depression with Psychotic Features, Paranoid Schizophrenia Axis II: deferred Axis III: deferred Axis IV: social, interruption in education, Axis V: admitting GAF = 24 family stressors

Treatment Team (present members) Psychologist: Erika Rausch Attending physician: Dr. Jacobe

Nurse: Ruby Sibaya Social worker: Martin Vauk Clinical Nurse Specialist: Louise Ralston

Patient’s Strengths: Voluntary admission, compliant with care. Starting to verbalize he wants to feel better.

Discharge Criteria: Patient not a danger to self or others.

Target discharge date: 7 days from admission.

I have discussed my treatment plan: Patient informed of new diagnosis Depression with Psychotic features. Informed on continued plan for psycho education regarding disease process and importance of compliance with psychotrophic medication. Patient demonstrates/verbalizes to staff no intent to harm self or others. Patient identifies various thoughts, feelings that initiate/provoke depressive thoughts. Patient beginning to demonstrate a reduction in disturbed cognitive/sensory perceptions. Patient verbalizes understanding that distressing symptoms are related to and can exacerbate mental illness. Patient verbalizes to staff importance of taking psychotropic medication but states that he sometimes does not like the side effects.

I am participating in my treatment plan: I agree to participate in my treatment plan.

Patient signature: Anthony Martin

Name: Martin, Anthony MR#7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall Psychiatric Unit Behavioral Monitoring Date: Monday to Tuesday Patient Location Patient Activity Staff

Initial Patient Location Patient Activity Staff

Initial 0700 1900 In dining room sitting alone CW0715 1915 Dayroom watching TV CW0730 1930 Dayroom pacing CW0745 1945 Dayroom pacing CW0800 2000 Dayroom sitting alone CW0815 2015 Dayroom lying on couch CW0830 2030 Dayroom lying on couch CW0845 2045 Dayroom sitting alone CW0900 2100 Dayroom sitting alone CW0915 2115 Dayroom sitting alone CW0930 2130 Dayroom pacing CW0945 2145 Dayroom watching TV CW1000 2200 In room sleeping CW1015 2215 In room sleeping CW1030 2230 In room sleeping CW1045 2245 In room sleeping CW1100 2300 In room sleeping MM 1115 2315 In room sleeping MM 1130 2330 In room sleeping MM 1145 2345 In room sleeping MM 1200 2400 In room sleeping MM 1215 In dayroom With Dr. Jacobe DL 2415 In room sleeping MM 1230 In room With Dr. Jacobe DL 2430 In room sleeping MM 1245 In room With Dr. Jacobe DL 2445 In room sleeping MM 1300 In dayroom Sitting alone DL 0100 In room sleeping MM 1315 In dayroom Sitting alone DL 0115 In room sleeping MM 1330 In room With RN DL 0130 In room sleeping MM 1345 In room With RN DL 0145 In room sleeping MM 1400 In room With RN DL 0200 In room sleeping MM 1415 In room With RN DL 0215 In room sleeping MM 1430 In day room With Ms. Ralston DL 0230 In room sleeping MM 1445 In day room With Ms. Ralston DL 0245 In room sleeping MM 1500 In room sleeping CW 0300 In room sleeping MM 1515 In room sleeping CW 0315 In room sleeping MM 1530 In room sleeping CW 0330 In room sleeping MM 1545 In room sleeping CW 0345 In room sleeping MM 1600 In room sleeping CW 0400 In room sleeping MM 1615 In room sleeping CW 0415 In room sleeping MM 1630 In room sleeping CW 0430 In room sleeping MM 1645 In room sleeping CW 0445 In room sleeping MM 1700 In room sleeping CW 0500 In room sleeping MM 1715 Dayroom sitting in chair CW 0515 In room sleeping MM 1730 Dayroom sitting in char CW 0530 In room sleeping MM 1745 Dayroom eating dinner CW 0545 In room sleeping MM 1800 Dayroom eating dinner CW 0600 In room sleeping MM 1815 Dayroom eating dinner CW 0615 In room sleeping MM 1830 Dayroom lying on couch CW 0630 In room sleeping MM 1900 In room Sitting in bed CW 0645 In room sleeping MM Staff signatures: day shift: Dan Louis evening shift: Carlos Wilson, CNA night shift: Mildred Miller CNA

Risk: o AWOL X Suicide X LOS order o Other:____

Name: Martin, Anthony MR#7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall Psychiatric Unit Behavioral Monitoring Date: Tuesday to Wednesday Patient Location Patient Activity Staff

Initial Patient Location Patient Activity Staff

Initial 0700 Inn room sleeping DL 1900 0715 In room sleeping DL 1915 0730 In room sleeping DL 1930 0745 In room sleeping DL 1945 0800 dc line of sight In bathroom DL 2000 0815 2015 0830 2030 0845 2045 0900 2100 0915 2115 0930 2130 0945 2145 1000 2200 1015 2215 1030 2230 1045 2245 1100 2300 1115 2315 1130 2330 1145 2345 1200 2400 1215 2415 1230 2430 1245 2445 1300 0100 1315 0115 1330 0130 1345 0145 1400 0200 1415 0215 1430 0230 1445 0245 1500 0300 1515 0315 1530 0330 1545 0345 1600 0400 1615 0415 1630 0430 1645 0445 1700 0500 1715 0515 1730 0530 1745 0545 1800 0600 1815 0615 1830 0630 1900 0645 Staff signatures: day shift: Dan Louis CNA evening shift: ____________ night shift:

Risk: o AWOL X Suicide X LOS order o Other:___

Name: Martin, Anthony MR#7695914310

NNeeiigghhbboorrhhoooodd PPssyycchhiiaattrriicc HHoossppiittaall Psychiatric Unit Sleep Flow Sheet

Date and time in bed

Date and time out of

bed

Hours Slept

Did patient sleep all night? (yes or no)

If did not sleep all

night, (document in

progress notes)

Comments Staff Signature

Monday 1500

Monday 1700

2 Patient sleeping in bed

CW

Monday 2200

Tuesday 0745

9.75 yes CW/DL

Tuesday 2200

Wednesday 0730

9.5 yes CW/MM

Wednesday 2100

Thursday 0600

9 yes CW/MM

Thursday 2230

Friday 0730

9 yes CW/MM

Friday 2300

Saturday 0600

7 yes CW/MM

Saturday 2100

Sunday 0800

11 yes EP/NR

Sunday 2230

Monday 0730

9 yes EP/NR

Name: Martin, Anthony MR #7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall Vital Sign Flow Sheet Date: Monday

Time BP HR RR T O2 Sat

Pain BG Time BP HR RR T O2 Sat Pain BG

0700 1900 0800 2000 118/72 80 24 97.0 98%RA 0900 2100 1000 2200 1100 2300 1200 2400 107/74 70 16 98.0 98%RA 1300 0100 1400 0200 1500 0300 1600 0400 110/72 60 16 97.2 97%RA 1700 0500 1800 110/70 64 20 98.6 98% 0/10 0600 Date: Tuesday Time BP HR RR T O2 Sat Pain BG Time BP HR RR T O2 Sat Pain BG 0700 1900 0800 120/78 88 20 99.7 99%RA 0/10 2000 0900 2100 1000 2200 1100 2300 1200 110/72 80 18 98.0 97%RA 0/10 2400 110/72 64 16 98.0 99%RA 1300 0100 1400 0200 1500 0300 1600 116/78 70 16 98.2 99%RA 0/10 0400 1700 0500 1800 0600 Date: Wednesday Time BP HR RR T O2 Sat Pain BG Time BP HR RR T O2

Sat Pain BG

0700 1900 0800 120/78 88 20 99.7 99%RA 0/10 2000 0900 2100 1000 2200 1100 2300 1200 2400 118/72 118/72 80 24 97.0 1300 0100 1400 0200 1500 0300 1600 110/70 64 20 98.6 98%RA 0/10 0400 1700 0500 1800 0600

Name: Martin, Anthony MR #7695914310

NNeeiigghhbboorrhhoooodd HHoossppiittaall Vital Sign Flow Sheet Date: Thursday Time BP HR RR T O2 Sat Pain BG Time BP HR RR T O2 Sat Pain BG 0700 1900 0800 110/70 78 16 98.0 98%RA 2000 0900 2100 1000 2200 1100 2300 1200 2400 106/72 70 24 98.0 98%RA 1300 0100 1400 0200 1500 0300 1600 110/74 60 20 96.6 98%RA 0/10 0400 1700 0500 1800 0600 Date: Friday Time BP HR RR T O2 Sat Pain BG Time BP HR RR T O2 Sat Pain BG 0700 1900 0800 120/78 88 20 99.7 99%RA 0/10 2000 0900 2100 1000 2200 1100 2300 1200 2400 110/70 60 22 98.0 99%RA 1300 0100 1400 0200 1500 0300 1600 116/72 70 20 98.2 99%RA 0/10 0400 1700 0500 1800 0600 Date: Saturday Time BP HR RR T O2 Sat Pain BG Time BP HR RR T O2

Sat Pain BG

0700 1900 0800 120/78 88 20 99.7 99%RA 0/10 2000 0900 2100 1000 2200 1100 2300 1200 2400 1300 0100 1400 0200 1500 0300 1600 0400 1700 0500 1800 0600

Name: Martin, Anthony MR #7695914310

Date: Sunday Time BP HR RR T O2 Sat Pain BG Time BP HR RR T O2 Sat Pain BG 0700 1900 0800 120/70 80 18 99.7 99%RA 0/10 2000 0900 2100 1000 2200 1100 2300 1200 2400 110/72 64 16 98.0 99%RA 1300 0100 1400 0200 1500 0300 1600 116/78 70 16 98.2 99%RA 0/10 0400 1700 0500 1800 0600 Date: Monday Time BP HR RR T O2 Sat Pain BG Time BP HR RR T O2

Sat Pain BG

0700 1900 0800 124/70 88 20 99.7 99%RA 0/10 2000 0900 2100 1000 2200 1100 2300 1200 2400 1300 0100 1400 0200 1500 0300 1600 0400 1700 0500 1800 0600