AR601 Mental Health Forms And Disposition EKG 60111
User Manual: EKG 60111
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State of Alabama Alabama Department of Corrections Research and Planning P. O. Box 301501 Montgomery, AL 36130-1501 BOB RILEY GOVERNOR RICHARD F. ALLEN COMMISSIONER March 1, 2006 ADMINISTRATIVE REGULATION NUMBER 601 OPR: TREATMENT MENTAL HEALTH FORMS AND DISPOSITION I. GENERAL This Alabama Department of Corrections (ADOC) Administrative Regulation (AR) establishes the responsibilities, policies and procedures for mental health forms to document and report Mental Health Services. II. POLICY It is the policy of the ADOC that Psychologist and Psychological Associates, contracted mental health staff, security and medical staff will use approved mental health forms in documenting and reporting mental health transactions. III. DEFINITION(S) AND ACRONYM(S) This section is not used in this AR. IV. V. RESPONSIBILITIES A. The Director of Treatment is responsible for developing and updating forms associated with ADOC Mental Health Administrative Regulations. B. ADOC Psychologists, Psychological Associates, classification, security staff, and contracted mental health staff are responsible for using authorized forms designated for fulfilling mental health policies. C. The contract mental health and medical provider will supply the forms depicted in Annex B, Medication Administration Record; C, Problem List; E, Physician Orders; and F, Medication Error Report. PROCEDURES A. All ADOC forms shall be completed in ink, signed, and dated. VI. B. All corrections shall be initialed and dated by the person making the corrections. C. Mental health forms shall be filed in the inmate medical record as shown in Annex D, Inmate Medical Record Format. D. Requests for changes in mental health forms shall be submitted to the Director of Treatment/designee for consideration. DISPOSITION Any forms used shall be retained and/or disposed of according to the Department Records Disposition Authority (RDA). VII. FORMS AR 601, Mental Health Forms and Disposition, establishes Mental Health (MH) forms listed in Annex A, Index of Mental Health Forms. VIII. SUPERCEDES This regulation being a new regulation does not supercede any other regulation at this time. IX. PERFORMANCE A. The Bradley Agreement, dated August 8, 2000. B. National Commission of Correctional Health Care: Standards for Health Services in Prisons 2003. (P-A-09). C. The Code of Alabama 1975, Section 22-50-11. _____________________________ Richard F. Allen, Commissioner ANNEX (S): Annex A, Index of Mental Health Forms Annex B, Medication Administration Record Annex C, Problem List Annex D, Inmate Medical Record Format Annex E, Physician Orders Annex F, Medication Error Report 2 of 13 AR 601 – March 1, 2006 INDEX OF MENTAL HEALTH FORMS MH FORM NUMBER FORM TITLE 001 Authorization for Release of Information 002 Inmate Orientation to Mental Health Services 003 Reserved For Future Use 004 Quality Improvement Program: Review of Inmate Suicide or Life-Threatening Attempt 005 New Staff Orientation 006 Staff Training Report: Monthly 007 Staff Training Report: Quarterly 008 Referral to Mental Health 009 Inmate Self-Referral Log 010 Non-Availability of Psychotropic Medication 011 Reception Mental Health Screening Evaluation 012 Reception Mental Health Screening Log 013 Mental Health Code Input 014 Psychological Evaluation Update 015 Psychological Evaluation 016 Intake Form for Substance Abuse 017 Treatment Coordinator Assignment Log 018 Psychiatric Evaluation 019 Abnormal Involuntary Movement Scale (AIMS) (Modified) 020 Psychiatric Medication Consent: Lithium 021 Psychiatric Medication Consent: Antipsychotics 022 Psychiatric Medication Consent: Antidepressants 023 Psychiatric Medication Consent: General 024 Psychotropic Medication Report 025 Psychiatric Progress Notes 026 Housing Unit Temperature Log 027 Emergency Forced Psychotropic Medication Report 028 Involuntary Medication Request 029 Notice of Involuntary Medication Hearing 030 Record of Involuntary Medication Review 031 Mental Health Unit (RTU/SU): Inmates Receiving Involuntary Medication 032 Treatment Plan 033 Correctional Officer Input into RTU/SU Inmate Treatment Planning 034 Treatment Plan Review Annex A to AR 601 Page 1 of 3 3 of 13 AR 601 – March 1, 2006 INDEX OF MENTAL HEALTH FORMS MH FORM NUMBER FORM TITLE 035 Outpatient Psychiatric Services Log 036 Outpatient Individual Inmate Contact Log 037 Group Attendance Roster 038 Mental Health Segregation Rounds Log 039 Review of Segregation Inmates 040 Progress Notes 041 Mental Health Consultation to Disciplinary Process 042 Mental Health Watch/Restraint Procedure 043 Reserved for future use 044 Inmate Status/ Precautionary Watch 045 Crisis Cell Utilization 046 Use of Physical Restraints for Mental Health Purposes Monitoring 047 Use of Physical Restraints for Mental Health Purposes (Log) 048 Mental Health Unit (RTU/SU): Admission/Transfer Form 049 Mental Health Unit (RTU/SU): Discharge Summary Form 050 Mental Health Unit (RTU/SU): Discharge/Transfer Form 051 Intensive Psychiatric Stabilization Unit (SU): Inmate Orientation and Expectations 052 Mental Health Unit (RTU/SU): Initial Nursing Assessment 053 Intensive Psychiatric Stabilization Unit: Inmates with Extended Stay 054 Mental Health Unit (RTU/SU): Admission and Discharge Log 055 Intensive Psychiatric Stabilization Unit: Programming Monitoring 056 Mental Health Unit (RTU/SU): Treatment Planning Status 057 Intensive Psychiatric Stabilization Unit: Inmates with Extended Stay Monthly Report 058 Reserved for future use 059 Mental Health Unit: Critical Incidents and Disciplinary Action 060 Mental Health Unit (RTU): Inmate Roster-Last Day of the Month 061 Mental Health Unit (SU): Inmate Roster-Last Day of the Month 062 Residential Treatment Unit (RTU): Inmate Orientation and Expectations 063 Residential Treatment Unit (RTU): Program Monitoring (MHP, AT, Nursing) 064 Record of Sanity Commission Hearing 065 Statement of Sentence 066 Pre-Admission Security Evaluation 067 Pre-admission Statement 068 Reserved for future use 069 Petition for Involuntary Commitment Annex A to AR 601 Page 2 of 3 4 of 13 AR 601 – March 1, 2006 INDEX OF MENTAL HEALTH FORMS MH FORM NUMBER FORM TITLE 070 Outpatient Services: Monthly Activity Report 071 Intensive Psychiatric Stabilization Unit (SU): Monthly Activity Report 072 Residential Treatment Unit (RTU): Monthly Activity Report 073 System-wide Outpatient Services: Monthly Activity Report 074 System-wide Intensive Psychiatric Stabilization Unit (SU): Monthly Activity Report 075 System-wide Residential Treatment Unit (RTU): Monthly Activity Report 076 Monthly Report of Psychological Activities 077 Intensive Psychiatric Stabilization Unit: Transfers to State Psychiatric Hospital Annex A to AR 601 Page 3 of 3 5 of 13 AR 601 – March 1, 2006 MEDICATION ADMINISTRATION RECORD MEDICATION ADMINISTRATION RECORD Hour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 5 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Medications 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 5 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 5 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Hour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 5 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Medications SAMPLE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 5 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 5 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 5 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 5 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 5 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Hour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 5 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Medications CHARTING FOR Physician Alt. Physician Allergies NURSE’S ORDERS, MEDICATION NOTES, AND INSTRUCTIONS ON REVERSE SIDE. THROUGH Telephone No. . Alt. Telephone No. Rehabilitative Potential Diagnosis PATIENT Complete Entries Checked: By: Title: PATIENT CODE ROOM NO. Disposition: Inmate Medical Record, Right Date: BED INSTITUTION Reference: ADOC AR: 617, 618 Page 1 of 2 Front-side Annex B to AR 601 6 of 13 AR 601 – March 1, 2006 MEDICATION ADMINISTRATION RECORD INSTRUCTIONS: a. Put initial in appropriate box when medication given. b. Circle initials when medication refused. c . State reason for refusal on nurse’s notes. d. PRN Med: Reason given and results should be noted on Nurse’s Medication Notes. DATE Temperature/ Pulse Blood Pressure 1 2 3 4 NURSE’S MEDICATION NOTES Date/Hour 5 6 7 8 9 PATCH SI TE / INJECTION SITE CODES: CHARTING a.Charting in error. CODES: b. Patient refused. c. Patient out of facility. d. Drugs not given. Indicate reason in Nurses medication notes. 10 1. 2. 3. 4. 11 12 13 14 RIGHT DORSAL GLUTEUS LEFT DORSAL GLUTEUS RIGHT VENTRAL GLUTEUS LEFT VENTRAL GLUTEUS Medication/Dosage 15 16 17 18 5. RIGHT LATERAL THIGH 6. LEFT LATERAL THIGH 7. RIGHT DELTOID 8. LEFT DELTOID Reason 19 e. See Nurse’s Medication Notes. f. Patient did not retain medication. g. Effective 20 21 22 9. RIGHT UPPER ARM 10. LEFT UPPER ARM 11. RIGHT ANTERIO R THIGH 12. LEFT ANTERIOR THIGH 23 24 25 26 13. UPPER BACK LEFT 14. UPPER BACK RIGHT 15. UPPER CHEST LEFT 16. UPPER CHEST RIGHT Results/Response SAMPLE Disposition: Inmate Medical Record, Right Reference: ADOC AR : 617, 618 Page: 2 of 2 back-side Annex B to AR 601 7 of 13 AR 601 – March 1, 2006 PROBLEM LIST Name: _______________________________________________AIS #: _________________ Medication Allergies:_____________________________________________________________________ Medical: Chronic (Long -Term) Problems Roman Numerals for Medical/ Surgical Mental Health Code: 0 1 2 3 4 5 6 Date Code Initially Assigned: _________ Capital Letter for Psychiatric Behavior Date Identified Chronic Medical or Psychological Problem Mental Code Date Resolved Provider Initials SAMPLE Disposition: Inmate Medical Record, left top, yellow Reference: ADOC AR: 606, 613, 614, 615 Annex C to AR 601 8 of 13 AR 601 – March 1, 2006 INMATE MEDICAL RECORD FORMAT LEFT SIDE TOP RIGHT SIDE TOP Problem List – Yellow Paper – 60108 AL Physicians Orders ADOC MH-032, Treatment Plan ADOC MH-033, Correctional Officer Input Into RTU/SU Inmate Treatment Planning ADOC MH-034, Treatment Plan Review DNR Forms (look in CHOICES manual) Living Will Advance Directive Physician Order #60110 Discharge Instruction Sheet #70060 (if inmate released from prison) Under Chronic Tab Nursing Progress Notes Tab Doctor Progress Notes Tab Progress Notes #60111 Sick Call Request #GLF1002 Progress Notes #60111 Transfer Receiving Screening Form #70009 Emergency (Body Man – Non Schedule Event) #70007 All Chronic Care Forms (Nurse/MD) Diabetic - Physician 60517 - AL Diabetic - Nurse 60518 - AL CV/HTN - Physician 60519 - AL CV/HTN - Nurse 60520 - AL Seizure - Physician 60521 - AL Seizure - Nurse 60522 - AL Pulmonary - Physician 60523 - AL Pulmonary - Nurse 60524 - AL TB - Physician 60525 - AL TB - Nurse 60526 - AL Extra Progress Notes (Form #60111) Under Medication Administration Tab Non-formulary Pharmacy Request Form (PHS) MAR (medication administration form) #Secure Pharmacy Plus Self Medication Administration (KOP) Forms Refusal of Treatment Form #70108 Under Consultation Tab Diabetic Record #CAL - 5B1 Monofilament Testing For Diabetics (Form 60516-AL) Annual Diabetic Check List (Form 60514-AL) Diabetic Intake Screening (Form 60515-AL) Under History and Physical Tab Yearly Health Evaluation/Notification of Next of Kin (Form 60513-AL) Special Diet Request #60130 Kitchen Clearance Physical Assessment #70042 Intake Health Evaluation (Form 60511-AL) Identification of Special Needs #GLF1005 TB Screening Form (Form 60512-AL) Intake Screening/Notification of Next of Kin (Form 60412-AL) UM Referral Review Forms #2/05/04 Emergency Room Referral #70062 Confidential Medical Data #60109 Off-site Visit Reports (to exclude x-ray reports) Consultation Request Forms #60136 Eye-Chart #70029 Under Lab/X-Ray/EKG Tab STAPLE EVENT FORMS T OGETHER Short Stay Record 23-PHS Infirmary-#70048 Under Hospital Tab Emergency Room Records - Free World gggggg End of Right Side ggggg Annex D to AR 601 Page 1 of 3 9 of 13 AR 601 – March 1, 2006 INMATE MEDICAL RECORD FORMAT gggggggggg LEFT SIDE CONTINUED gggggggggggg Psychiatric and Psychological Reports ADOC MH-002, Inmate Orientation to Mental Health Services ADOC MH-008, Referral to Mental Health ADOC MH-011, Reception Mental Health Screening Evaluation ADOC MH-014, Psy chological Evaluation Update ADOC MH-015, Psychological Evaluation ADOC MH-016, Intake Form for Substance Abuse ADOC MH-018, Psychiatric Evaluation ADOC MH-019, Abnormal Involuntary Movement Scale (AIMS) (Modified) ADOC MH-020, Psychotropic Medication Consent: Lithium ADOC MH-021, Psychotropic Medication Consent: Antipsychotics ADOC MH-022, Psychotropic Medication Consent: Antidepressants ADOC MH-023, Psychotropic Medication Consent: General ADOC MH-024, Psychotropic Medication Report ADOC MH-025, Psychiatric Progress Notes ADOC MH-027, Emergency Forced Psychotropic ADOC MH-028, Involuntary Medication Request ADOC MH-029, Notice of Involuntary Medication Hearing ADOC MH-030, Record of Involuntary Medication Review ADOC MH-039, Review of Segregation Inmates ADOC MH-040, Progress Notes ADOC MH-041, Mental Health Consultation to the Disciplinary Process ADOC MH-042, Mental Health Watch/Restraint Procedure ADOC MH-044, Inmate Status/Precautionary Watch ADOC MH-046, Use of Physical Restraints for Mental Health Purposes Monitoring ADOC MH-048, Mental Health Unit (RTU/SU): Admission/Transfer Form ADOC MH-049, Mental Health Unit (RTU/SU): Discharge Summary Form ADOC MH-050, Mental Health Unit (RTU/SU): Discharge/Transfer Form ADOC MH-052, Mental Health Unit (RTU/SU): Initial Nursing Assessment ADOC MH-053, Intensive Psychiatric Stabilization Unit: Inmates with Extended Stay ADOC MH-064, Record of Sanity Commission Hearing ADOC MH-065, Statement of Sentence ADOC MH-066, Pre-Admission Security Evaluation ADOC MH-067, Pre-Admission Statement ADOC MH-069, Petit ion For Involuntary Commitment Mental Health Workshop certificate copies Annex D to AR 601 Page 2 of 3 10 of 13 AR 601 – March 1, 2006 INMATE MEDICAL RECORD FORMAT gggggggggg LEFT SIDE CONTINUED gggggggggggg Under Other Documents Tab Segregation Health Log (60527-AL) Treatment Record and/or Blood Pressure Log (60529-AL) Special Needs Communication #60418 Informed Consent to Medical Services #60104 (suture, I & D, invasive) Refusal of Treatment Form #70108 Non-compliance Notice #70057 Authorization of PHS to Release Medical Records #60137 ADOC Form MH-001, Authorization for Release of Information Release of Responsibility #60115 Refusal to Submit to Treatment #70032 Receipt of Medical Equipment (eye glasses, dentures, appliances) #70005 Medical Restraint Form (if used) Hunger Strike Forms (if used) Progress Notes #60111 (extra) Infirmary In-Patient Record - PHS Infirmary STAPLE EVENT FORMS T OGETHER Infirmary Admission #70050 Inpatient History and Physical #70020 Infirmary Assessment Sheet #PHIL110 Daily Patient Assessment Sheet #70055 24 Hour In-take/Out Put #70059 Vital Signs Flow Sheet #70063 Flow Chart for Alcohol Drug Withdrawal #60120 Progress Notes #60111 Infirmary Nursing Progress Notes #70049 Flow Sheet #70028 Hunger Strike Forms (if used) Infirmary Discharge #70051 In-Patient Hospital Records -Free World STAPLE EVENT FORMS TOGETHER Authorization for Release of Information #60102 FILING ORDER TOP TO BOTTOM M OST RECENT DATE ALWA YS ON TOP AND DESCENDING CHRONOLOG ICAL O RDER Annex D to AR 601 Page 3 of 3 11 of 13 AR 601 – March 1, 2006 PHYSICIAN ORDERS Name:________________________________ DIAGNOSIS: (If Cell:_________________________________ Changed)______________________________________ D.O.B.______/______/______ _______________________________________________________ Allergies:_____________________________ _______________________________________ _____________________________________ Use Fourth GENERIC SUBSTITUTION IS NOT PERMITTED Date: _____/_____/_____ Name:________________________________ DIAGNOSIS: (If Cell:_________________________________ Changed)______________________________________ D.O.B.______/______/______ _______________________________________________________ SAMPLE Allergies:_____________________________ _____________________________________ _____________________________________ Use Third GENERIC SUBSTITUTION IS NOT PERMITTED Date: _____/_____/_____ Name:________________________________ DIAGNOSIS: (If Cell:_________________________________ Changed)______________________________________ D.O.B.______/______/______ _______________________________________________________ Allergies:_____________________________ _______________________________________ _____________________________________ Use Second GENERIC SUBSTITUTION IS NOT PERMITTED Date: _____/_____/_____ Name:________________________________ DIAGNOSIS: (If Cell:_________________________________ Changed)______________________________________ D.O.B.______/______/______ _______________________________________________________ Allergies:_____________________________ _______________________________________ _____________________________________ Use First GENERIC SUBSTITUTION IS NOT PERMITTED Date: _____/_____/_____ Disposition: Inmate Medical Record, right side and Pharmacy ADOC AR: 617,631 Annex E to AR 601 12 of 13 AR 601 – March 1, 2006 MEDICATION ERROR REPORT Name and title of person making error: _____________________________________ Date:______ Time:______ Inmate name & ID#________________________________ Type of error (check all appropriate): __________ wrong inmate __________ wrong dose __________ wrong time __________ wrong medication __________ illegible ____________wrong mode of administration ____________omitted ____________transcription error ____________dispensing error ____________cross-reactivity other:__________________________________________________________________ Physician notified:__________________________ Date & Time:________________ Description of Medication Error (include name(s) and dose(s) of medication involved, how error was discovered, cause of error and action taken). ____________________________________________________________________________________ SAMPLE ____________________________________________________________________________________ ____________________________________________________________________________________ ________________________ ___________________________________________ _______________________________ Signature & Status of person completing report Date & time Supervisor’s Evaluation (include cause and corrective action taken to prevent or minimize future errors of this nature). ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ______________________________________ Signature & Title ___________________________ Date & Time Disposition: Director of Treatment, Quality Improvement Reference: ADOC AR 617 Annex F to AR 601 13 of 13 AR 601 – March 1, 2006
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