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
March 1, 2006
ADMINISTRATIVE REGULATION OPR: TREATMENT
NUMBER 601
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. 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.
V. PROCEDURES
A. All ADOC forms shall be completed in ink, signed, and dated.
B
OB
R
ILEY
GOVERNOR
RICHARD F. ALLEN
COMMISSIONER
2 of 13 AR 601 – March 1, 2006
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.
VI. 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
3 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
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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
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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
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AR 601 – March 1, 2006
MEDICATION ADMINISTRATION RECORD
MEDICATION ADMINISTRATION RECORD
Disposition: Inmate Medical Record, Right Reference: ADOC AR: 617, 618
Page 1 of 2 Front-
side
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NURSE’S ORDERS, MEDICATION NOTES, AND INSTRUCTIONS ON REVERSE SIDE.
CHARTING FOR THROUGH
Physician Telephone No. .
Alt. Physician Alt. Telephone No.
Allergies Rehabilitative
Potential
Diagnosis
Complete Entries Checked:
By: Title: Date:
PATIENT PATIENT CODE ROOM NO. BED INSTITUTION
Annex B to AR 601
SAMPLE
7 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.
CHARTING a.Charting in error.
CODES: b. Patient refused.
c. Patient out of facility.
d. Drugs not given. Indicate reason
in Nurses medication notes.
e. See Nurse’s Medication Notes.
f. Patient did not retain medication.
g. Effective
DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Temperature/
Pulse
Blood
Pressure
NURSE’S
MEDICATION NOTES
PATCH SITE /
INJECTION SITE
CODES:
1. RIGHT DORSAL GLUTEUS
2. LEFT DORSAL GLUTEUS
3. RIGHT VENTRAL GLUTEUS
4. LEFT VENTRAL GLUTEUS
5. RIGHT LATERAL THIGH
6. LEFT LATERAL THIGH
7. RIGHT DELTOID
8. LEFT DELTOID
9. RIGHT UPPER ARM
10. LEFT UPPER ARM
11. RIGHT ANTERIO R THIGH
12. LEFT ANTERIOR THIGH
13. UPPER BACK LEFT
14. UPPER BACK RIGHT
15. UPPER CHEST LEFT
16. UPPER CHEST RIGHT
Date/Hour Medication/Dosage Reason Results/Response
Disposition: Inmate Medical Record, Right Reference: ADOC AR : 617, 618
Page: 2 of 2 back-side
Annex B to AR 601
SAMPLE
8 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
Disposition: Inmate Medical Record, left top, yellow Reference: ADOC AR: 606, 613, 614, 615
Annex C to AR 601
SAMPLE
9 of 13 AR 601 – March 1, 2006
INMATE MEDICAL RECORD FORMAT
Annex D to AR 601
Page 1 of 3
LEFT SIDE TOP
Problem List – Yellow Paper – 60108 AL
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
Under Chronic Tab
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)
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)
RIGHT SIDE TOP
Physicians Orders
Physician Order #60110
Discharge Instruction Sheet #70060 (if inmate
released from prison)
Doctor Progress Notes Tab
Progress Notes #60111
Nursing Progress Notes Tab
Sick Call Request #GLF1002
Progress Notes #60111
Transfer Receiving Screening Form #70009
Emergency (Body Man – Non Schedule Event)
#70007
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
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 TOGETHER
Short Stay Record
23-PHS Infirmary-#70048
Under Hospital Tab
Emergency Room Records - Free World
gggggg End of Right Side ggggg
10 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
11 of 13 AR 601 – March 1, 2006
INMATE MEDICAL RECORD FORMAT
Annex D to AR 601
Page 3 of 3
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 TOGETHER
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 MOST RECENT DATE ALWA YS ON TOP AND
DESCENDING CHRONOLOGICAL ORDER
12 of 13 AR 601 – March 1, 2006
PHYSICIAN ORDERS
Name:________________________________
Cell:_________________________________
D.O.B.______/______/______
Allergies:_____________________________
_____________________________________
Use Fourth Date: _____/_____/_____
DIAGNOSIS: (If
Changed)______________________________________
_______________________________________________________
_______________________________________
GENERIC SUBSTITUTION IS NOT PERMITTED
Name:________________________________
Cell:_________________________________
D.O.B.______/______/______
Allergies:_____________________________
_____________________________________
Use Third Date: _____/_____/_____
DIAGNOSIS: (If
Changed)______________________________________
_______________________________________________________
_____________________________________
GENERIC SUBSTITUTION IS NOT PERMITTED
Name:________________________________
Cell:_________________________________
D.O.B.______/______/______
Allergies:_____________________________
_____________________________________
Use Second Date: _____/_____/_____
DIAGNOSIS: (If
Changed)______________________________________
_______________________________________________________
_______________________________________
GENERIC SUBSTITUTION IS NOT PERMITTED
Name:________________________________
Cell:_________________________________
D.O.B.______/______/______
Allergies:_____________________________
_____________________________________
Use First Date: _____/_____/_____
DIAGNOSIS: (If
Changed)______________________________________
_______________________________________________________
_______________________________________
GENERIC SUBSTITUTION IS NOT PERMITTED
Disposition: Inmate Medical Record, right side and Pharmacy ADOC AR: 617,631
Annex E to AR 601
SAMPLE
13 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 mode of administration
__________ wrong dose ____________omitted
__________ wrong time ____________transcription error
__________ wrong medication ____________dispensing error
__________ illegible ____________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).
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
________________________
___________________________________________ _______________________________
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
SAMPLE
