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Comprehensive Assessment Tool

munt-MivLO BtMAVIUKAL HEALTH SYSTEM
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o Previous Patient

o Patient Not Admitted

,dmitted Patient

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IDENTIFICATION INFORMATION
Patient Name:

H
I

Date: ?// g'//3-

Sex:

Age: 2~2=z

Beg. Time:

6 Male

DOB:

/

Accompanied By:

/^1 & <FF-Voluntary

Legal Status

End Time:

o Ml Hold

o Female

Date/Time Initiated:

o Transferred from ED

CHIEF COMPLAINT (In patient's own words)

Why are you here today? (subjective-patients words);
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Reliable Informant? ^Yes o No l^me^__^^y7j2g:^7^^^4^£^s^_Belatlonshlp^/^^^^^
PRECIPITATING EVENTS

Briefly describe the events that qccurred In previous 24-71 hours which prompted an assessment today:
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Temperature:

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o Stable at ER:

Intake steps taken to keep patient safe:

Belongings Separated

/
p'lntake Room H ^

Patient Monitored via Camera

OBS Rounds

/

Family, friend with patient
Patient Wanded

<J Intake ID Badg
PRESENTING PROBLEMS/SOMATIC SYMPTOMS
i

MAJOR LIFE AREAS

ADMITS

DENIES

AS EVIDENCED BY FREQUENCY, INTENSITY, PURAVON

Problems with work or school
Grade/School
Occupation/Source oflncome:

?elerloratlon in hYgiene/grooming

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Social withdrawal

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Loss of energy/interest in activities

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Ability to parent
Other
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MANGINES,
Revised 1/2013

exhibit

CARSON

MR# 000014338 10/24/1990
A# 01177210018 07/18/2013
DR. N. HOGAN

M

IPL

HBHS 0024

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AS EVIDENCED BY FREQUENCY, INTENSITY, PURATI.ON

DENIES

ADMITS

LEGAL HISTORY

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Does the patient have any legal
Issues current/past?

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Is the patient currently on
probation/parole?

"H
 A5 EVIDENCED BY FREQUENCY, INTENSITY, DURATION

DENIES

ADMITS

MILITARY HISTORY

If yes, which branch and type of discharge?

Did/does the patient serve in the
armed forces?
SPIRITUAL/CULTURAL

ADMITS

DENIES

AS EVIDENCED BY FREQUENCY, INTENSITY, DURAVON

Cultural/Spiritual issues affecting

assessment and/or treatment

SUBSTANCE U5E

o Denies substance use - continue to next section

Have you used any psychoactive or mood altering substances within the past 12 months?1 JfNes
^Cigarettes

o-Alcohol

'

!

o No

^Marijuana

o Pain Meds

o Tranquilizers

o Over the counter

o Heroin

o Hallucinogens

? Cocaine

^Opiates

o Inhalants

o Methadone

o Stimulants

o Other

Amount/
SUBSTANCE CHECKED

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Age of 1st Use

Frequency

Duration of Use

Method of Us*

Last Use

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patient have a history of withdrawal, OT, blackouts,

en was
was the
the last
last Incident?
Incident?
If ves, when

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What Is the longest period of sobriety?
When?

Current Withdrawal Symptoms:

4/TVo symptoms reported

o Nausea

o Fever/Chills

a Delirium

o Agitation

o Tremors

o Cramps

o Vomiting

o Diarrhea

o Anxiety

o Aggression

o Change In blood pressure

Symptoms Checked

Frequency

Duration

Most Recent Complaint

9~
MEDICATIONS/MEDICAL

o Denies any medlcatlon(s) - continue to Current Medical...
Current Medications

Frequency

Dosage

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How long on

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Prescribed by

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MANGISES, ^10/24/1990
Revised 1/2013

MR*
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0/2013
A#
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DR

N. HOGAN

HBHS 0027

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PHYSICIAN'S ORDERS

Dat8//Time

(as indicated)

RATIONALE

PHYSICIAN'S ORDER

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HIGHLANDS BEHAVIORAL HEALTH SYSTEM

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8565 South Poplar Way

HEALTH SYffTUM

Littleton,' CO 80130

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.

MANGINES,

CARSON

A# 01177210018 07/18/2013
DR. N. HOGAN

WHITE - PATIENT CHART

10/24/1990

MR# 000014338

YELLOW - PHARMACY

M

IPL

PINK - PHARMACY

HBHS 0059

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M/iTands BEHAVIORAL HEALTffSYSTEM

Nursing Staff Shift Progress Notes

III rf-SVlORAX.
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^SP I (Q 15 Min) ? SP II (Line of Sight) ? SP 111 (1:1 = RN note Q Shift) ? RTU (Restricted to Unit)

Revels:

Check all that apply:

^ Assault

Suicide

? None
? Medical:

Precautions:

? Fall

Q Elopement

^^exually Acting Out (SAO) ^Victim ? Aggressor

Ef Compliant ? Non-compliant*
? None This Shift
Report of medication effectiveness in patient's own words (Required on Day and Eve. Shift only):

Medication:

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Peaci^L
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Nursing Shift Progress Notes: (All * items require a note to give details) Do
Self Harm:
Aggression:
Thought Content:

RJjL.

? Self Harm behavior/plan*-^^

? Ideations*

? Denies

0 None

(<T>
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? Ideations* ? Verbal Threats*
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0^Cooperative ? Withdrawn ? Intrusive

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? Other'
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? sao*

Alfect:

? Pushes limits*
? Manipulative ? Negative
? Depressed ? Angry/Irritable
? Happy
ongruent DBIunted
? Ipcongruent
? Bright/Full

Appearance:

? Neat

Activity:

? Attending structured activities ?"self ADLS

Behavior:

Mood:

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GEfClean

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TsiSL

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?
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patient description of symptoms; staff observed behaviors, education and interventions based on the
\ Si 'rogress Note to include
individualized Master Treatment Plan, patient response to interventions and any significant events.

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Signature/Title:
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MANGINES , LCARSON

MR# 000014338 10/24/1990
A# 01177210018 07/18/2013
Revised 04.12

DR. N. HOGAN

M

IPL
HBHS 0103

;

 :

li

lj  'Highlands BEHAVIORAL HEALT®

YSTEM

Nursing Staff Shift Progress Notes

IM.tUVIORAl.
i. •!

?

^Jeyels:

t (Q 1 5 Min)

? SP II (Line of Sight)

? SP III (1 :1 = RN note Q Shift)

? RTU (Restricted to Unit)

:

i

lfP Check all that apply:
?"S uicide

? None

Precautions:

? Medical:

?-Assault

? Fall
? Elopement
n-Sexually Acting Out (SAO) - n-victim ? Aggressor

ja^Sompliant

? Non-compliant*

-

il

!j
? None This Shift

Medication:

I:

Report of medication effectiveness in patient's own words (Reauired on Day and Eve. Shift only):

L

/»¦» aULjl

:

Nursino Shift Progress Notes: (All * items require a note to give details)
Self Harm:
Aggression:
Thought Content:

? None

? Ideations"

? Denies

? Ideations*
Appropriate ? Grandiose*
Cooperative ? Withdrawn
Manipulative ? Negative
J2-Depressed
Happy
? Incongruent
Bright/Full
? Clean
Neat

^H^None

Behavior:

?
?
?
?
?
?

? Verbal Threats*

^Q-Self Harm behavior/plan*
? Aggressive*

? Paranoid*

J3-Sisorganized*
? Intrusive
? Pushes limits*
? Angry/Irritable
? Blunted
? Showered

? Hallucinations'

? Other'

^impulsive ^-Q-Restless
? Other*
? SAO*

? Sad ? Other*
? Manic
^Q-tTabile
? Flat ? Other*
j2-Anxious
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? Other*
^OTDisheveled ? Poor hygiene
? Assistance needed with ADLS*
? Attending structured activitlep0'~3elf ADLS
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Mood:
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Appearance:
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progress Note to include patient description of symptoms; staff observed behaviors, education and Interventions based on the
individualized Master Treatment Plan, patient response to interventions and any significant events.

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? Day Shift Note ^"Evening Shift Note

Date: 2'Uklfak.

k

Time: AZXZ 40

TS Night Shift Note
Signature/Title:
RN Signature:.

Dmmigines ,

CARSON

MR# 000014338

J°/24/1990

A# 01177210018 07/18/2013
Revised 04. 1 2

DR. N. HOGAN

m

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HBHS 0104

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'M'igflands BEHAVIORAL HEAL'

Nursing Staff Shift Progress Notes

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nfrj.\yrort.Aj.

SP I (Q 15 Min) ? SP II (Line of Sight) ? SP III (1:1 = RN note Q Shift) ? RTU (Restricted to Unit)

\vels:

Check all that apply:

ts§

SYSTEM

? Elopement

^Assault

^ Suicide

? None

Precautions:

? Non-compliant*

? Compliant

? None This Shift

Medication:

? Fall

(T^fepxually Acting Out (SAO) -ft Victim ? Aggressor

? Medical:

Report of medication effectiveness in patient's own words (Required on Day and Eve. Shift only):
Nursing Shift Progress Notes: (All * items require a note to give details)
Self Harm:
Aggression:
Thought Content:

? Self Harm behavior/plan*
? Aggressive*
? Other
? Hallucinations*
? Paranoid*
Appropriate ? Grandiose* ? Disorganteed*
? Restless
? Impulsive
? Intrusive
Cooperative ? Withdrawn
? Other*
? Pushes limits*
? SAO'
Manipulative ? Negative
? Sad ? Other'
? Manic
? Labile
? Depressed ? Angry/Irritable
Happy
? Flat ? Other*
? Angry
? Anxious
? Incongruent ? Blunted
Bright/Full
? Other*
? Disheveled ? Poor hygiene
? Showered
? Clean
Neat
? Assistance needed with ADLS*
Attending structured activities^ Self ADLS
?Other* '
Symptoms interfere with ability to attend to ADL or groups *

? None

? Denies

? None

? Ideations*

?

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Night Shift Note
? Evening Shift Note
Signature/Title:
Time:

RN Signature:.

im

2_

WANGINES ,

CARSON

MR# 000014338 10/24/1990
A# 01177210018 07/18/2013
Revised 04. 1 2

DR.

N.

HOGAN

M

I PL

HBHS 0106
;

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!;§

%

m

HIGHLANDS BEHAVIORAL HEALTH SYSTEM

ADULT UNIT ONE

MULTI-DISCIPLINARY GROUP NOTES

DATE:

Ijr?^

FRIDAY

i

..

...

Time In:-

>¦

.•

•

•.

.

: . ....

!

.

Time Out: &"%€> . . \wN/-v.' Objective:, identification of Patient's individual goal(s) for the day and education
V '."A.-• about coping skills.'; •••; /YiY/iA
Y-'-'V V.'A
'
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V"^
Goals/Safety PlanniBS^.-^ / /: ¦;
i",',. • ; :
v.-; >'?¦¦¦¦¦ St
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Group.-;-:. L? : \I/)Ja J V Paf'er,h Attended., :. "

'C^BsIltiad^^ BTO • ; • Meeting / Inappropriate;.:: D/C,/:. Excused

Y:

Signatiu-eLHq^^i^OA

Patient response or law ot response: tit p;

Discipline:,

V. ¦

Affect:

Time Out: 11 30

DAnxious ^Labile DOther

DBIunted

DFIat

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,

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Time In: 1045

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Thought Process: ? Focused ? Insightful ^Unfocused ? Distracted ? Loose QPsychotlo
Behav lor: 3f Engaged DMonopollzIng Clntrusive ?Hyperactive Dlncongruent Affect
Q Distracted

Adjunctive Therapy

Mood:
Signature:

? Anxious

? Superficial

? Withdrawn

? Cooperative

DOther.

pf Stable DDepressed ? Frustrated OAngry ? Guarded ? Bright DRelaxed

Problem Solving

oncentration

Group Objectives: Fo£us/Q

Team Building

SagTaii^tijp

Positive Coping Skills

Caisure Skfii? ^erclsfey
Mood Improvement

Relaxation

(jl)
AT

Discipline: OT

Problem Being Addressed:

Did Not Attend

Patient::/4tended^>

Refused

RTU

Meeting

Inappropriate

D/C

Excused

Patient Response - Therapist Observation

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Time In:. 1 145''VVV."v"' i'I- I
'
Stiiikin Thinking (Week 1)

or CBT 'forT'sycjiosis

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... . . ...

.

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f: • ^S-Dlstraoted ... D Oriented:". ?'Disoriented;, ? DetachedD Withdravyn' f DOther-"- '•

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Y •" M?#?. R

; Grdlip objectives: Learn';..demonstrate; practice, boundaries, iimits:i: personal space.":-!
.
Signaturm^^^^. i (Week.1); Learn;, demonstrate, practice slaying present, breathing; grounding. • •; ! ;
Discipline: Social Work " .,
Problem Being. Addressed: •

"

Patient: Attended

Did Not Attend.

Refused:

. •' .

RTU

'
:• .Meeting ' : 'Inappropriate

D./C. .. Excused-

Patient response or Uck of response: (If patient did not attend", pleaseexpjpjri) . .

MrA
m

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MANGINES,

CARSON

10/24/1990
MR# 000014338
A# 01177210018 07/18/2013
DR.

N.

HOGAN

M

I PL

HBHS 0130

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MEDICAT QN RECONCILIATION FORM

m
m

Date/Time:

Weight (lb):

_ Height (in):

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ALLERGY/INTOLERANCE

REACTION(S)

ALLERGY/INTOLERANCE

Smoking Y/ N

weeks gestation) Breastfeeding?

Pregnan(? NO/ YES: (

0 ji^jll /

REACTION(S)

REACTION(S)

ALLERGY/INTOLERANCE

] IrAx^Jo)

3

5

2

4

6

MEDICATIONS PRIOR TO ADMISSION
[List all medications, nutritionals, herbal supplements, and pumps or patches used to this.visit or admission.]

rfSTOther;

?Pharmacy:

? Provided List
Source'.fei^atient JZI Family'
Obtainedby: 4//r' f /^oq^ y2-

(licensed staff)

and

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RESUME MEDS ON:
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DIRECTIONS

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ADMISSION:

MO Date/Time "Jfi&'bS ^Ljc)

V.O./R.B.

DISCHARGE: V.O./R.B^

(dp p

MD Date/Time

Based on your visits at Highlands Behavioral Health Systems, you may safely continue only the medications circled.

DISCHARGE "YES" above. If you have any questions, please contact your primary care physician.

PRESCRIPTIONS GIVEN AT DISCHARGE (see Physician Discharge Order)
MEDICATIONS (and Strengt

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**Please brine this medication record with vou to vour nhvsician office or on return to the hospital**

Page

lilpiS

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of

(_

Medical Record Copy

Highlands Behavioral Health System
8565 S Poplar Way / Littleton, CO 80130
720-348-2800

MANGINES,

CARSON

10/24/1990

MR# 000014338

A# 01177210018 07/18/2013
BEHAVIORAL
:-v

MR (10/08)

DR.

«'

Original copy - Chart

Canary - Pharmacy copy

N. HOGAN

M

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Nurse Identification
,  nH
Signature /?

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Nurse Identification

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Signature

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Date/Time
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PHYSICIAN

PATIENT'S NAME

MANGINES,

PRINTED

CARSON

10/24/1990

MR# 000014338

A# 01177210018 07/18/2013
DR. N.

HOGAN

M

IPL
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i

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PHYSICIAN

PATIENT'S NAME

MANG INE S ,

PRINTED

CARS ON

10/24/1990
MR# 000014338
A# 01177210018 07/18/2013
DR.

N.

HOGAN

M

IPL

HBHS 0149

Init

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CARSON
10/24/1900
07/18/2013

MR# 000014338
A# 01177210018
DR.

I PATIENT#

HOGAN

M

IPL

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Vital Signs:

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Bowel Movement > -18 Hours Ago

Parameters of abnormal vital signs < to 1 3 years old:

Parameters ot' abnormal vital signs > to 13 years old:
•

Systolic 0/P;e;'0 or >150

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Systolic B/P < 70 or >130

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Pulse > 1 00 or any irregular pattern to palpable pulsations

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distress

•

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Temperature of > 1 02.5F

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ACTION

NOTES

Date

Diastolic B/P <_50 or > 100

Date

STAFF

RESOLUTION

Time

Time

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MANGINES,

CARSON

MR# 000014338 10/2 4/19
A# 01177210018 07/18/2013
DR. N. HOGAN

M

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HBHS 0161

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END OF SHIFT SIGN OUT/ Signatures:

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? Elopement
? Fall

? Sexual Aggression Q Seiyral Vlcllmlratlon
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? Nona

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MANGINES,
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;e of RN Leaving

CARSON

MR# 00001433B

A# 01177210018 07/18/2013
DR. N. HOGAN M IPL

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06:15 A

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13:45 P

2 1.45 P

14.00 P

22-00 P

09:30 A

14:15 P

22:15 P

08:45 A

14-30 P

22:30 P

07 00 A

14'45 P

22:45 P

07' 15 A

15:00 P

23:00 P

ji

t

07:30 A

c&l

I

I 13:45 P
' 17:00 P

08:45 A

1

Location

Initials*

16:00 P

08:30 A

O'OOA

A

Behavior

TIME

Initials'

Location

A

08:15 A

00: 45 A

01:30 A

Behavjqr

I

? RTU; Restricted to Unit

? SP III; (lit - arm* length)

07:45 A

i

00:30 A

Room: '2<Sl€Q5

? SP II: (Line of Sight)

I

OT=Activity Room

5=Withdrawn

LEVELS;

.

i

LOCATION CODES

BEHAVIOR CODES
1 = Awake/Alert

TIME

I

23: 15 P

M

13:30 P

23:30 P
23:45 P

'Two staff initials for staff-staff hand-offs

A :Document lime of level status change

Initials:

StaffSignature:

I,nitidis:

Staff Signature:

initials: j£L

StaffSignature:

Initials:

Staff Signature:

Initials: _Q\ Z

Staff Signature:

Initials:

Staff Signature:

Initials:

Staff Signature:

Initials:

Staff Signature:

——

!

E4U3 OF.5HIFT,5)GN OUT/ Signatures:

u

0730

Signature of RN Leaving '

Gki^muL£Ai

/-

PrecaMtlpn Typs;

/

J2 Suicide
? Elopement
? Fall

? Sexual Aggresslorva Sexual Victimization
G Medical Risk
C None

^ETAssault/Homlclde

1530

awre of RN Leaving
iigna

MANGINES,

1

.2330
of RN Leaving

CARSON

10/24/1990

MR# 000014338
A#
DR.

07/18/2013

01177210018
N.

HOGAN

M

IPL

¦sion 03.01.10 Highlands Behavioral Health System

HBHS 0187

;

 I.

i

' "

Hifjllands Behavioral Health SjHtem
Code Blue/Medical Emergency Documentation

Date:

Time: Ibf)D

Unit: _J

^ Where was patient found? 1 A

]folS lOfi

Who found patient? vil M Off

Condition of Patient when Discovered: iPHr^SpcO^iV'-C j
m
A M Maik/

Qjllkd

Action Taken:

Call gllLicJI uia jgofL C teak

Time Code Blue Called: f)'

-bid QpoL fXLia

Time 911 Called:

Staff Responding and Role:

4.

ou\ zm2 ijkm).
^Bathci1 Mdrjh]/ T/O

1.

2.
3.

5.

Mr\'jaaa

~pO

jfekfi£ .

6.

- ^u^yyu/^ /

Action Taken: 4 J/\j

  <0i izia qaE thrw.

(pp "r/Uv m4 . CA feZ/A. MOCIiMC

uuidaij^i

-\pJawg-\r<h yi<?(yd w ztff/ffM/rQtzo^OA-

£LjiU\da,H-f<'tvYtr&/-^_

jzCTime CPR was initiated: t/
am/pm by:
H
^Time CPR discontinued: QcfcT) am/pm (if applicable)

o^4irway checked

^Designated Person(s) Performing Chest Compressions:

patient breathing? - ¦•¦

•

¦

. II tzfAirway repositioned ~Z ^ ^

'i ,er AED applied at

5
S

? Designated Person(s) Giving Breaths:

by; ^OU

Cj^ad-- bM to&fofohii -

gjgW) ==? Was patient (JefibrilWted? Yes/No When?

am/pm

? Other staff performingXT'R:

^Results o^defibnllation:^^^,
OxygeivStarted at

" A>
»

n^Akk,^lrni}Af\ \\riW,f

^Circulation checked

&

_

gdDpes patient have a pulse?

.

_

—

<4- "g^/% y(Ovdn/\ "Jniifjd. AfT) n ftyvh ifa3 jgc.

rX}( I

y

i

\Avt W

iSljuyJk rate via nasal cannula/mask

(Z^du^bUl(pdi^t{L-(We^C—
ital Signs: (q3 to S minutes)
Time

-U

o

cn

mm:

i

B£

Pulse

a

a

Resp.

a

Q

P. Ox%

Time

Pulse

BP

i

P. Ox%

Resp,

3

L

n

I?tr

'A-

1

5-t

P

Medications Given: ? Yes ja^o -- (.Vhka )/\ A-M,
ft

Time

Medication

Route

Dose

S ¦§
—

Sr

vh

=-D

fl
M,Q

Srd

! +

'40

J
A#
DR.

'i, 6 Version 8.2.2011

>ju

MANGINES , CARSON
MR# 000014338
10/24/1990

01177210018
R.

BERGES

Sie

07/18/2013

\

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I PL

J '
HBHS 0206

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