Inpatient Record Review

Patient Name, DOA, Planned D/C date , Age, Diagnosis, Reason for admission 580.8(a)(2), 582.8(a)(2)

Informed of rights, MHLS 9.07

Assessments: thorough and comprehensive, include strengths, needs and recommendations 580.8(a)(2), 582.8(a)(2)

Psychiatric asessment, AIMS

Social Assessment: cultural assessment, education assessment/barriers to learning

Physical Assessment: allergies, special needs 27.5(b), 527.5(b)(10), 580.8(a)(2), 582.8(a)(2)

Nursing Assessment

Risk/Other Assessment: lethality, violence, falls, elopement, trauma, nutritional

Substance Abuse Assessment

Legal Admission Status: documents present 580.8(a)(2), 582.8(a)(2) Part 15 &17

Advance Directives & Preferences/Health Care Proxy: previous, current, medical, mental health 527.7, 527.7

MD Orders: timed, dated, phone orders countersigned w/in 24 hours, legible, rationale for med changes, medication over objection justified 27.5(e), 580.6(a)(8), 582.6(a)(6), 580.8(a)(2), 582.8(a)(2)

Special Treatments justified and monitored: restraint, seclusion, ECT, observation levels 27.7, 27.9, 527.8

Consults requested as needed 27.5 (c ), 580.8(a)(2), 582.8(a)(2)

Leaves/passes: rationale, approved, monitored Part 21 580.8(a)(2), 582.8(a)(2)

Consents available for: release of info; ECT Special Procedures include: purpose, date, witness, time limits 27.9, 527.8, MHL 33.16

Treatment Plans: intial, comprehensive 27.3, 580.6(a)(2), 582.6(a)(2), 580.8(a)(2), 582.8(a)(2)

Treatment pPlans include: goals and objectives which are patient outcome oriented, methods and frequency of treatment, patient involvement, family/collateral involvement 27.3(b)

Treatment Plan review: relate to stated objectives, revised as needed, patient involvement, family/collateral involvement 27.3(d), 580.8(a)(2), 582.8(a)(2)

Progress Notes: relate to treatment objectives, discuss significant events, reflect activities, groups, education, staff, interventions, medicaton changes 580.8(a)(2), 582.8(a)(2)

Discharge Planning: begins at admission, involves patient, family, collaterals 27.4(c ), 580.6(a)(4)

Discharge Summaries: reflect course of treatment and progress toward stated goals, disposition and aftercare arrangements, crisis outreach availability 580.8(a)(2), 582.8(a)(2)

ECT: Verify that records show that: ECT staff are carrying out their roles and responsibilities, Pre ECT medcial order signed by the ECT psychiatrist, Proper consents obtained, Notes documenting each session, Progress notes completed (at a minimum) after every 2 sessions, Justification present for exceeding the number of planned session, Notes reflect that necessary procedures were follwed during ECT sessions, Presence of a summary note done after a course of ECT which evaluates the therapeutic outcomes, reviews any adverse effects and plans post ECT patient management.