Age/Sex: .. | Attending: ful11 ..I.:.

'
un11. Juuu0c Account #: Jo1u.0.l/oJ

Admitted: 10130/09 "' | io Location: J 2A

Status: |1` . l! Room/Bed: J.222
l111..:1vc:rlliu11 |)c: ...[.I!| .Is |||CLions
.` l, O`iiO keco1dea Documented
Iuu.uu. !'SY: /ull.11 |I1'.1Ui1`..I..ll!.. -::t:.'lcIll |.otL1iucu'
1lcoiI:..1 re,'llet1t

UP.
||iiLc 1
lluncl O`:;:.
Eye:. Llper1
|c:L '|..tJ l\c.].I't:
..| v.luI |c,|.|i,;
|OL|l|.l+I
Muvc1r1e1IL
Movement
MOVtlllCllt
|Iui Cu11111clll".
|lll \I.'
.c\ ii
|1_Hl |:_
.cTL Leg
'l.|
',c tui. 1..t/I 111 OJ | Ao't:ool11'nL
.Ll |~ o:.`l`
.l1 Asce'clllerll 'i<l)P
1.0. |lq.u |HlIiI
l1eur111g ||i.u|'|llCI\l
|:JuJ |l|l|1. 111t
Mucuu' Me11101a1tt'c.
|c!I |:c.
R 1,Jt1L 'ic.
.:.I Currrill .
- -- L.11'd lu/,i_,Lu .| -:`.l|c!
Cu1\ll1Jvo:Cul.r |. .|!.`
uU.... .::iictl .|:
' | .lur
..
..J lljll 6 `l.\I:
JILi lM'lr11rE D |
1Jll .\!
U0Jll lJ11I nU'p !ul |ul1n! C;re Liv<'
CLINICAL Jucd||u1^1!uu lECORO
' |Il1 11 0.'. 0u ul U '
'i0 Intervention ue:c1jL10| : Ls .||t(Li uno
.-.lIvi Ly .t0u:u |c.oiJcJ Oocu11<111.ed
1002002 PSY: AuT11 n:to|,/.y:t+: As:es:,11ienl (C<Jnl 111uedl
Does |ut1 ci novt o |o0u+oii
B'utIuL1t Defir1lldLOr.
|u:u1vu:Uu l u LUl'CIi` :
Circulatory S:c::lli:I\ lllP
Altered |.u+uIoy Site
io1+c1 |u1c to Affected 'lc c.u1u:cd
Pro.irrral Pulse L!uJuCEI`
/unt of Edellld loted ProAillldl Lu Affected '\1c
Lol''oI |uf11 l Pro,imal to Atrected Site.
Skr Prximal to 1TcClcU Site
Skin Co I or Pm" i ||o 1 l0 Affected .Hc
`L!'uI`l |IUTiu1 |u Affected Site
uJo1 |u!:: tu Affected Site Evaluated
u1.Iu1 |u!.0 U1ardCLer
|Oun! o' |ucTu Noted D Stu1 AfIecteU ':1c
Capi 1 lary Refil I D1>tol lU Affected Sie
.|1 |1SIu1 !0 Affected Site:
.i1 ,D1Dr J1.Iu to A f ectcU ::u
Sensduon D l olu1 LU Attected .l-
Circulatory L0ICl\
rc']!:!|, As-essment ---
1'1u111
Age/S.x: .J '
Uni t : Juiu.o..
At tendi ng: RuL11.f.' 1 ci1rLl
Account J: .o+uu.1nJ

.
JI I [_I NI'. I 1111'AE u |

|:t
Aun1cu: lU/3U/(J0 dl 11: JC Location: . 2A Doin1r1 1 on |0S|11u Patient ':tc '1V'
|lNI CAL DOCUMHIT l\I U hLLUrU
|I1IIl ! 11 0.0 :! .:
Stu!08: DI' HI Room/Bed: J.. .:
IiI.tl+I UL:!j.! ll .!5 UI1c LI1O1.
1 ...', |uicd Recorded Jocu.||.nteu
l,
IlU.0u. |'| uIIi lllolt.Jl'Yf'-y'.Ltlll' -.:.t:.:.iI.H1 ! C.o|L1|iud.
Rt; l |ulUIy Jll ['
Pre;iuuc |c:l! U1 ::!|.|
TolJCCO Use Nov O! |ii 'icvJu l. |l0I\I!i;
O|lL
|I0 01 !Ulu..
|u| S/L 1 11s er day
'J |tJ jy.1;
q|.l` +htt
l!U1i1 kcierrcl.
.t1I .| .`t..u11\l lllSlluLlluJ _i.:l | l! jl1ll ulU.U1 Ccrcglvc/'-
+i. I |. ..U.|.|
Is Pacicnt |`:c1L
/|1 |o jcI'II 'c : C:u11Lag1ou 'c,|1 |u | o1y i1i1cC1I1 u J! LUl_ `CccU
Red SLU
| pcL ie1L (urTently e.,e1 1 enc11;g . .! I0luv11ng 1 u. dc.S
tJorlJ c1Cl 1c . II
Fever icolci llu U 4' u
Cough? N
hr''. 1:Iciil lotqn |-uLc Lliui : icl:`
Couyl n.| |.l ood produced'
`0!`L !IuCul
lliyht .Wcu!:

N
Une,lcreu weignt loss7 N
|uliyue? N
Hu;li` N
|:. ..|+.,lI.'+ :Oi .|J | dl.lergie- c .i.J. i1iTC1IUU'! N
(37 o '!
(not itlated O
d 11 ergy 0I COPD)
l 1t.:11u1 .. ''.UI, O1 |i: u pus1L1vc 'fB .:i `Ci N
Cluse CUIu.l .!l persun IU ln. TB? N
From |iL:tvcu!1DJ Ut5LI1|l1U| Sts u.reel ions l 1u111
A,livi Ly dcLui|cu 'cc0iucJ |UCU|LU!Lt1

1002002 PSY Admit History/Systems l.:u..+cuL \1OIIiucd.

L1U5c cuilutt w1lH any jcI.UI hcving an l11tlue11Lo-1ke l l |1it 'I
Ill |u1i1 l of |Ul `C1:cU |uu:1JS Resp1raLOry JTC1uII |U1\\ L1 |iIi, i-
NEGATJVE NEGATJVE
Mask u||1`U |o'`t|` i`.J1. ond receiv19 dIIJ!/:|dI'l'I.| !ti1TL.
rC.|ra tory Assessment \J\f'
RUL Breath SounLls.
'|| Hicoth Sounds
LUL Hicu!h Sounds:
|L o|uU+ `0UtU5
Resp1rdtory Etrort
Cough
'Ul| Co1u|
,,uLu+ Consistency
`puLum Alount
Cap1 l lary rcT!11
Oxygen/Resp1 |u`i As'essmenL ---
1 O"ygen
u Delivered Per.
u. 'lti. / Minute
Sp02 Continuous Mor lUting:
.pu.1 lJLci cU FjJc0
Kc5|+JdloI( Lm|Cl
~~~ cu..i0`il.l1nu1 /''t:'.Cil
^c:c: . l
Unit # : 'u01:,
Admitted: l0/3(J;OC u! !d
Status: |` |'
lme1,c:11L10n Oe'.,u'111L1u11
ilcll<lly '.+i:
Attending: l\O!.l..I`I
Account . JH40U2l/4H3
Location: J .A
Room/Bed: J ... |:
'.C0iIu
'

SLs Directions
uJ.u:ntu
1002uu: PS'I. {1Uiilll |1J1I`,/``1:ill: F..:.t..' .|c!l '.o|l:ucu.
|o1.Ilt:.i lilJl HA 't.
Od'I1I'|l:1JI\d1 A:,SeSClll<llt |l
ol LOIIi|lI!il
1UIII1+1] ||I`JUt' | lItVJo' .+ |I.u:.
Ct!11Le11Ll.ptai'cJllCC .! E111es :.
. .:o.1 .u!
|' u oJWc| Sou11us
|uu HJcI ..u.J
11 , cc' .Juil:
I .1 oc.c Huvt111t11 L
lJe:oLl'1L1on .! .Io!
L0/30/u'
uJeI
lUJICU 'oll 6 Nc111 knJcr
l\IJC.Ju111en | I!II/l\1I N
Di',Le11L1on.
|uod+rHJ:
|c|.uiu T1nuer11e:...
|l+U:I\c,.. IU 'ulju1 |\iJ
luL o,;
GI C01m,11L'
--- lluLr11i ut1dl l:.,C',II.IJ\
',l'jrro o t1u1.1tir1al 'l |1Ul11+!I .o|:'.
'J:
WI IL I ' '/| D |
D01111nion Huspltal Patient Care *Live
'ILF| DOCUMENTATION 'LLu\J

From Intervention Jc:0|1]!1Dn

ActivitJ Occurred
.

'|
JI! ll.':l. ol 0'
.!. ':..|i: | r'Glll
Recorded DOLu111er1Led
lLO.uu: |. Adrn Histoo/S1stems F''c':mtI! |1lI.I`JcU!
tlutri t J I\J I (01111,cnL':
Gcni |Uot:t} F`::.'lk:It
GU fl DEN I ES
oc1 tUJr11ld, Assesouient o|I Y
'0-uu1 Hi story: NOT c.u1! Active
Seual Orientation:
|UiJu u:tJ
c|iuu.L1vUc.+c|0
Reproductive Mcle.
LMP
ALnon11ctl Uri11at10r1
Uri r1e F[|LuIdICt
'ut'+cl:
l Jl|
Agt/Sex: -JJ 1
Unt : JUUIJU l ol :'
AuN1!!cU: ll1U1U' a l1o
Status: 0 1` IN
lnter'Vc:ll Iul |ct.[Jt i Ull
-' |y |..uiitl
Attending: l\uL1,_l<1l11uro
Account *: oJuo1~oo
Location : J F
Room/Bed : J...!
|cctu:u
>
.ts D1 lLLions
uuctrc0tu
l(JUU((' f'''1 |!|I lJ1lU,.'.|cI| ~..c,+cnl ' UILJuLU!
ul'cl` Tyfk.
lJe'.Cr lfJL 1ur1 ul Cdth.Ler |...! .+
|,`.1 u |c.. ,.ii. ..ijl|i
GU ll1i1.1l
Lnuuc | r |!c o:,`'1|iCHl
tr ....l| lJ c||l |.
i.Jo.i ic S;'..Ldll ..lI +
||O\Al 111e tUJIlk:I11
l |1t1cIt. Sy, Lt:ill.
li,.: , .Lt:d! Lom11cr1L,.
--- i'hLcu lu - |.|u1 ;;:.:i+.l
llu:cu\cd.elddl 'l Jt'
McJClllu:,leldal l,''.`||icI ..|
t.cl`.l l .c.! V11dlt'. ,t
..Il j.: .I:|i_
Le l1 ||.| ..|c|l1
h1_Ill |cac |11 1111
_ L, ,"lf<E |

.. `
U0I1H1UH rlospit al |uL1tHl Care *l 1ve*
CL 1 NI CAL OOCUMLIH F1 I ON RECORD
| 11I!J \\.'U._..U .l c.
':JT lJIL!vLI1l Jc..:`]Lo| .l U1reLt l11,
t1v11y Occurred |'ccu|u:u UULc1|IclILU
lUU2002 l`' F0I|1 liiSLOry/Sy>t:rrlS A'ctS'.lllellt \liucI.
Left Lower Extremity:
Ou`uC/Lu1
lu!o`1'
Nlu;u
.o!j1I: U1 Joint Swelllllg/Ter1demess
'lu;tu1oske l eta l Corrrcnt
|un\|!ud1 Assessu1em
Functional AssE:ssment .||l. Y
|uncLl ona l Comncnt :
Phys1cd

1 L1111naL1u11s lnterfor111g w1L11 Lttui1|iu i<LL 1

11L1c:c N
u:r\!c.
ULl1c! ||1|1lui1U. lnteder1r1g .1li hLC1ui1OIJJ Act1v1Lie> |
Descr1be.
MecJ spccicl equ1pn1entlsuppl |. Iot r0ut :c C.. H
'cC1:1 Equ i pn
Do ou EAtrc1se \H u |c_u1t lcsis '
Type u! E.<ec1 SE: RIJHIHllG. WE lGHTS
Frequency of t-:it!:c !n't TIMES A ot
Ariy Cl1ang.: ` Sleep pdtlern:
Hu SLEEP ||do.L.
--- I ntcgu111er1tMy A:,se::srru:11t ---
tl'ulll
Age/Sex: .: |
Unit#: .Ib0::.'.'
Admitted : lU/:iO/O' ul l lC
Status: DIS I N
!11Lc1venL1u11 |'c,L!I,l lull
. vl 0.itd
,
.
Attendi ng: |l!!..I
Account . buu.!c
Location: J 2A
Room/Bed: . ...
|cCo`ucu
'
ls D 1rect10 ns
DocumenLCd
1 uo::uu2 l''r: ildlllll |11`lt..,:.1cIl, -'.:..,;I'cil ICOllLlnuellJ
|i!:_uI!.:l\cj .1 OUll[S
f'11u1 l11stu1'}' J! ctir0n1c ..iI, 11un |'co1'|! .u|l: N
|II 111'Lury uf .!un 111fc:cL1u1i?
|11 Lcuu111<:nJ1) .:.!c1 .l|
||`.I'Lc' Cl ..i UI` df'j'liillhj wiJUllu:''
|ii:cllcc L | VUUllUS ll1d L c ,t:|l||.c ,+UL 0 Lec'1
lIc_o|..l!ll` t!.I:"
u! I 11c I.1 J.;JI\. 1uca L \UIi
{l I lI`I|/\.!.1 ',U
HI l11c1rn11n: 1.nJ |I:':1JIg Cled11tllry/111tdct
# | I llCi, 1011/i.Juu11a uit:;1 nu Ch"nye Odte
1 |I.1 . 1 UH ApfJ'OA 1111d l. n1 L11ou ' HLu!lC:..
f1 |11c 1 s 111 /Wound S 1 ZE \t11
l l11c Iolon/,wund De | (cm
ill l..1:+Oiouui.u :u_.
)I Inc is 1 on/Wound Odor
; I ||\ .idfl, \iuu11J |I.: lI+t: l!Ir:u|+l
/I l!!.I'.!Ii/I.0 lJl'eS:..111y/[1eaL111e11l.
i I I H .o.;1uu11d L.lI+IIv'IL:
_ fil 11 1AMS.1 1111fr 0 |
D01111nion lIU'l'd1 |ul1t|l Care *L+v*
'|1.L. ud.u|t|l!ll| 'tL|.

|iu+ IIIcIvcIl`l'| Description

Act1v1ty utcucu
u
l'I llllt:d I f, .:0. J1 0'
.|. 'i:I lull: |IiI
Recorded UCUlI|CIlC0
1002002 P'Y Ad1111C H1swry1':y:,tems /s.c::||.c.I .Ji:II 'UC(J
| lnc1s10111wound Locat1011
#2 lnc1s1011/Wou110 Type.
{, llI`IllC.I+d Dressrg Clean!Dry/111tact
#2 lnc1s l+IlJ|Uu|U |ie..1 LuI_C Date
#. IC1`l|1 Approx1111ated Wit11oul Reoness
j. Incision/Wound .zc |T!
#2 Incision/wound Depth (cml
#2 lnc1s1011/\.Jound |uc.
I nc \ :! on/Wuunu UUU!
|. | nc 1 . 1 Un/ Wounu u|+io_c |ut
;. Inc \`on/Wound Dress i ng/T |culIIl
#2 lnc1sio11/Wound Corrrent.
'||..| |!.!11 .l.
Age/Sex: . |
<
, i 11 | I l.| 0lI~l .

''., ..
Unit #. 'U0|u.o+.
Admitted: !u.''U!lJ c| |l"d
Status: DI'. .Il
Attending: Hol,.i
Account . J0001783
Location: J 2A
Room/Bed: J 222 lJ
Dom1111on Hospllal |ul-n! |uic 'L1c
L|!'L. DUCUMEfH AT |J| RECOi<D
|t 1r1Lc:d 11J.: al li.
lI.(.(1on 1|c:.i lLlull
.+' Occuic:c |:iu-u
JJ|0 I' Y
GLL bL,Lfj[k 20(S
Allrr11L ll1"tu1y1SyLe111::, A"e:oflldll I
'|o1I .J1L1CJ11:,'.
l|l1 'UIu
''+L| .1J;+ 1l!ut1u11:,.
NONE
|iU.oLii.
'|: Cnrec[lons
Docurcncd
'0Ui`!1uucU
'I,,|. '/<,c,uul 1[1rul10r1d |.-|o| Al.Juse CJ1' Neglect 111': N
|V\ucn. .c cI f'r1ys1cdl anu/ur PsyU1olcy1cal Abuse N
Doe" tr1e PJt1ent Feel Scfe at Hume Y
From I nterve11t 1011 uc:0:pl i un
Activity dtCuiU c..iucl
i0UU0. P'Y Adrll H1:tury1Syslt111s Ac:essrent '
Motor /Act l Vl |} NCrrlid !
----RISK ASSESSMLNT----
Su1c1do ' ldeotion. N Suic1ue Plon7 H
Descr1Le Su1c1dol lhoughts/Plcn/Meons.
l'rev1r1us Su1c1,e Atlernpts
Wr1en/tlow'
IMPULSIVIEU DROVE INTO CAR Atm CAUSlD . CAR c|. LISIOM
UN ED .1U9. iENT TO GEORGElOwN UNIVERSITY HUSP
YESTERDAY HAS EXHIBITED BIZARRE BEHAVIOR SINCE THAT
TIME BUT PT IS POOR HISTORIAN AND DENIES REPORlED
BEHAVIORS
'I lJ1rect 1u11J
Docu111cr11.cu
.:.n'I cU.
IJecLr11,c Auus.:' [Have you knovin o+cu0- 1-it10 has aLtempted/cornntteu .u\uH
.,,...:.11 1cc: ;11lRLJf1klJ\fL o1!i.
----M Llll,\L 'IAI U' |/m1 u|:l.'lL IN SUIT
lel1ov1ur' CLJOERATI Vl
TEARFUL
SUSPICIOUS
RESTLE'S
! HAVE A LOI ENERGI"
llAS ADD
|1l ANX I DUS
"I 'l|L |`'l
'ull:|IC I AL
li '. ! RESTRICTED
ANXI |J'
ll1 1c11Lo L o|1 . Or'ienLed to
ll.0u<Jl1L |i..-' lllDECISJV[
oiOCK I NG
RAMBLING
UlI l` RC l' Itu||'
DI SORGAN IL ED
CIRCUMSTANTIAL
ll1uu<Jhi. Cuilldll. PARANOIA
H:RSEVERAI I VE
COIKEl<N |UH J0o 'UR I fY
POOR MEMORY
i'ODR CONCENTRTION
::..I0:1 DENIES
':p.:cLl1: |lt|li!
HESITAIH
kli'EAlS 'ul.1!.|l|
lit1en /How /Re 1ct10n/ I rpac t
AJdn10nal Su1c1dt Risk t1c1iH | u |1y |l:v1D|
Sev d11.xiely/pc111c/ay1 'l
IDS \ORK AS '1Hl''db
liu1111c1ual lde"thi11 N liu111ICIUJI |i.i N
uc,01Lc |Io||+616u| Th0uyr1ts/f'iilns/Medn"
| l l.1111
A_c/.c: ' Attending: 'J: r`.11`U L
Un+ t : JJuJ... Account : .ct...-o

Aun11!cd: li|'. ol iJ:,d Location: J ZA

Status: DJ' I N Room/Bed: J c..b
I l1!.:I! 1u11 |:.: q,L \lJ SLs D 11-ec l .u|s
l.i1 | Occurrell Recor-cled Documented
iUU.u.:. |` /U.T |11l!}/,.lLJ: A.c..|c: (cont1nuedl
Hom1cidctl1V1ulcnce -i |u!Ut
|/ A
Sc I .u-uc l ve |:u.+|J` Y
.t De-.t1'L1Clive1Han11 |Cu1Ul`'
I rn um ONAL CAR ACC ltl1
THI S L|
.c.1l- Se.t-Destn1CLIVe bchuVIU1S'.
SEE ||0\L
I} kece11t .J..
Fecent Loss. E"plct 111'
lllllniLaled |
LdcL ..`
'.,ti..!l
Desui Le Jyll1v. 1 "'.
REPOIHEDLY P,\IWIOID o SfAH .t P1:YC11I ATRISI.
b/A||i bEHAVIORS R/ CAf{ ACC!DENI THAT |L NOT
1II'/| OF PT .-.I NG FEE LI NG I HAT ||d||L WERE
FOLLDil NG HER. f'T C MAlY. MANY [UfST IO RE HER JOb
SECURI TY 'O Tri!S WRITER
"RES I RA |I`
Tc:ch111 que/Mdr1ulJs / l U+ LU i!J] Pt Conu-ul tr1eir |Iu|.l
' /\IJP1 opriute. PL/Fa1111 ly helps 111l1ent1 fy1n such Techniques
'cJ..:+ 'ond |!u 1ucc: I o k1sk 'u:+ cLi:+il/..|u:
l 01 /Uu '1iu! . l ncreise hyd1oluyicJI .l Y 11Resli'"1nt1ecluciu11
'l1-01111ly |..!J un |IC11u1' iJti1 |.Uh, Ul |t!I`d11!.tC1U.1J\.
lil111i11s | lnclLH.11119 |O111`.u11l 1s Discussed u. Appropl'1ate
----CAf[ 1Nl |1l .|1
1;1,c:s J! ..`i. |!.
l11L :J` Ody.
,
JllLIAMSLi11rlAED

u .'.
Dominion Hospital |u1|! o:c *l1ve*
CLJN!CAL DOCUMENTATlllN RECORD
|1'l JI lJ/U':J dl (JLjJ
From Inter-vent 1 un Oescri pl i 011 `1o 'i.!::
Activity UCU!!tU l<ccorcled 1Jucu111er1Led
L
,
,,}
Iuu.Uu. '. Am1 '1.lJ/`'!|IS Assessment + ||1JU!
Add 1 1l ona l Dr-ugs J: |'.I! ca l U:e N
Type of Drug
Ho,, Often
Ho'' Long Used
How Mucr1
|u.l U'cU
Type U1 Iu_
How Often
|Uw |Ul_ Used.
How Much.
Last Used
Type of Drug
Huw Often
How |Ul UsEd
How Much
Last Used.
Drug 0.t |ClltI\l
Does Pdtie11t Drink Alcoholic Beverages N
Type of Alcohol
How Often
HCw Long
How Mucr1
LiSt U!1|
1|L U1 A lcurio l .
How Ofcen
How Lung
How Much
Last Orin|
Type of Alcohol
Hovi Otten.
-|cohu I \u!I.
|Dw Long
|Uw Much
Last 01i l
'J J|1'\l'! CAl JON PRUTOCOL u.|..l\... .|.L. -,t,i|!' | ..|I
' ||I
Age/Sex: ,: I
Unit #: 'u:i.l '`|.'
Admi t ted : I013U/09 U1 | |n
Status: .!. .!I
lnLcrw11L1un .ct+l1'+
Ac L l v I LY OccurreJ

Attending: l':!!l'1.:
Account #: .o.|..cJ
Locatwn : .
Room/Bed: J c.. |
'-tO.lu

St<; fJ1rectio11s
Documented
luu0u. |1 -d'111 111:.Lury/'ystem::. L.c..|1clll ' |,oii.:J)
|+uu,tu.\.1'J1J1_
ll`t|OI
la lI ,_y .'||: | Swea ! .
AllAlely:
-_11.111Ul1
faLLlle 1'1UrLutt\
-ut11I` D1lurld1ICcS
1+.u! |1.lUl|..l1.t'
l1c.1dJCi1c;1ful |1+: |lJ |cu0
Oi..utJ.1.llUuU!JJ .cn.iL
,.olc
Gelv io||:.ct!`
i-| | | ICL'J/11 IJI.
-11-iillltilLAI IUILLLlMlIUIJIUibl[ Dl'[AL tt-
l'1lcu;n_.u_.Jl .uc:i.:t\|\ :| u\u.
.u\e
l! |i.. ... |1u1` .J|u,
.i.|
|:\ |.il C..1JJ1ulL 1I v.y |+C+. l
,
.1I1 IAMS.L -l D

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RecenL Etposures
Pre or |cl1u1u1 Event:
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Location: J
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CL! NJ CAL DOCUMENT AT I ON RECOl<D
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Activity Occurred Recorded DOCUllkllldl
l'O.'u. PSY lJ++! li1story/Syst.e111s Asses:rclil + lCOnLruedJ
Learning preference
Barriers to learning
Tead11119 metr1od
Nev</Re1 nf01ce111ent Lo.ng
Speci fie top1c(sl taught.
Response/evdluation
Eauc Content
-- Med i .d|:| |cCUu.i l 1 uL 1 u1,
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fll1y 1s Patient H:LoT!1u|I
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un | #: |0'. | o l Account # : Jd4U0U l 7b3

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! 1 1 Lervel l L l ll 1 1 De:.c 1 1 1, r 1 u1 1 .|. Di rec t i ons
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CL I N I CAL Ju'J|t\+ll ud RECORD
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From I ntervent i on Descr - r pt l on L S 0 1 1 c. | | u| |
Ac t i v ny dt.o``Uu HccJucJ 1Joc. u11rcnt el
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|oI c|l Notes
Create
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10/30/09 231 0 |H| Iu/JU/U 231 7 ERC
A . MEIJ I CAT I ON EFFEC T I VENESS : Pt ra L e: 111erJ c | I | .o. y a: "yuuJ " u l |. | |
Pt den i es any s i de ef f ect s to nkus dl Ur i , t i me .
B . 'u|!d| STATUS |t up and v V i t bl e 1 n 111 1 l 1 eu . GllServeu un |.: puy1Ar u11 e ! 1 1
the bdck | uu|c Io| the mJjori ty of the s t r i |' Pt . prece1 1 L s 11 1 Lh d .o| | . | .!J
a ffect ou anxi ous rrood Pt . dHes need f or Tx s t a l eJ uo l .| to ' c
r,ere . thi s s Just a mi sunaer"s tancl i ng " . i ' L den r es eve r l ' ar r d s l u le1 1 1t: n l c 1 1 1 Jde
, o L0 ddrn i s s rn Pt . o|Ic0 to |eqJc' t |\'1 d r scr r dr'\J e . ' ucvc| .,.| c 'u |'c
CN od dec i ded to remd i n at DH Pt . der r r es dil. auJ r tor y t1| v . . 0uI
ha l l uc i nat i ons at thi s t i 11e
' SAFETY STATUS : |I O|! a l ocked uni t unu 111iJ 1 nta r ned o|| l iu 1 J J 1 1 1g r ' tc l r J C L I LAr
thrughout shi ft Pt flld r nlc i ned on ruul l lle Qbn 1 n a nd r |KIutri .|e.
trwougt1 out shi ft On I . I rI . gave " s d fety lcv:I u f | 0 / | U out u l lO l, L .
ae11 1 es any s ui ci da l oi hom i c i da l i deo t r or| il t || . | ||e
D . PATI E IH/ FAM I L Y EDUCAT I ON : Pt . d t tenJecl : | grus ui| J ur r l l ull 1 v 1 L r c::, l l r r :.
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Unit #. . . . . . | o : .:

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Locati on : J .-
Room/Bed : J .. |
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2 CARE GOALS Domi n i on M Adu l t Al 4 .
3 STANDARD DOMI N U| HOSP I T AL W I DE CARE A I '
1 |`! ||hl LH AnAi ety A . 6 .
5 : PSY PROBL EM: Al tera t 1 un l r l Tr1 ougl1L Prc . Al 7 .
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u0cu| t|| A1 | |I| OF E VL RY SH I F T - - The | ! LdL SLanaards appropri d t e for t h i s p"t 1 em de t i ned OI l l | |c| jd I t | i | |[:u | u l I |
I o le ducu1 1 imcd c.cry .l1 1 t . | 0 | `cV lcVI
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t i le Mri Aau l L u c| l | Popu l d t 1 ur 1 Ca r e
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have Deen | | i c! throughuut the st 1 1 ft | unI c: . uI|c se aocumenlE:Ll ) . 1|` Ck.v 1 L\` n|1 | O I
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- DuC Ulliclll 1 0/ J[/ 00 231 4 `|| 1 01 30/09 2314 SNR
l : Rev 1 eV of |u ! J L|l '|oo, t '. :.L cI .. on PLAH J |l|t
De11 c l u11icnla l _c 1 8 - 0 yrs - YOUNG ADLT Al 3
2 C/|c o0A|': |HI l | U| Mli Adu I t Al .
3 . ' | /|I/| DOM I NI ON HUSP J l AL W l lJE '/|. Al S
1 PSY |ROo| AnAl eLy Al 6
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1002003 Psychosoc i a l As<es sment SIU + /
- Document 1 0 13 1 /09 0948 AXZ 1 0/31 /09 l OOb \/
Reason For F0H1 : S I U|
Pt I s psychot i c
Does Pati ent Met '| \e i c lo| Current Leve ol co|c
Superv 1 or l n l u1 11d .
|l Jo| Lu_cdC . ||U| .| E NGL I SH
.u. i u I iCu l t u|d lEduc at i ona l l || t l uctc.
Pt works i n the Stite Department . She yrd t ud l i.:u I lU||l
U1U !r1 ll|L SC|ool of Forei gn Services She wu5 || C
,c| acci dent 10/27/09 She repo|tcd u ,o ! e LhaL :|
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U know what I wUU1 U l0cI l i ke IJ be 1 11 iJ Cd|`

acc1 dent . Later she d i d not reca l l sayr nu t hat Pt
. . . L.. J. i s susp i c i ous . ta l k i ng LJ hersel f . c|0 i s L-|I | ' l | |_
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l0i : l /c uol : o|l 1 0 / 3 1 / 0 Jc0 .|
A At End o f Shl f t
I Ktv | C U | o \ | | | \ ||.||t'l v/ St clUS on PLAJ o| |t
iJevc l . 1p111c1 1 l o l c | I U }|. YOUNG ADL I Al 3 .
an;i ety P t deni es Ai V ha l l uc i nat i ons
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F I l . H I STORY----
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Age/ 'c. \ Attend i ng : l<uc t 1 . l< 1 d1 "1 o
Uni t #: J1 J uuu l 6 I 2 Account #: .J0 . +o:
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Admi tted: |:.0`Uv O | | ! :i Locati on : J 2A
Status : DI ' I H Room/Bed: J .. o
l | |-| . c| \ J| ! Je: ,cr r L 1 u1 1 :l s D 1 rect 1 01 1 s
AC L ` V J |, .. . c .J KtC01"dell

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CL I N I CAL DOCU11El ll AT I ON RECORD

Fr om I ntervent i on Descri pt i on
Ac t i vi ty Occurred
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1 '1 1 1 1 1 < l i I I U. 0. : | 0..:
SL u 1 1 ecl 1 u1 1 : I r ' l ll l l
Reco1 d.:d D0cu111.::r 1 L t:ll
I G02003 Psychosoc i a l As:;es1 11 e11 L s t d C cor 1 l 1 r i ud J
L i v i ng Arra1 1gen1enl Own P l ace
lkeds I l l | 1 v 1 ng ArTange1 1 1ent
.oc.i| .uu| 'vL. E ;ce l l ent
0p,u| Per" SOrH l |c111 1 l ,
F r i ends
T n:at1 1 1enl Part i c 1 par 1 l'; Parents
Suppo1t cJ..|.c.
Pt Stat es I| cL s l 1e eApects Lo be ul. |.Ja . |.! 1 1 :,1' 1e
c|c to stay . she 10ul d l i ke her parents to lc
rvo l ved i n her I- r1ere .
Des Li be T yp i ca l Do; : worr . `UncI . c.:I, ! : |
wi th f ri ends on t110 pnone
Hubbi es / I nteres ts . Readi ng
Rel 1 9 1 0n : CHR
Exerci s e
li tch 1 ng mov i es
Study i ng l anQuayes
CHR I ST I AN
Sp 1 r 1 Lud l Pract i ces None
Pl bel 1 e ves 1 n Hi gher Po\"er Y
Descri be H 1 gner Puwel' ' :
God
' : .I |:.! Co111p l e L ed : |'
Degrees /Cei1 l | to Lc: FOREI GN SERV I CE | |'|
GTU
Lurrel lt Studer 1 L N
Whel'e N/A
U1 Jnge ! School Ptr r or1a 1 1ce : N
Descr l lle Change In Schoo I |c` Iu|mo|tc`
P1 ob l e1ns . l| 8et1 a v 1 ur ot Scr 1uo l N
1 ou|c N
L ea rry Prob l eins 1 SpeC 1 i I |u0.:l d
'c..` ! be |cc`1 ng1 beha v i 01'il l Pr oo I e111s :
1 1/A
Age/Sex : :. '
Un+ t # . I U00.oL :
Admi tted: l l / 30; 0 al |o
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Attend i ng: . | ||ur Jr u
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Locat i on : J .
Room/Bed: J . c
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Pt J.e Ca r fe i no: . N
!y,c. o f Ca f f e i ne : Nw
! per Day :
'i l Cu!lHt l l l S I UkY ---
l 1 col 1 1 1e | N
Kid o f tobacco .
l_c F i rst 'eJ
Pocks / l 1 ns per day
o. + To| y \Ld,
Any C0nseque1 1 ces .
do.
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Age/ Sex ; .. | At tendi ng ; l<u L l 1 l< 1 .: l 10 1 C1
Uni t I; JCJ UUU ! o J 2: Account # . Jo+0UiUJ

Ami tted ; 1 0/30. 00 :| I .d Locati on: J 2A

Status : D J ' , I N Room/Bed : ...
l r 1 Le1 ver 1 L r ur 1 Dcsc1 r pL 1 u1 1 SL s D i r-ec t 1 ons
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Cl l NI CAL DOCUMENT AT I ON RECORD
|' l l l L cJ | ' u '. : ' ..
From
Cha nqe
CP
A 0
CP
l ntervemi un Desc r i p t i on
Occurred Rccor, ded
Sls 0 1 rec l i un'.
Act v |y
Type Date 1 |c |, Jo | c

1 1 1 11e ., Co1 111 1 e'1 1 t

Ducu1 1e1 1 l c:d
| | .
Act l 'J l I y |:| I '/o | '0: T |t I..o ..| rudl )
1 1 00205 1 PSY , Thougt 1 t 01 sorder , A, sess ( cunt 1 nucd l
Encouragt pt to eAp l ure ouo, .c
UC|dv1 U|' t hat 1 11crease :uc a l ioL J uu
* E ncourage t lJ eAp l ore adapt i ve
beh"v i ors tnat ne l p to dCCOrp l i 'J1 ADL ' s
Ed St atu:, 1 01 31 1 09 162J h i s l U/ 31 /09 1623 h | s
1 0Wi99 UPDATE ' Cl a r i fi cat i on of MCditd t l ons D
Ed 'La|o. 1 0 / 3 1 /09 1623 hi s | U/ J! /UJ lo.J M .
1 05 1 009- A CARE AREA STATEMENT MH Aau l t + IJ AL li 1J J | .| | |
--DOCUMENT AT END OF EVERY SH! F f --
l o be aocu111en ted every shi f t , lu |cvi e1,1
current Pt prob l ems and lc ver i fy La|
the MH Adul t Piti ent Pupol a L u1 | Care
Sta ndards |ovc been fol l owed .
Ea Stdtus 1 0/31 /09 1623 h i s 1 0/ 31 / 09 l: | | :
1 300006 Age Speci f i c Care : Young Adul tt1ood D
l Assess pat i ent ' s sel f - percept i on f or
moti vati on,
2. Assess llody i mcge
3 Ass i s t wi th Uc|l I _ uset ul cop i ng
rnechamsms and support sys tems
4 Encourdge to t a l k ubJoL
i l l ness / i nj ury how i t may : ccl
`
p l ans . fami l y / f i ndnces ,
Encourage pat i ent and fami l y i n
dee i s i on mak i ng and pat i enL ,:|: l
wanted ,
6 Educate re i njury preven t i on anu
hea l thy l i festy l e .
E d 't d t us 1 0/ 31 / 09 1 623 h i s I J / Jl /UJ I c:J .
1 572301 ASSESS : Wei gt1 l as Ordered and Record u
- Ed Sta tus 1 0 / 3 1 /09 1 623 h i s 1 01 31 /09 1 623 h i s
1 751 000 VS Mon nor D . Do |y 01 ' c| MD u1 Jc: 1 '
Ed `Ic luS 1 0/31 /09 1 623 hi s 1 0/ 31 /0' lb2J || i .
21 20363 MH Da i l y Nurs i ng As sess1 P en D | vc., .i huur :
- Ed Stc lus 1 0 / 31 / 09 1623 h i s 1 0 /JI / 09 1 623 t 1 1 s
21 20365 ASSESSMENT . AT LVd i Uol \ UH ! D I 1 1 11.:
Ed Sta tus 1 0/ 31 /09 1623 hi s U/ J /UJ I o. | | :
2 1 20366 MH Psycho - Eaucat i ona l Group ' u
tU Sta tus 1 0/ 31 / 09 1 623 h i s 10/31 /09 1 623 h i s
2120370 MH 'o Group Therapy Ses s i on J
Ed Status 1 0/ 31 /09 1623 hi s 1 0/ 31 / 09 l c.J h i :,
2 1 20752 Preceptor Document a L |J0 Co-Si _n + J
Ed Sta tus 1 0 / 31 /09 1 623 hi s 1 0/31 /09 1 623 h i s
3766530 NUTR I T I ON , Moni tor Mea I s , kecurd ! |
Ed '' ul . 1 01 31 / 09 1623 M I . 1 01 31 109 1 623 h i s
4 1 36600 MEOS , Admi ni s ter PAI N-MEDS( prn/ srd1 1d 1 1 1g J D
1 Moni tor effect i veness / s i de II cc l .
'a|0 any adverse 1eact i uns l
Ed .Lcl u. 1 0/ 31 109 1623 t i i s 1 0 / 3 1 /09 | o.J l ,
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Uni t # : JO\GU l o l :..
Admi tted : I/ 30/0 O 1 1 ',t
Sta tus : D I S II
Attending: k0 L 1 1 . l, khJ1 d |
Account #: Jo|0. l loJ
Locati on : J .-
Room/Bed : J 222 - 13

I | . |c| .| . |CJl l Descr lt .J | .|. u l |cc l1 0rt 5

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OPS J RE G DPS SCl lMI TZ . DAV I D RN
EkC J NUR . lkC ClllHPC ! Ull 1 DGAI< | | |
G'lL J NI. JR GSL l L iol', Gl E Nl;A ' RN
l | |o J HJH | | |H b. ACK . EL I ZAllE I I I RN
JLIJ J I/UR JI II WHl GHT . JESS I CA . |
KAU J NUI< K>0 Ul l l NGER . K I MBERL Y tCT
L X I ,I llllf< . UT +J''r . l I'|Il t RN
MJf J NUR . || PE RRY . MJRI | +H 1-11
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CL I N I CAL DOCUMEllTAT I ON RECORD
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CP
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|a,.
| . | |.o t 1 : u: 1 u' a l .o.:
.'ge/ S ex : 3 3 F HLLilYS , LYNNAE D ( DIS 2}
|
Page : l
Uni t # : J0 0 0 0 1 8 12 2
' ccount# : J8 4 0 9 0 2 1 7 4 8 3
,dmi tted : 1 0 / 3 0 / 0 9 at 1 1 5 8
J . 2A- J . 2 2 2 - B Printed 1 1 / 0 2 / 0 9 at 0 6 3 3
Roth , Richard L Period ending 1 1 / 0 2 / 0 9 at 0 6 3 3
Dominion Hospital Pat ient Care PATIENT NOTES FOR DISCHARGE SU
Occurred Recorded Notes : Al l Categori e s
Cate o ate Time b .luthor Date Time b
1 0 / 3 0 / 0 9 2 3 10 ERC CONCEPCION , EDGAR 1 0 / 3 0 / 0 9 2 3 17 ERC NURSE NOTES
. MEDICATION EFFECTIVENESS : Pt . rates med efficacy as " good" at thi s time .
Pt . denies any side ef fects to meds at thi s time .
B . SYMPTOM STATUS : Pt . up and vi sible in milieu , observed on the payhone in
the back lounge for the maj ori ty of the shi ft . Pt . presents with a constricted
af fect and anxious mood . Pt . denies need for Tx . , stated " I don ' t need to be
here , thi s is j us t a misunders tanding" . Pt . denies event s and statements made
prior to admi s sion . Pt . wanted to request discharge , however spoke to the
CN and dec ided to remain at DH . Pt . denies any auditory or visual
hal lucinat ions at thi s time .
. SAFETY STATUS : Pt . on a locked unit and maintained on bui lding restriction
throughout shi f t . Pt . maintained on rout ine Ql5min . and mouth checks
throughout shi ft . On 1 : 1 Pt . gave a safety level of 1 0 / 1 0 out of 1 0 . Pt .
denies any suicidal or homicidal ideat ion at thi s t ime .
D . PATIENT/ FAILY EDUCATION: Pt . attended all groups and unit activities this
shift .
E . AOL ' S : Sel f care , complete .
F . MEDIC.lL ( IF INDICATED) : Pt . denies any somatic complaints at this time . No
s / s of di stress evident at thi s t ime .
G . NUTRITIONAL STATUS : Pt . ate 1 0 0 % of meals thi s shi f t .
Note Type Description
No Type
3 1 / 0 9 1 0 4 7 /Z
None
ZAK, ANITA 1 0 / 3 1 / 0 9 1 0 5 0 /Z SOCIAL SERVICES NOTES
Psychosocial Assessment was comp leted and placed in pt ' s chart . Pt denies
feel ing depressed in any way at thi s time . She denies recal l ing any of the
statements that led to her admi ss ion here . At this time , pt appears coherent
and in no danger to herself or others . She is exhibit ing no sx of psychos is or
depress ion . Pt asked quest ions about d/c and ques tions were answered . Pt
plans to di scuss d/c wi th MD .
Note Type Descript ion
No Tye
1 0 / 3 1 / 0 9 1 4 4 0 /Z
None
ZALK, ANITA 1 0 / 3 1 / 0 9 144 0 Z SOCI.l SERVICES NOTES
cL did not attend group , as SDO was being d/c .
Note Type Description
Nc Ie
1!onogram nitials
Z
ERC
J . NUR . & `Z
J . NUR . ERC
Ncre
Name
Z.lK, ANITA
CONCEPCION, EDGAR
Nurse Tye
SW
MHT
Aqe/ Sex : 3 3 F WI LLIAMS , LYNNA D ( ADM IN)
|
Page : .
Uni t P J0 0 0 0 1 8 12 2 J. 2A- J. 2 2 2 -B Printed 1 0 / 3 1 / 0 9 a t 1 3 4 9
Account# : J8 4 0 9 02 1 7 4 8 3 Roth, Richard L Period ending 1 0 / 3 1 / 0 9 at 1 3 4 9
.ci t ted : 1 0 / 3 0 / 0 9 a t 1 1 5 8 Dominion Hospital Patient Care ACTIVITY THERAPY ASSESSMENT
.
AT Initial As ses sment
PROBLEMS TO BE ADDRESSED BY ACTIVITY THERPY :
Othe r :
Difficulty I denti fying and Express ing Feelings : Y
Poor Concentrat ion : Y
Disorgani zed Thoughts : Y
Poor Impulse Control : Y
Low Frus tration Tolerance :
Distractabi li t y :
Restlessnes s :
Low Sel f-Es teem:
Social Isolation/Withdrawal :
Poor Reality Tes ting : Y
I nadequate Social Skill s :
Dis torted Body Image :
Poor Leisure Time Management :
Inadequate Leisure Skills :
Leis ure Time/Act ivities Related To Drug/Alcohol Aus e :
Phys ical Problems /Safety Concerns : psychos is , impuls ivi ty
CONCLUS I ONS : ACTIVITY THERPY INTERVNTI ONS WI LL FOCUS ON
PROVI SI ONS OF ACTIVITIES J FACI LITATE :
Identification and Express ion of Feelings : Y
Focus of Attention and Organi zation of Thoughts : Y
At tending, Concentrating and Completing Tas ks : Y
Feelings of Mas tery and Self-Es teem:
Development o f Reali s t ic Body Image :
Social Interact ion: Y

Development of More Functional Social Skills : Y

Development of Impulse Control : Y
Identification of Leisure Time Skills and Interes t s :
Development of Structured Leisure Plan For After Discharge :
Identification of Healty Alternatives to Drug Related Behavio r :
Othe r :
Monogram Ini tials Name Nurse Type
KAO J . NUR . KXO OTT INGER, KIMBERLY ACT
-
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moL i v a t i o n .
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--DOCUMENT AT EMO OF |v| H! SHI FT--
To bE documented every .' |L !0 `: . c..
cun- ent Pt probl ems 0 1 1d to ve1 |, t hat
Uc hH ^uu I t Pat i ent Popul a t i on Care
Stanudrus hav e been fo 1 1 owed
1 0 1 30 / U' I .. :. ' i: 1 -1 1 U ,1. End vi n 1 1 1.
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Care t andd1 ' ds rel ated to | '|c t ol l ow1 ng
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|
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u E f f ect l vC|u.S of 1 1 1 ed1 cat r nn/ pa 1 n
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1 . Moni tor effecti ve1 ss / s i de eff ectS
( and any adverse reacti ons )
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ef f ect i veness of med1 cat 1 ons _
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percept i on of e ffect i veness .l
medi cat i ons _
|u' 1 er 1 t cuJc o | i on r e l u'c0 lU c | I c.L.
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* |u L J Cm uUuCu I 1 0u !6o|0 | n To| |u_cl|c|!
0l u|I e|, j coprg ski l l s
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Ui eropy rC | ate0 L0 |
' FSS1 st pul i enL t o 1 0c|\!fy
a|: c| ] ,.J.c : S ! luuI 1 0|S and p ct |
|0| suct1 event s
* Ass i s t i n the devel opnent . | cop 1 11 y
s k i l l s to manage d|i ety
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1 0 /30/09 MVP
DI I Uf<8E |u|u|| | . llE8
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* . 'Hu|| Di sorde1 . Assess 0/ oJt 0J MVP
* P1 1ys i c i an to assess mental st at us . and
ef fecti veness of medi cat i ons
RN to "ssess menta l status and pa t i ent
percept i on of effecti veness of
medi cat i ons .
* Pati ent educat i on 1el a ted lu thougt 1 t
di so1der and effects and s i de ef fects ot
medi cat i ons admi ni stered to t reat
i l l ness .
* Encourage pat i ent to d Ltend group
the1apy rel ated to [ ] .
* As s i s t pt to ID behav i ors that
al i enate s i gni f i cant others and fami l y
niembers
* Col l abo1ate wl t h pt to i denti fy
anxi ous behav i or and coprg techni ques
* Col l aborate wi t h pl Lo establ i sh
do ) achievable rout i ne
* Encourage pt to expl ore adpt i ve
beha v i ors that i ncrease soci al i zat i on
* Encourage pt to expl ore adapt i ve
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Uni t s
MIT I |NG <1 I I PAT I EM I |0H PURPOSE OF COMLET I NG P YCHlhOC I AL I i I STORY :
.|o .
1 1 1 1 ''.. 1 mcr v 1 eweu pc L 1 ent ancJ rnmpl eted psychosouc l hi srnry . Pa t 1 er 1 L den i ed
u|, l\ .o c bdlCJ Vl OI' df. ork . tou l u noL |cco I ! s t a te11r enLs sre i s repurted Lo
| .: 1 1 1ddc: l .I l 1i ng recent auto ccc 1 dent 1J s t c ted t hat st1e . wi l l ug Lo
c.j | , w i th PHP : l l1 1 1 : 1 s wlr a t i s requi rcd by tr1e State Deparl1 nent i 1 1 urder
LO 1 co| r L O v1or
I MPRESSI ON .
f uday pa t i errt reser l LS :.c l l grou11ied . d 1 esseJ 1 bus i ness att i re . ori eted * 3 .
muUu r s cn, 1 ous . c ft ec l v1 1 ae r a1 1 g rg . ;yc cont act good . demeanor i s pl easant
and coopera t i ve . Pi t H :nt uen 1 es any recent symptoms of depress i on or other
1 11oou u . | .|u|.c. . dcr 1 1 es dny audi t or y O|` v i sua l ha l l uc i nati ons . deni es any
| r :m!u l | u-a | | o l. sel f o( other . Pat i ent acknowl edges prior ep- i sodes uI
;.:e:rl r ' e: 0 1 u1 1 / a 1 1 1 ety uur i ny yr ad schuo l ( c t Georgetown Uni v SFS l for l'lhi ch she
wo'. |ca cO w 1 t t 1 lIicd CdL i on and br i e f tr 1erapy Pati ent acknowl edges di agnos i s
J | ADD PJt i em cck nuv l edges | r1 a L U1e four monU1 ass 1 9111nent wi th DOD tha t s t1e
Sper l [ 1 1 1 l r uq . .| c| e she was on u base ||cL c. " mo|t ared every day . get t in g
c 'user' :n c l U`\|

\Iu' s tress t ul cnd f ed r f u l . Uon ret ur from I raq pcL 3L

.. . . .,. I cu_. l r d v 1 1 1 g .l ecp d i s turbance for severd l accr. but then s l eep cyc l e
r'egu l d tEJ and pat 1 er 1 t |uL|eJ to wor> . trans fernd to St ate Department where
repurt ed l y S i le rr as e,ceedtd work per for1 dnce cxpectat i ons
LAN .
L c'u vci 1 ri 111" 1 l ed a t t e1 1 d 1 1 1g p:ych 1 a t nct c comp l et i on of psycr1 osoc i a l
|+ . |o|, cr lO po:, s 1 b 1 l l ty of d meet i ng wit h pc t i ent and r1er mother on l l /6/09 a t
c|.
a L 1 c1 1 t w i .1 1 || po ( i ce report of ctcc 1 aent s rre i purpo|ted to have
,. .o.eJ w 1 | ' c| L 0111 orTow to p:yc hi c t r"I ' t LJ cou
J |:t : | t l l il'. sougl r t l eyJ l counsel to cc:t! l rer l court over crr crges
t: l ' u r ng t rw1 iJ cc 1 de1 1 L .
IJa t 1 .: 1 1 L cu1 1 r 1 1. s t o Sc t et y cr 1d | :. ( 1 1 0U ' rer s t ay i ng i n L c home . i l ' |:
Ate11l i 1 11j pcycl l l d L r r s \. J oO+u .. | c | ctbuve .
Note I ype 'c.I1 ,| |.
N1 1 T ._ |1 c
Act i vi ty
'lL
Occurred |ecu|`ucu
':I e Ti me b' ldte T i 1r: t 1v .m|,'
I i . i |_ | l C l l / 04/ 09 Trre 1 5' I cu1 1 t .i.l
1 002003 Psycr1 osoc i a l Asses srnenL .I0 ( co n t i n ued )
Superv i sor I n lu||su .
Pri ma ry Language . ENGL ! SH HIGL ! SH
Soc i c l /Cul tul ' al /Eaucati ona l I nf l uences
Pa t i ent i s Jc o I IWu s i bs bor to mi dd l e c l ass
parents . ra |sea i | suburb of At l anta . a ttended
Spe l l man Col lege for undergrad . progressed to
grad school at Georgetown SFS . was then empl oyed by
DOD . sent to Iraq for four montl1s |2007 ) . retured
to DOD where she reports hav i ng exceedeu ..u| r
performance expectat i ons . then moved to Stote Dept
in March U+ . Pa tl ent has support i ve parents (
reti red educators lPat i ent l i ves al one i n apt i n DC
and curret l y works for State Dept as an ana l yst .
----FAMI L Y H I STORY----
Fami l y Psych Hx : Y
Farrn l y Psych Rel at i onshi p Aunt
J( 0c ' cT| y Psych Hz .
Sc hi zophreni d i n mate ma I dun|
Fami l y H ~ of `ui c i ue . N
! kC t 1 F1 t v l l i \ | l ' |l 'I'i T 1 1 11c : | ' 1 I F ami l y .ol . l J- Rcl a L i oish i p
U0.UU: PoyCl r(JouC l a I ASSeS SllJerl t s t d ' A
- Docur 1 ": 1 1 L 1 11 0: ! 0': l :iJ: MXS l l 1 04 / U' 1 6 MXS
Reuson Fur Adr11 1 s s i on .
Pd t i er r t Iu, dCllll l t ted Lu ||| J| 1 0/ J0/ 09 a11d I c l | AA 011
1 0 1 3 1: 0 . i | 0.:,. t tc. . | J to ddm i s s i on pat i ent
had r<pGrcd l y been beho vi r ry i a bi zcrre way oI wu|-
l St J t e Dept l and was t11 en I a rodd tra f fi c acc i de1 1 t
wn i cn .ne i r.:ported to trave ae l i bera t el y Ccucu
Today ,e | cl c.c|| . s t o t i 1 1g l1' 1 at sht i s nol . uc
+ny st re | :. |cu| | uumtL td to PHP 0cc,L " thal Lrre
Stii l e |cu|.| | | :: orller tJ || | . .
!Jue . | c . l 'ccl Cr 1 |+ o |J| Cur Tcnt . c.c O l :| c |
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Oesu1 oe F am1 l y H, ot Sui ci de"
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l iescr i be ' : + y CD H""

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CL! N I CAL DOCUMET A T ON RECORD

:;
' 1 n L cu | i / l i U al l! 7 G l
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A L 1 v 1 L y
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h1 t l t1 1 l l 'yci i , . lJ i 1 ec1 L1 1 1er 1 l 1 1 , . Y
Descr 1 r,e c. .. . I I
Oulpa L i eri L L 1"2d lil k21 i t a l o.J. ' o..+ U1 1 1 v Coun:el |
cn\c| for depressi on . o| | -ic|, s I cc d i : Lui0oCc
1 n 2006 Overi ght | 3 . |J/'0/09 d U |cn
A d 1 scr1a191.
AdJ i L 1 u1 1 0 1 ;u 1 c 1 ac . . | L l e111el l t '. 0 | r i > Y bd1 a v i o1
r lur 1 c i da l / V 1 u l e1 1ct' R 1 s ... . .
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Del l e ! : |e
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Acr i v i t y '.: | - I I / 0+/ 0: T i 111t : l ;: ! < cont 1 1 1ued l
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a t ri end
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Hobbi es / l ntei - ests . EAerci se
Hc i \ on CHk CHRI ST I AN
.pi r i tual Pract i ces Church
Pt Bel i c .c. 1 Hi gher Pov1er Y
Des er i be Hi ':| Power'
.o||iocu .
| a .I Grade Comp l cted . Gradua te degree
Degrees /Certi f1 cotes . Mc.Ier. 1 Fure 1 yri Rc l a l 1
Current Student N
Where :
Change 1 '.|JJ Per onnance .
Descri De Chanu I n .chool Per' u|"oucc` .
L n . A1 Tdrl<J.111e1 1 L O."n | u,c
|
||. e^. .! l | Beha v i or at Schoo l :
'.J - l , . : | Ar1 u ndl ic: ll l '
'UL i ii I .,. | cl..o cJ.o
Su1,Gl ' l f'el ' :un( ' ! |dill I I
| r 1 e1 1ds
l I c:Jt ll1c1 1 L J1 t 1\ 1 p: i | Pat l enl . po1ems
viho d re 1 1 1 tow
upiu1 . L01 1 . r 1cl l l '. .
.
.
"M, ,. | c| . Cul lie uc.. : u.. i1, cuu: 1 n l f l BJ l t i mure
ca l l eu L 1 1e111 . My LJ. 1 / 1 LOOk lilt' to |'c c| : L
Georye1 ow1 1 - l Uuy: u | |c| Ty acc i denl 0ccou.c | u | u
nu| | c.: vc i 1 1y med 1 c u l t n; n.me1 1 l I W:, o.| | c| c|
by L|c o' 1 ce cnu ol r d cc1 1 . f i |.ci pr i nted
and L hc:n .l.ocJ W|l I cov1 ng L | c sce11 e J | O|
dCCi Oei l l ..
'-. . | , , . .:, ... c il l / 0 :. |
uJ. 1 by b aU : :U
t.c| I ng outduo1 |u|
J| ao|- out \ gyr
D 1 1 1nd u uc l = l | .
Truancy :
Learry Prob l ems/Speci d l EducaL i on H
Desui be Lea ri ng/ Beha v i oral ||u cT.
Currenly Erp l Jycu
'l Occupa Li on
T i me at Curr enL Job
Job Sct i s fac t i on :
Longest Ti me a t One Job
F r equent Job Changes .
Rec1son for Job Chcnges
----EMPL01 MEI H i I l . t

Ana l ys t
1 o ,ca
Hi gh
4 . 5 years
N
unnp l oyed i n L c s t Y ea r N
Reuson for Unempl oyment " :
Docuukn lcu
l l i 1 i l '.. |
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Uni t . O'. . | o | .
Admi t ted :
Stctus : l ||
At ttndr ng : lut 1 1 . R 1 cr1 a 1 .
^ccount : J0J. o I
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l me1 v'1 1 L l l> 1 l Occr i pL l ul l 'l. U l |CC\ T UHL

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Pa1 .nl Ocu,pa l t on
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F ranc i a l lieeds . Den 1 cs any s l ressur:.
Den | tS oebb
Dell !e: comp1; I s Tvc ;t|.I|
!olc. ' ihe man.1
money " very we 1 1 dnd
| l oVc yood Sdv 1 ngs"
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Documented
UL
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W I L LI AMS . L YWIAE D |
UUlll l | | .:| Husp 1 Lol Pat i ent Care *L l c
c.lu.l| DOCUMENT AT I ON RECORD
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I | . | l l I l | l ' | i | - l ' l O i (1 Jl l L i rH 1ed l
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21 20370 lH `n Group Therapy SL` si o| A
L|CulC 11 /04/ 09 ;4o |11W l l / U4/ 09 Jo EM>-1
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PROBLEMS TO BE ADDRESSED BY ACT I V ! T Y THERAPY
Ottii r .
Di t fi cu l ty I aent l f y 1 ng and [,1wes> 1 ng Fee l | l . ` Y
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CUNCLUS l u|l . /1I V! T Y l HERAPY l| I |RV|H1l uH. '- ||' FOCUS UN
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CARE AREA STAT EMENT MH Adu l t .. \
--DOCUMENT AT ENO OF EVERY .nl'J
! be documented every stn ft . to rev 1 e11
turrenL Pt . probI cms and to veri t y L|uL
the MH /0.I L Pat i ent Pou Iat i on Cae
Standa rds have been to l 1 owed
1 1 / 04/ 09 1 547 EM\ 1 1 104109 1 54 7 | 'I
1 1 104/09 1 54 7 EMW 1 1 1 04/ 09 1 54 7 EMl
Age Speci Ic Care : Young Adu l t hood + A
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mot i va t i on .
2 Assess body i mage .
3 . Ass i st wi th i denL i fy 1 ng u: ef u l cop i ng
mecha ni sms and support systems .
4 Encourage to t a l k aoout
i l l ness / i nJury - how i t may o l l ctl
p l ans . fami l y/ fi nances .
5 Encourage pat i ent o|J l a | . \l y 1
deci s i 0n mak ing and pa t i ent Cdre . i |
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6 Educate 1-e i nJ ury prevcnt 1 0n and
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1 1 /04/0< 1547 EM1i l l / 04100 1 547 |
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1 1 /04/09 1 547 EMW 1 1 1 04/ 09 1 5+7 EMW
VS Mon i t or ! L
1 1 /04/09 1547 | 1 1 /04/09 |S47 EMi'
1 1 104/09 1 54 7 EMv 1 1 104/09 1 547 EMW
Mil Da i l y No|s i 6g Asses sment + C
l l04/ 09 1 54 7 EMvi 1 1 104/0< 1547 EMW
1 1 / 04 1 09 1 547 EMW l ! / 04/ 09 1 547 EMW
ASSESSMENT AT Eva l uaL i on !
1 1 104/09 1 54 7 EMvi l l / 04 / 0J 1 54 7 CMW
1 1 /04/09 1 54 7 EMW 1 1 1 04/ 09 1 54 7 EMW
MH Psycho-Educa t i onal Group + C
1 1 /04/09 1 547 EMW 1 1 /04/09 1 547 EMW
1 1 /04/09 1 547 EMW 1 1 /04109 1 547 EMW
MH SW Group Therapy Ses si on ! C
1 1 /04/ 09 1 547 EMW 1 1 /04/09 1 547 EM\'
1 1 104109 1 547 EMI' 1 1 /04 109 1 547 EMW
Preceptor Document a t i on Co- Si gn C
1 1 1 04/09 1547 to 1 1 / 041 09 1 547 EMW
1 1 /04/09 1 547 H 1 1 /04109 1 547 EMW
NUTRI T I ON Moni tor Mea l s . Rec0rd ! C
1 1 / 04/09 1 547 EMW l l /04 1 09 l b+/ tMW
l l / 04/ 09 1 547 EMW 1 1 104 / 09 1 54 7 EMW
MEDS . Admi n i s ter PAl N - MEOS( prl s L i1 1d i ny J C
1 . Moni Ior ef fect i venes s / s i de e f fects
( and any auverSe react i ons l .
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Al lO /ll'|| | TE I S GOOD |/lr(``cU F E EL ! | HAPPY CALM U|TERM I NED AND CALM
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Create 1 1 / 0b/09 1 238 MKS 1 1 1 06/09 1 242 MXS
.ocI AL .1d|| GROUP NOTE
GROUP TOPI C Coprg/Surv 1 v cl '| I | | .
Ou;e1 "vat 1 0n o f Sy1nptomol ogy M 1 n 111a l
Group Part i c i pa ti on : Apprur i ct t e
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Mood : AnAious
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her re ferrdl here Sr1e then went on lo Sdy .| |c r 1 ad exper i enc ed sevt d l t.0uts
oI severe depress i on i n recent years Lut uII| 0uLcu these Lo . | l uo l . o| c |
stressors i n he I i fe e . g . academi c demands of | uJ schuv '
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A t t ec t Appro1Kt d lc:
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Note Type Desc r t p l i on
H. _ N|
:li v i_|a l e I I /Uo/UJ T i me I 1 l U
1 051 01 3 CARE AREA STATEMENT PHP Adu l t +
--DOCUMc N | Al END OF EVERY :'1 1 1 r--
To be documented e.ery s hi I t . Lo r'ev i e1,
current Pt p|u0I cmS and to vc| l ly t t1 cL
tl 1e PHP Adul t Pa l i ent Popul a t i on Ccre
St.1 1dd ras have been I u1 0Wc0 .
D0cument 1 1 /06/09 1410 MVP 1 1 /06/09 | 4 l . |1'
1 ) Rev ew of Pat 1 e11 t
J Devel opmental Age Io1U yrs- YOUNG AOLT AI J
2: CAE GOALS Domi ni on K Adul t | l 1
.. '1 AMOARD DOM Ml oM nu'|I T AL w|u| 'ARE C l 5
4 . PSY . PRObLEM . Anxi ety A | o
b . PSY . PR08L EM : Al tera t 1 0n 1 !lJoq|| Proc : Al ? .
A ul c` J | ecr <. l r Uu
Pi<OBL EMS w/ St d tus u1 1 l ' LAN o' CAl<L
''
Age/Sex : 1. .
Uu L #: JUuLU 1 8 J
Admi tted :
bLa\u> . D I ' |c|:
l 1 1 L el 'Vl: l l L UH |.c:. p ' .. . .
L((U(Tell
Attendi ng : |I | H 1 Ci h J 1'tJ
Account . Jo+|I J.I oI \
Locati on : J :I'/\
Room/Bed :
Hc`| Jcu

Sts Di recti ons

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WI L L I AM ul llAE u
|
Uom1 mun Hus 1 L,| 'cl1 ent Core *L i ve'
CL l 11 1 CAL DOCUMEl!TA r l ON RECOl<ll

| ` I ntervent i on DES ci pt 1 0n
Occu1 red Recuracd
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IJ1 1 1 1 kd i I i : : | ' / J .
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Uucu1 11e1 1 i ell
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Act i v i ty |: c 1 1 109109 f 1 111e l .
MH Da i l y |u|: i | . A. .c.sanL A | .c|, .+ ' u . l 0ocJ
Document
---Ment a l
1 1 /09109 1230 DPS l l /091 09 1 23S DPS
Status |-u|
|d . l | |
o|cnl c L u . Ori ented tu Pc1 on onl y
| .J= | c.c ot I l l nes s . Yes
E ye Cont act : D i rect
|ucc|:L i C11 |t Ir
Me1110ry |ntac L
'pcecf1 C l ear1 <:e l l MJdu l J teo
Ber1dv i cw Co111 puscd
Thuuyht |tc.. Cot1erent / Lu< 1 C a I
Ar f eel B l unted
LP
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ri d ve ke1 1 hC t r wuuur 1 uut || |c ' : | L \ Un l es s |LlCl\- oc J.c.|c| . |cu . \|. \ Rev 1 ew- Sl ll'T | o:
T hought Content : Sel f lCtcl1 ng
Appectrance : C l ean and Nedt
Mood . Cal m
I ns i ght F a i r
Mut or . St eddy/ Nu E t 1 a1 1euu: |..c
JuJc1 ' tnt 'o |
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s upun Pc l nl t1 ad . pet wet er1 d . n L tl l ln l y o t ruct ured way , exerci s i ng .
cd L 1_ uul = | | t1e1' 1 1 1uU1 ei - 01 w 1 U1 t 1 1 e1 1 1.b c J rt111d i m11 g busy +uL J I t11e
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I '.. c ':| : J god l d l i ' eC ted Pci l i tnt de1 1 1 es any t 1 arrt u l i dea ti on toward sel f u1
uL 1 1er . dCk1 10.1 l edycS sure s l eep Ji o t urbdnce over | |c weekend 1vh1 ch she
a l l !" I DuLes Lu her an>

1 er y about court u: Lc tUf ll(] / TCw illld the ongoi ng e111p l oyrr.ont
. l : | o. 1 1 1 vcs L 1 gct L 1 u1 1 U1 d t she r1 ils LJ tdce wi t t 1 r1er governrentdl agency
|:: | i conL llc. Lo u t ft: 1 p au. 1 Dl c eAp l M1 a t 1 0n l u: r1 er tra f f i c acci dent anJ
f l a t ouL den i es olhtr acc usat i ons uf b 1 La rre 0c|:v o at work . Pat i ent den i es
.y :y1 1 1 pLu1 1 i s .ojc: | 1 1e o f d p.}|u|1 c epi sode .
..'
P a l 1 ent ~ . | ' J l l. .:1 1d CLU l 1tjr i ny 1 1 1 Lhe AM w Hh | c| mut t i e1 and f r i e1 1 ds d`
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J oent i ty 'u- T r i gge1s .
Homi c i d a l l deil t i un N
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Pl an .
T ype
Agyress i ve/Assoul l we Bd1av i or Leve l Luw l1 1 1 u l se Ccinl r ' u l H 1 0r1
Sa fety Level : 9 - 1 0
|u"|um: NO UNSAFE bEl lAV I OR NOi ED
--APPET I T E--
Nut r l t i ona ! Stal us ooL|
Crnrnents :
AJL/HY.| | Ht
u|uT\0_/u|c:: Apprri ate/ |ccl/ Cl ean
Cm11nt s :
--MED I CAT I OIJ:-
1 s pati ent comp l i ant I ' med i c a t i on |c | | |. . ll
I I no . exp 1u NOT O/ |tJ'
|cJ1 cc t i on S 1 Jc | | |cls N
I f yes . e;p J 0 1 n
Mon 1 tonng o f ef f ect s oI ned 1 co l i uns. LG 1 1 1c l 1.Je
St a f f observa t i ons 0 l e f fec t ( s J NO i ON MED
Pt ' s percept i ons 0 e f fect ( s J Nd' dN MEDS
|'| ,;1 caI 'omp1 a 1 nts NOlE
Age/Sex : .:
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C L I N I CAL DOCUMENT A ON RECORD
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From
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C1 Jtt l l / US/09 12] UPS l l / U'J/09 l.'/ DPS
P l S I A l lS | . .||+ ' || LAST 'I GH ' WI T H F R l l NDS AND WORKED OUT DENI ES ANY SXS
OF OERE SS I ON o| FEEL I NGS !d HARM .:. ' '| OI Hl: RS PRE OCCUP I ED W I TH COURT DATE
':|||NG UP liUT ' A Y WG |u:I I I . | . NO UNSAF E lEHAV I OR NO I ED . THOUGHTS ARE CLEAR AND
'|t||u I S | ul CAL
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Tvoe Date T i me |_ 'o lc T 1 1 1 1 c |:y ||lllc| Ll n 1 t s ( Jl ul l l h.'
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|oL I c|L h0|cS . PHP GROUP NOTE
Credte 1 1 / 09/ 09 1 248 MXS 1 1 /09/U9 1 250 MXS
SOC I AL VORK oRuU| |uI|
GROUP l OP I C : Cuprg/Surv 1 v.i l Sk i l l s
Ob:,e1 vat l U|1 ul S:rnptorno l oyy P|SE||
Group Pirt 1 c 1 pat 1 0n Appropri ate
I lcc! . Constri cted
Mood . An i ous
Peer I n teract i on Appropri a te |J : | | peers
Stoff J nterac t i ow Cornpl i ant
l [u .e Control Good
Affect . F l a t
Conre1 1 ts Group focused on need fo1" a .jo|| sys le1 11 .u | |..v-. y . |l l .| l |
L o KC0 u00JL |ov |g Io I y d|0 !lU|S ao suppo| t dur 1 1 1y Ui i s t l |uc .. | C S .
Note Type Descr i pt i on
No Te None
/.l v+ l_ 'o lt ! 0 l 0J 11 T3 |: .
Pat i ent Notes NURSE NOTES
Create 1 1 1 1 0/0' 1 352 EMW 1 1 1 1 0/0'. 1352 EMW
|' not in a t tendance today due to ochcdul .a lra1 b H 1n de1 y .
Notu T ypC Desc r i p t i on
No T voe None
Act i v i ty |1 | 3 l l l- T i me :. |
|oL C0L Notes SOC I AL SERV I CES NOT ES
Create 1 1 / 1 1 /09 1221 MXS l l / l l /09 .J |/'
Ul :.l|o| PLANN I NG NOTE :
Pati ent empha t i ca l l y decl ined a ftercdl"e ojjU l || |||t i l | S | L| u i l GP ps1 cl 1 i u L 1 i L
or ||erapi st . Pat i ent does not fee l ,hc l S i n need 0 l |u| ` L|U| Li ce || | t|. l
However . she is p l ann i ng to di scuss th i s Iu|L||ci wi t h the syctll d l r i t ol I|| c
State Depa 1trnnt .
N0te T ypC Descr i pt i on
No T None
Act 1 vi t v !ate l l / l 1 /09 1a6 1 53'i
5021 01 0
Docuent
DI SCHARGE : Cump l ete D 1 scha 1 ge Form +
ALSO :
Comp cLE paper form -|-n go i | :q ||Ul||t
1 1 1 1 1 /09 1535 E MfJ 1 1 / l l / 09 I.Ic ||i1
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PAT I ENT EDUCAT I ON OUTCOME STANDARDS/ II SCllAl<GE Nl E
At d i scharge pt and/ or lud I can verbi lI c u1 1 derstdnJ u f
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Al l ovs custrnn zat i on o f Pa t i t| Care
P l an .
1 1 / 1 1 / 09 1 536 h l S 1 1 / 1 1 / 09 1 5J6 h l S
Psycr1 osoc i a l As,es smet std + lJ
l J / l l/09 1536 I . 1 1 1 1 1 1 09 ! 536 h i s
PSY : Anx i et y Di sorder. Assess u
* Phys i c i an to assess nEnla l s ldtus and
e ff ec t i veness of medi cati ons .
* RN to assess an* 1 eL y and pat i ent
percept i on of ef fect i veness u l
medi cati ons
* Pat i ent trucat1 01 1 re l d led t u e f fect s
and s i de ef fects of nEd1 cat i ons
adm1 mstered to trea t i l l ness
* Pat i ent Educdt lO n r' tgor drg 1 1 1 anage1 1 1 tn1
of anA 1 ety . coprg s k i l l s .
* Encourage Pat i ent to at tend group
the1 `apy rel ated tu [ J
* |.: i .I pa t i ent to 1 dent 1 fy
anA1 et y- pr oduc1 11g s nuat i ons a 1 1d p l ctn
l u| such events .
* As s i st 1 tr1e devel op1 r.nt . | .J, | |
s > I! ! s I0 manage anx 1 ety .
1 1 / 1 1 /0' 1536 tl 1 1 1 1 1 / 09 1536 l1 1 s
P'Y : Thougt1t Di sorder . AS scsS u
* Phy s i ci an to assess menta l s l u Lus . a|J
e ffect i veness Jl med i ca t i ons .
* RN to assess men t a l s tdLus :| . J pa t 1 c1 1 L
per-cepl i on o l effect |veness of
med i co t i ons
* Pa t i ent educa t i on 1`Cl at eJ | J L 1 1ouynl
di soroer and cl lct L. and s i Lie e f f ects o |
med i ca t i ons adm1 n 1 s tered t o t r 'ea t
i l l ness .
Encourage pa t l :n| |. i t ter 1d p
tr1erdpy rel dted to j|
* As s i s t t Lo I D ud1 a v i or:: tl 1 dt
a l i enate s 1 gH | i ccnt o t11 ers and f a1 11 1 l y
members
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--IOCUMEIH AT END OF EVERY SHI F T--
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EDUCAT I ON . l nterd i sc \p 1 i nary
1 1 / 1 1 / 09 l :Jc h i s 1 1 / 1 1 /09 1 53 | i .
DI SCHARGE . Compl ete D i sc| u |e F urrn
AL SO
Compl ete paper f0l|l| v.itl go 1 ||C|||C
1 1 / 1 1 / 09 1 536 i . 1 1 / 1 1 / 0 'or h | .
QUI CK ADMI SSI ON DATA +
Nur s i ng Qui ck Start
1 1 / 1 1 /09 1536 | : 1 1 1 1 1 / 09 1 5j6 h l S
D
D
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0
Monogrdm I n t i i l s Name Nurse Type
AVB J NUR . AVB BOOMSA. ANN V RN
DPS J REG . DPS SCHMJ TZ . DAV I D RN
EMW J . NUR EMW2 WI TTI NG . EL I ZABEl H RN
KOO J NUR KOO OVERSTREET . KR I S T I N D ACI
MJ J NUR MJ JOHNSON . MELAN I E AC f
MVP J . NUR . MP PERRY . MARI LYN RN
MXS J NUR MFSl SANDI FORD . MARY SW
h i s autornat t by prgrdr
Jucu.|.| | |.u
Un i t: |. . , .,
.
A * J
.|
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Age/ S ex : 3 3 LL1.- , L: | D S RCR ) Page : 1
1 1 / 1 2 / 0 9 at 0 7 0 1
1 1 / 12 / 0 9 at 0 7 0 1
FOR DISCHAGE SU
Uni t # : J0 0 0 0 1 8 12 2
ccount# : J84 0 9 0 2 1 8 1 1 8
imi tted :
. -
Roth , Richard [
Dominion Hospital Patient Care
Printed
Period ending
PATIENT NOTES
Occurred Recorded
ate Time by Author Date Time by
Notes : Al l Categori e s
Category
1 1 / 0 4 / 0 9 1 4 4 1 MXS SANDI FORD, MARY 1 1 / 0 4 / 0 9 14 5 3 MXS SOCI.n SERVICES NOTES

MEETING WITH PATI ENT FOR PURPOSE OF COMPLETING PSYCHOSOCIAL HISTORY :
Thi s CSW interviewed patient and completed psychosocial hi story . Patient denied
any bi zarre behavior at work, could not recal l s tatements she is reported to
have made fol lowing recent auto accident and s tated that she i s wi l l ing to
comply with PHP if thi s is what i s required by the State Department in order
to retur to work .
IMPRESSION :
Today patient present s wel l groomed, dressed in busines s attire , oriented x 3 ,
mood i s anxious , affect wide ranging, eye contact good, demeanor i s pleasant
and cooperative . Pat ient denies any recent syptoms of depres sion or other
mood disturbances , denies any auditory or vi sual hallucinations , denies any
harmful ideat ion to self or othe r. Patient acknowledges prior epi sodes of
depres sion/anxiety during grad s chool ( at Georgetown Univ SFS ) for whi ch she
was treated with medicat ion and brief therapy . Patient acknowledges diagnos i s
of AD . Pati ent acknowledges that the four month assignment with DOD that she
spent in I raq, where she was on a bas e that was " mortared every day, getting
closer and closer" was stres s ful and fearful . Upon return from I raq patient
acknowledges having sleep disturbance for several weeks but then sleep cycle
regulated and pat ient returned to work, transferred to State Department where
reportedly she has exceeded work performance expectat ions .
PLAN :
1 . CSW voi ce mai led attending psychiatri st re . completion of psychosocial
history and possibility of a meet ing with patient and her mother on 1 1 / 6 / 0 9 at
9 . 0 am .
2 . Patient will bring police report of accident she i s purported to have
caused, with her tomorrow for psychiatri s t to read .
3 . Patient has sought legal counsel to represent her in court over charges
ensuing from accident .
4 . Patient commi ts to safety and has her mother staying in the home with her .
5 . Attending psychiatrist informed of all above .
Note Tye Description
No Type
1
1 / 0 5 / 0 9 1 6 0 8 MJ
None
JOHNSON, MELIE 1 1 / 0 5 / 0 9 1 6 0 8 MJ NURSE NOTES
ACTIVITY/ EXPRESSIVE THERAPY GROUP NOTE
GROUP TOPI C : Movement Therapy
Observation of Symptomology : Minimal
Group Part icipat ion : Involved
Affect : Flat
Mood : Calm
L~C; Interaction : Minimal
S taff DLC:3CLlOD : Compl iant
Impulse Control : Good
Pt/ Fami ly Educat ion Done : Yes
Person Taught : Pat ient
eadiness to Learn : Recept ive
Sel f - Es teem
Teaching Method : Group Sess ion/Class
_"ge/ Sex : 3 3 F
Uni t # : J0 0 0 0 1 8 1 2 2
ccount# : J8 4 0 9 0 2 1 8 1 18
lmi t ted :
+L , L+ D ( DIS RCRJ
. T-
Roth, Richard L
Dominion Hospital Patient Care
frinced
Period ending
p_iTIENT NOTES
Page : .
1 1 / 12 / 0 9 at 0 7 0 1
1 1 / 12 / 0 9 a t 0 7 0 1
FOR DISCHARGE SU
Occurred
ate Time by _iuthor
Recorded
Date Time by
Notes : Al l Categories
Category
1 1 / 0 5 / 0 9 1 6 0 8 MU JOHNSON , MELP.IE 1 1 / 0 5 / 0 9 1 6 0 8 MU
Comments :
Note Type
No Type
1 1 / 0 5 / 0 9 1 6 3 5 MP
Outcome : Comm . Understanding
Description
None
PERRY, MARI LYN 1 1 / 0 5 / 0 9 1 6 3 8 MP
( cont inued)
NURSE NOTES
PATIENT PRESENT FOR GROUP SESSION TODAY INOLVED AFFECT AXIOUS SAYS SHE WENT
TO THE GYM YESTERDAY ATE DINNER AND TALKD WITH FRIENDS . SOCI.i WITH PEERS .
SET GOAL TO CONTINUE TO PROGRESS AT RESOLVING CONCERNS FROM JOB . SAY SHE HAS
NO SAFETY ISSUES AND RATES SAFETY AT LEVEL 10 . PATIENT SAYS SHE IS SLEEP ING OK
AND APPETITE 1c GOOD . EXPRESSED FEELING HAPPY CALM DETERMINED AD CAM.
Note Tye Descript ion
PSY . PROBLEM: Anxiety Diagnosis
1 1 / 0 6 / 0 9 1159 EMW WITTING, ELIZAETH 1 1 / 0 6 / 0 9 12 0 2 EMW
Pt states she is " proud she has been able to wi thstand everything, not
spi raling into a deep depress ion or internalize the things people have said
about me . " Denies safety is sues , SL= l O .
Note Tye Description
PSY : PROBLEM : Alteration in Thought Proc
NURSE NOTES
Diagnosis
l l / 0 6 / 0 9 1224 AV BOOMSA, ANN V l l / 0 6 / 0 9 1225 AV PHP GROUP NOTE
PSYCHOEDUCATION GROUP NOTE
GROUP TOPIC: Stress Management
Observat ion of Syptomology : Minimal
Group Part i cipation : Appropriate
Af fect : Appropriate
Mood : Anxious
Stress Management
Peer Interact ion : Appropriate to all peers
Staf f Interaction : Compl iant
Impulse Control : Good
Af fect : Appropriate
Pt / Fami ly Education Done : No
Person Taught :
Readines s to Lear:
Teaching Method :
Outcome :
Comment s : pt sharing w/e plans and concerns about court date on tues ,
accept ing support ive fb about same
Note Tye Descript ion
No Type
1 / 0 6 / 0 9 12 3 8 MXS
None
SANDIFORD , MARY
SOCIAL WORK GROUP NOTE
11/ 0 6 / 0 9 12 4 2 MXS PHP GROUP NOTE
Age/ Sex : 3 3 F WILLIAMS , LYNNAE D !I3 RCR ) Page : 3
1 1 / 12 / 0 9 at 0 7 0 1
1 1 / 1 2 / 0 9 at 0 7 0 1
FOR DISCHARGE SU
Uni t # : J0 0 0 0 1 8 12 2
' ccount# : J8 4 0 9 0 2 1 8 1 1 8
Jmi t ted :
. -
Roth, Richard L
Dominion Hospital Pat ient Care
Printed
Period ending
P.rTIENT NOTES
Occurred Recorded
ate Time by Author Date Time by
Notes : Al l Categori e s
Category
1 1 / 0 6 / 0 9 1 2 3 8 MXS SADI FORD , MARY 1 1 / 0 6 / 0 9 1 2 4 2 MXS ( continued)
GROUP TOPIC : Coping/Survival Ski l l s
Observation of Symptomology : Minimal
Group Part i cipation : Appropriate
.r. f fect : Flat
Mood : An.xious
Peer Interact ion : Appropriate to all peers
Staff Interaction : Compliant
Impulse Control : Good
Affect : Constricted
Comment s : Group focused on ambivalence and res i stance to treatment . Pat i ent
sat silently l i stening for most of group . Close to end of group she talked
about " doing more thinking" about the recent series of event s that resul ted in
her referral here . She then went on to say she had experienced several bouts
of severe depression in recent years but attributed these to situational
stres sors in her l i fe e . g . academic demands of grad school .
Note Type Descript ion
No Type
1 1 / 0 9 / 0 9 1 0 2 7 MXS
None
SANDIFORD , MARY 1 1 / 0 9 / 0 9 1 0 3 4 MXS SOCIAL SERVICES NOTES

MEETING WITH PATIENT :

Thi s CSW met wi th pat ient for purose of assessment and discharge planning .
Patient reported that her mother is cont inuing to stay with her and provide
support . Pat ient had spent weekend in a highly structured way, exerci s ing,
eating out wi th her mother or with friends and remaining busy most of the
time .
IMPRESSION :
Today patient present s dressed in bus ine s s attire with good grooming . Her mood
is anious , af fect is congruent with ideation, eye contact is good, thinking
i s clear and goal directed . Patient denies any harmful ideation toward s el f or
other , acknowledges some sleep disturbance over the weekend which she
attributes to her anxiety about court date tomorrow and the ongoing employment
status invest igation that she has to face with her governmental agency .
Pat ient cont inues to of f er plausible explanat ion for her traffic accident and
flat out denies other accusations of bizarre behavior at work . Patient denies
any symptoms suggest ive of a psychotic episode .
PLA:
1 . Pat ient wi l l attend court hearing in the . with her mother and f riends as
a support system .
2 . Pat ient will either return to PHP after court or return on Wed 1 1 / 1 1 / 0 9 .
3 . Patient encouraged to f ind OP providers so that she can follow up after
discharge from PHP .
5 . Attending psychiatrist informed of all above .
Note Type Description
No Type
1 1 / 0 9 / 0 9 1 2 3 5 DPS
None
SCHMITZ , DAVID 1 1 / 0 9 / 0 9 1 2 3 7 DPS NURSE NOTES
PT STATES SHE S PENT TIME LAST NIGHT WITH FRIENDS AND WORKED OUT . DENIES .i;NY SXS
OF DEPRESS ION OR FEELINGS TO HAM SELF OR OTHERS . PRE - OCCUPIED WITH COURT DATE
COMING UP BUT STAYING POSITIVE . NO USAFE BEHAVIOR NOTED . THOUGHTS ARE CLEAR AND
SPEECH IS LOGIA
Age/ Sex: 3 3 F ;v rLLIAMS , LYNNAE D ( DIS RCR)

Page :

1 1 / 1 2 / 0 9 at 0 7 0 1 Uni t # : J0 0 0 0 1 8 1 2 2
ccount# : J8 4 0 9 0 2 1 8 1 1 8
dmi t ted :
Roth , Richard L Period ending 1 1 / 1 2 / 0 9 at 0 7 0 1
Dominion Hospital Pat ient Care PATIENT NOTES FOR DISCHARGE SU
Occurred Recorded
ate Time by Author Date Time by
1 1 / 0 9 / 0 9 1 2 3 5 DPS
Note Type
SCHMITZ , DAVID
Description
1 1 / 0 9 / 0 9 1 2 3 7 DPS
Diagnosis
1 1 / 0 9 / 0 9 1248 MXS
PSY . PROBLEM : Anxiety
SANDIFORD , MARY 1 1 / 0 9 / 0 9 1 2 5 0 MXS
SOCIAL WORK GROUP NOTE
GROUP TOPIC : Coping/Survival Ski l l s
Observation of Syptomology : Asent
Group Participation: Appropriate
Af fect : Const ricted
Mood : .nxious
Peer Interact ion : Appropriate to all peers
Staf f Interact ion : Compliant
Impul se Control : Good
Af fect : Flat
Notes : All Categories
Category
( cont inued)
PHP GROUP NOTE
Comments : Group focused on need for a support system during recovery . Patient
talked about having family and friends as support during this time of cri s i s .
Note Type Description
No Type
1 1 / 1 0 / 0 9 1 3 5 2 EMW
None
WITTING , ELIZAETH 1 1 / 1 0 / 0 9 1 3 5 2 EMW
Pt not in attendance today due to scheduled trans it ion day .
Note Tye Descript ion
No Type
1 1 / 1 1 / 0 9 1 2 2 1 MXS
None
SANDIFORD, M`
DISCHARGE PLANNING NOTE :
1 1 / 1 1 / 0 9 1 2 2 3 MXS
NURSE NOTES
SOCIAL SERVICES NOTES

Patient emphati cally decl ined aftercare appointments with an OP psychiatri st

or therapi st . Pat ient does not f eel she i s i n need of further treatment .
However , she is planning to di scus s this further with the psychiatrist at the
S tate Department .
Note Type Descript ion
No Type None
Monogram Initials Name Nurse Type
.- ` J. NUR . BOOMSA, AN R
DPS J . REG . DPS SCHMITZ , DAVID RN
EMW J . NUR . EMW2 WITTING , ELIZABETH RN
MJ J . NUR . MJ JOHNSON , MELANIE ACT
` ` . MP :, MlL:` RN
MXS J . NUR . MFSl LltL, ``
Age / Sex : 3 3 F WILLIAMS , LYNNAE D ( REG RCR)

Page : .
U
ni t
_ ,
J0 0 0 0 1 8
1 2 2 J.3PA-
P

r
-
i

n
-
t
_
e
d
1
1
/ 0 5 / 0 9 at 0
8
5
E
Account# : J84 0 9 0
2
1 8 1 1 8 Roth, Richard L Period ending 1 1 / 0 5 / 0 9 at 0 8 5 E
Admit t ed : Dominion Hospital Pat ient Care ACTIVITY THERAPY ASSESSMEN1
AT Initial As sessment
PROBLEMS TO BE ADDRESSED BY ACTIVITY THERAPY :

Other :
Difficulty Ident i fying and Expres s ing Feel ings : Y
Poor Concentrat ion :
Disorgani zed Thought s :
Poor Impul s e Control :
Low Frustration Tolerance :
Distractabi l i ty :
Restles snes s :
Low Sel f - Es teem :
Social I solation/Withdrawal :
Poor Real i ty Tes t ing :
Inadequate Social Skil l s :
Di storted Body Image :
Poor Lei sure Time Management :
Inadequate Lei sure Ski l l s : Y
Lei sure Time/Activities Related To Drug/Alcohol Abuse :
Phys ical Problems / Safety Concerns : decreased ability to cope ,
D of stres s / anxiety

_oNCLUSIONS : ACTIVITY THERAPY INTERVENTIONS WILL FOCUS ON

PROVISIONS OF ACTIVITIES THAT FACI LITATE :

Identi f i cat ion and Expression of Feel ings : Y
Focus of At tent ion and Organi zation of Thoughts : Y
Attending, Concentrating and Complet ing Tasks : Y
Feel ings of Mastery and Sel f - Esteem : Y
Development of Realistic Body Image :
Social Interaction :
Development of More Functional Social Ski l l s :
Development of Impulse Control :
Ident i fication of Lei sure Time Ski l l s and Interests : Y
Development of Structured Lei sure Plan For After Di scharge :
Ident i f ication of Heal ty Al ternatives to Drug Related Behavior :
Other :
Monogram Ini tials Name Nurse Tye
KDO J . NUR . KDO OVERSTREET, KRISTIN D ACT
1 1 / 0 5 / 0 9 0 8 5 5 KDO
g(t.c- . J, _
Uni t ( Jl bc?
A.T t :ed
Statu s : |E G |' |
Al tenai ng : Rot h . R i chard |

Account # J8409021 81 1 8
|uca t i on: J 3PA
-oom/B.u
.` .J L L .D
_L YNNAE D |
Domi ni on Hos pi tal Pat i ent Care *Li ve*
Pa t i ent ' s Pl an Of Care
SLatus . AcL i _
l | | u Le0 . 1 1 / 04/09
|u+I c|tu
P rotoco I
|'uc
|' | | | J
1 1 109109
d \ 0722
L lL. l ` _ , I=.
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* SIG : Pa t i er 1 t ' s Anxi ety wi l l decrease ,A 1 1 104/09 EMW 1 1 1 16/09

!
AEB DAI L Y GROUP AT I ENDANCE AND
PART! CI PATION
* LTG : Pati ent ' s ^i c:/ wi l l Ot.`ud >0
AEB PT SELF- REPORT DURI NG DA! LY
ASSESSMENT REGARDI NG BOTH HERE AND AT
n
l:Y[Ru.t 11J_(
* SIG : PATI NT WI L L HAVE DECREASE I N
DI STURBED THOUGHTS AEB DCREASE/ .ACr OF
BEHAV IORS I NDI CAT I NG DECREASED
LuMc|MTkA1luM uR ALTERED THOUGHT
PROCESSES . A'u AEB PT SELF- RE PORT
|TS . P/TlcNT WI L L HAVE DECREASE I N
DI STURBED THOUGHTS AEB P T SELF-REPORT
REGARDI NG THI N KI NG AND FUNCTI ON I NG
I MPROVMENT BOTH HERE AND AT HOME
A , i. / .+/ .- EMW , ../../.-
* PSY Anxi ety Di sorder . >0.. I 1 11 04 1 09 LMw
* Phys i ci a n to assess menta l status and
effect i veness of medicat i ons .
* RN to a ssess anxi ety and pat i ent
percept i on of effect i veness of
medi ca t i ons .
* Pat i ent educati on rel a ted to effects
and s i de ef fects of medi cat i ons
uu|Ini s tered to treat i Jlnes s .
* Pat i ent educat i on regarding management
of anxi ety [ ] . . copi ng sr J >
* E ncourage Pati ent to a ttend group
therapy rel a ted to [ ] .
* Ass i st pati ent to i denti fy
anxi ety - produci ng s i tuati ons and pl an
for such events .
* As s i st i n the devel opment of copi ng
ski l l s to manage anxi ety :
A1J L
A l l0/ 09 EMW 1 1 1 16/09
l-
A ,l l /04/09 EMW , 1 1/23/09 I I
* PSY : Thought Di sorder . Assess 1 1 / 04/ 09 EMW

* Phys i ci a n to assess mental s tatus . and

effecti veness of medi cati ons .
* RN to as sess mental status and pat i ent
percept i on of effecti veness of
medi cat i ons .
* Pat i ent educat i on rel a ted to thought
di sorder a nd effects and s i de effects of
medi cat i ons admi ni stered to t reat
i l l nes s .
* Encourage pat i ent to attend group
therapy rel ated to [ ] .
* As s i st pt to I D beha v i ors that
al i enate s i gni fi cant others and fami l y
members
* Col l aborate wi th pt to i denti fy
.L=l+''''
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Domi ni on Hospi t a l Pat i ent Care | 1 ve*
at i c+t s a+ uI '|c
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ca l y a.ai ca. c c.. +c

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Age/ Sex . 33\ ;
Uni t # J00018 12Z
Adm i t ted .
Status : l<EG RCR
ALter i d1 11g : Roth . R i cl1 iJrd L
Account # : J840902 1 81 1B
l ocat i on : J . 3PA
Room/ Bed :
spi i |ua l . bc I i cfs pri vacy and
conf i dent i a l i ty .
J . The pat i ent and/or s i gni f i cant
others w i l l pa r t i c i pate i n the
p|utt.> ul coord i nat i on o f
resources i n prepa rat i on for
di scharge .
4 . The pat i ent and/or s i gni fi cant
others w i l l recei ve teachi ng about
the nature of the i r hea l th
cond i t i ons . procedures . t reatments .
sel f care a nd pos t di scharge care .
Verba l i L a t i on uI quest i ons and
concerns wi 1 1 be encouraged .
5 . The pat i ent and s 1 gni fi cant others
wi 1 1 have the i r envi ronment and
care managed to m i ni mi ze ri s k to
t hemsel ves and others .
b . The pati ent wi l l be supported i n
t he i r e ffort t o ret a i n personal
i dent i ty . sel f worth and pa t i ent
ri ght s .
<End o f text>

_ _). L YNNA[ D |
Domi n i on Hos p i tal Pati ent Care *L i ve*
Pa t i ent s P l a n Of Care
'
Stalus . Act i vt_
I n I t i a tLu . l l / 04/ 09
Compl eted :
Protocol :
|ue o
Pri nte>d
l l / 091 09
ot 0722
'!'
i
* Standards of Practi ce

-r-;;i ;;; ;
-
r-

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-
,,

-
--

.----
.

-
-;
ll l/ 04109 EMW
<End of text>
STANDARD . DOMI N I ON HOSPITAL PHP
Care Standards rel ated to the fol l owi ng
ca re goa l s :
1 . Pat i ent Care/Nurs i ng Process
2 . Pati Lnt Educa t i on
. Pat i ent Di scharge Pl anni ng
4 . Pa t i ent Safety/ I nfect i on Control
5 . Pat i ent Di scomfort /PAI N
6. Pat i ent R i ghts
A 1 1 / 04/ 09 EMW
* CAR[ AREA STATEMENT : PHP Adul t
-DOCUMENT AT END OF . EVERY SHIFT
To be qocumented every !h1 ! . to rev i ew
current Pt . p|u0JG8 du0 10 V0IJ J that
the PHP Adult Pati ent H0uJ I1 00 Care
Standards have u000 Jul 1 uW00 .
) 1 1 04/09 EMW 1 11 04 / 09 1548 1 . a t end o f each day
L.
* The pat i ent wi l l recei ve care whi ch A 1 1 04t 09 EMW
refl ects an ongoing process of
i nterdi s c i pl i na ry care based on the
pa t i ents spec i f i c needs and t he
PHP Pati ent Popul at i on Standards
of Care . These wi l l i nLl ude those needs
whi ch a re age- s peci f i e . Copi ng
responses wi l l be a ssesses and
addressed
* VS: Moni tor +
* MH Psycho- Educat i onal Group +
* CARE PLAN MH ADDI TIONS +
-Use i n pl ace of Add I nterventi ons-
Al l ows customi zat i on of Pati ent Care
Pl an.
Preceptor Documentati on Co- Si gn
* MH SW Group Therapy Sess ion +
* ASSESS : Wei ght as Ordered a nd Record
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1 1 / 041 09 1548 , . X l on admi s s i on
/_c/:u- J..
Uni t 1 JOOuo:i:'2
Attendi ng : Rot h . R i ct1a rd L
Account [ J8409021 81 1 8
/i ttLu . |uCuL Jn . , 3PA
'lolu, . R|u R|R Huu1/Htu .
* !c pa t i ent dr 1d/or s i gn i l i cant ot her s
can expect lo oc i nvo l ved i n the pl an
of care wi th o t t ent 1 on to cu | tu|c! and
rel i g1 0us |c i t | . . cor11ur1 1 co t i on
bo rri ers . jri vacy dnd conf i dent i a l i ty .
E f feet i ve rn11111un i cot 1 on methods dre
ut i l i zed ror t he hea r i ng and speech
i mpa i red as we l l u: ba rr i ers to
|o.._uo_c
'' | |i | 1 @
A 1 1 1 1 04/09 EMW
* The pat i ent and/or s i gni f i cant other I A 1 1 1 1 04/ 09 EMW
w i l l recLi ve tedcrr i ng about the nature
of thei r hea l th condi t i on . procedures .
treatment s . sel f care and o> L
di s cha rge care . Verba l i z a t i on o f
quest i ons and concers wi 1 1 be
encouraged .
* Pa t i ent and/or !; l gni fi cant other w i l l I A 11 1 1 04/ 09 EMW
part i c i pate i n the roces s of
coord i na t i on of resources i n
preparat i on for di scharge .
l he ,dL C|| wi l l recei vL care wt1 i ch wi l l I A 1 1 1 104 1 09 EMW
ref l ect a saf e env i ronment . I n fect i on
control needs wi l l be asses sed and
addres sed Care w i l l be g i ven i n a
control l ed envi rnment to reduce r i sk
of i n|ury or further i l l ness
* l he pat i ent wi l l be supprted i n the i r ,A \1 1 1 04/ 09 EMW
ef fort to ret a i n persona l i dent i ty .
sel f worth and pa t i ent r i ght s .
Part i c i pa tes i n age appropri ate I A 11 1 1 04/09 EMW
dCL v! L u> u0u prograTs at l evel of
act i v i ty . Abl e to i dent i fy da i l y .
even i ng , and weekend t rea tmenl goa l s
r 1LLF1u11 n.)SInu:
'1NJNu . DOMI NION . HOSPITAL WI DE CAE C l l / 041 09 EMW
Care Stanoards related to the 0 J 0W1 l]
. .
CdIL gUal s .

1 . Patient Care/Nurs i ng Process

. Pat i ent Educat i on
.
Pa t i ent Di s charge Pl dnni Hg
4 . PoL i ent Sa fety/ I nfecti on CunIiu!
b . Pat i ent Di scomfort/PAI N
o. Pa t i ent Ri ghts

[L h!
_ _
/
. L YNNAE D |
lomi n \ o| Hos i t l |L 00L |o|0 *L i ve*
Pa t i ent s Pl an Of Care
i i
* 'JJ|/!l u\ . ! nterd 1 sc 1 \ i na ry
* DI SCHAGE . Comp l ete Di s charge Form
ALSO :
Compl ete paper form-when goi ng home

Ib1 b
1 1 / 04/ 09 EMW
1 1/ 04/09 EMW
* Admi s s i on I ni t i a l Sa fety Assessment + l l / 04/ 09 EMW
* To be done on Admi s s i on *
* Psychosoci a l As ses sment std + l l / 04/ 09 EMW
* ASSESSMENT : AT Eva l ua t i on + l l / 04/09 EMW
1 1 1 04/ 09 EMW
L !
StaLUs :
! n i t dLtu
Compl eted.
Protoco l :
tc.
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1 1 / 04/09 1548 1 . !o |c uc| on
NTi . . i cn
1 1 / 04/09 1548 1 . 1 X
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Pr i n t r:d
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at 0722
,

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The pat i nt wi l l rece i ve ca re whi ch I C 1 1 1 04/09 EMW , l / 0
1
0Q MW l
! I 1
11 / 04 J
refl ects an ongoing process of
i nterdi sci pl i nary care based on the
pati ents speci fi c needs and the
hospi tal s Pat i ent Popul at i on Stdnua rds
of Care . These wi l l i ncl ude those needs
whi ch are age-spec i fi c . Coping
responses to hospi tal i zat i on wi l l U
assessed and addressed .
* The pat i ent and/or si gni f i cant others I C 1 11104109 EMW
can expect to be i nvol ved . i n the 0 0
of cale wi th attention to cul tural and
rel i gi ous bel i efs . COlni ca t i on
barri ers . pri vacy and confident i a l i ty.
L Jx O LdI| EL|u _

1 1 / 04/09 EMW
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