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PSYCHIATRIC TREATMENT
PLANNING
Second Edition
FUNDAMENTALS OF
PSYCHIATRIC TREATMENT
PLANNING
Second Edition
James A. Kennedy, MD
Associate Professor of Psychiatry
University of Massachusetts Medical School
Worcester, Massachusetts
Director
Demonstration Unit
Westborough State Hospital
Westborough, Massachusetts
President
KennedyMD Consulting
Shrewsbury, Massachusetts
Washington, DC
London, England
Copyright
Copyright 2003 American Psychiatric Publishing, Inc. ALL RIGHTS RESERVED.
Users of the manual are free to make unlimited photocopies of the following: Blank forms for the Master
Treatment Plan and Treatment Plan Review, Step-by-Step Instructions for using the blank forms, Sample Master
Treatment Plan, Quick Reference to Problem Categorization by the Kennedy Axis V, and the AIMS Plus EPS
(Abnormal Involuntary Movement Scale Plus EPS). Permission must be obtained from American Psychiatric
Publishing, Inc., to copy other parts of this manual. Use of the Kennedy Axis V and the Kennedy NOSIE (Kennedy
Nurses Observation Scale for Inpatient Evaluation) questionnaires requires a licensing agreement. Royalties may be
waived when these questionnaires are used for piloting or research purposes. Visit www.kennedymd.com for details
on licensing agreements.
Cautionary Note
Books published by American Psychiatric Publishing, Inc., represent the views and opinions of the individual
authors and do not necessarily represent the policies and opinions of APPI or the American Psychiatric Association.
The author has worked to ensure that all information in this manual is accurate at the time of publication
and consistent with general psychiatric and medical standards and that information concerning drug dosages,
schedules, and routes of administration is accurate at the time of publication and consistent with standards set by
the U.S. Food and Drug Administration and the general medical community. As medical research and practice
continue to advance, however, therapeutic standards may change. Moreover, specific situations may require a
specific therapeutic response not included in this manual. For these reasons and because human and mechanical
errors sometimes occur, we recommend that readers follow the advice of physicians directly involved in their care
or the care of a family member.
This manual is not presented as a standard of care. The clinical examples are just that: examples. They are not
intended to prescribe care for patients. This manual is intended to help treatment teams take a more systematic
approach to treatment planning. Each treatment team must use its own clinical judgment to decide how to use this
manual and its clinical examples. Even within this manual, the examples vary in the standard of care that they set
(i.e., some of the examples represent clearly higher standards than other examples).
The varying nature of the examples in this manual represents to some degree the wide range of treatments
available, as well as varying clinical standards for many clinical problems. Also, there are often different
interpretations of the standards set forth by various accrediting bodies. Finally, treatment teams have a limited
amount of time to complete treatment plans. Many examples are intended to represent plans taken from actual
team meetings; those examples certainly reflect to some degree that limited time.
Users should slowly replace the examples in this manual with examples developed by their own treatment
team members. These examples should better reflect the standards and treatment style expected from their own
treatment teams.
Computerized Treatment Planning
The current standard for computerized treatment planning is to generate the plan using a word processor; however,
this standard is rapidly changing. Visit www.kennedymd.com for updates on computerized treatment planning and
to download electronic copies of blank treatment planning forms.
Also available by Dr. Kennedy: Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning
(Washington, DC, American Psychiatric Publishing, 2003)
Manufactured in the United States of America on acid-free paper.
07 06 05 04 03
5 4 3 2 1
Second Edition
American Psychiatric Publishing, Inc.
1000 Wilson Boulevard
Arlington, VA 22209
www.appi.org
Library of Congress Cataloging-in-Publication Data
Kennedy, James A., 1946
Fundamentals of psychiatric treatment planning / James A. Kennedy.2nd ed.
p. ; cm.
Includes bibliographical references.
ISBN 1-58562-061-0 (alk. paper)
1. Mental illnessTreatment. 2. Psychiatric records. 3. Diagnostic and statistical
manual of mental disorders. I. Title.
[DNLM: 1. Mental Disorderstherapy. 2. Patient Care Planning. WM 400 K35f 2003]
RC480.5 K445 2003
616.891dc21
2002027688
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
CONTENTS
Preface .......................................................................................................................................... vii
Acknowledgments ....................................................................................................................... viii
Identifying Patient Data.............................................................................................................. viii
Introduction.......................................................................................................................... Intro1
Master Treatment Plan (Sample)..........................................................................................MTP1
Psychological Impairment ......................................................................................................... 11
Social Skills ................................................................................................................................. 21
Violence ...................................................................................................................................... 31
ADLOccupational Skills ............................................................................................................. 41
Substance Abuse......................................................................................................................... 51
Medical Impairment .................................................................................................................. 61
Ancillary Impairment .................................................................................................................. 71
Blank Forms ............................................................................................................................. BF1
Questionnaires............................................................................................................................Q1
Appendix..................................................................................................................................... A1
vii
Preface
This manual forms the cornerstone for the Kennedy Approach to Psychiatric Treatment Planning. This
approach is based on the Kennedy Axis V questionnaire, which organizes psychiatric problems into
seven categories or problem areas:
Psychological Impairment
Social Skills
Violence
Activities of Daily Living (ADL)Occupational Skills
Substance Abuse
Medical Impairment
Ancillary Impairment
This approach allows use of the Kennedy Axis V to capture baseline problems and baseline level of
functioning for each of these problem areas. These baseline findings can then flow directly into the
Master Treatment Plan and Nursing Care Plan via the Problem List and the problem descriptions. This
approach can then continue through Treatment Plan Reviews and Nursing Care Plan Reviews, progress
notes, and measurements of outcome.
This manual includes blank Master Treatment Plan forms, blank Treatment Plan Review forms,
sample Master Treatment Plans, and numerous sample Individual Problem Plans. In addition to this
manual and the Kennedy Axis V questionnaire, support for the Kennedy approach is available in
Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning (American Psychiatric
Publishing 2003) and online.
Online Support
Visit www.kennedymd.com for support and updates to the Kennedy approach to psychiatric treatment
planning and outcome measurement, including additional sample plans, training and credentialing
opportunities, updates of blank forms, and other information.
viii
Acknowledgments
I express my gratitude to the contributors to the first edition of this manual. Their help was essential to
its success. Many aspects of the first edition continue to be vital to treatment planning, therefore, they
have been included in this edition.
Since the first edition, many clinicians have helped with numerous suggestions and clinical
examples related to treatment planning, many of which have been integrated into this second edition.
Especially useful have been recommendations relating to the integration of the Nursing Care Plan into
the Master Treatment Plan. Clinicians from a wide range of facilities, as well as visitors to
www.kennedymd.com, have provided suggestions and help.
At Worcester State Hospital, Worcester, Massachusetts, I owe thanks to many current and past
nursing and psychiatric staff who were helpful with the integration of the Nursing Care Plan into the
Master Treatment Plan. Also, staff in the Mental and Behavioral Health Services at Our Lady of the Lake
Hospital, Baton Rouge, Louisiana, were very supportive, including Frank Silva, MD, medical director,
and Cami Ledford, BSN, RNC, clinical instructor.
I express my appreciation to Rose Mary Carroll-Johnson, MN, RN, editor, Nursing Diagnosis: The
International Journal of Nursing Language and Classification. She provided vital help with the integration
of nursing diagnoses into the Master Treatment Plan.
My thanks to Gretchen H. Horner, RNC, former administrative director, Memorial Hospital,
Johnstown, Pennsylvania, and Kathy Andolina, RN, MSN, CS, at The Center for Case Management, Inc.,
South Natick, Massachusetts, for their support of the concept of using an outcome measure to help
structure and track clinical care.
Special thanks to Chris Beaudoin, CNS, for her support during my visits to work with staff on
treatment planning at Greater Bridgeport Community Mental Health Center, Bridgeport, Connecticut;
Steve Sorkin, PhD, for his support during my work with staff on treatment planning at the Northern
Virginia Mental Health Institute, Falls Church, Virginia; and Dorothy Erney, RRA, Quality Coordinator,
Binghamton Psychiatric Center, Binghamton, New York. I also express my thanks to staff from the
Hudson River Psychiatric Center, Poughkeepsie, New York, and the New Hampshire Hospital, Concord,
New Hampshire.
I appreciate Joseph Black, MD, Chief Psychiatrist, Competency Program, North Texas State
HospitalVernon, Vernon, Texas, for his years of support for my systematic approach to psychiatric
treatment planning, including the use of the Kennedy Axis V questionnaire. The appendix includes a
sample Master Treatment Plan provided by Dr. Black, which is organized around the Kennedy Axis V
subscales.
Finally, without the structure provided by the Kennedy Axis V questionnaire, this manual would
not be possible; therefore, I refer you to the Acknowledgments section in the companion manual,
Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning (American Psychiatric
Publishing 2003).
INTRODUCTION
Intro1
Introduction
Intro3
INTRODUCTION
CONTENTS
History and Development of the Manual .......................................................................................... Intro5
Overview ................................................................................................................................................... Intro5
Moving From Diagnosis to Level of Functioning ...................................................................................... Intro5
Kennedy Axis V ......................................................................................................................................... Intro5
Abbreviations ............................................................................................................................................ Intro6
Online Support.......................................................................................................................................... Intro7
Notes
Introduction
Intro5
Kennedy Axis V
To develop this systematic approach to treatment planning, I selected Axis V from the Diagnostic and
Statistical Manual of Mental Disorders. Axis V, which measures psychiatric symptoms and level of
functioning, seemed ideal because of its focus on adaptive, problematic behaviors and outcome. In the
next step, drawing from Axis V and similar scales, I developed the Kennedy Axis V (see the
Questionnaires section of this manual for a copy of the Kennedy Axis V).
The Kennedy Axis V divides the symptoms and behaviors from Axis V into four problem areas:
Psychological Impairment, Social Skills, Violence, and ADLOccupational Skills. To complete the
problem categorization, I added Substance Abuse, Medical Impairment, and Ancillary Impairment. This
categorization forms the basic structure of the manual. The categories are elaborated in the next section,
Rationale for Categorization of Problems by the Kennedy Axis V. In addition, the Kennedy Axis V can
be used to measure outcome of treatment in each of the subscale areas.
Intro6
Abbreviations
The following abbreviations are often associated with the treatment planning system presented in this
book:
AA
Alcoholics Anonymous
ADL
AEB
As evidenced by
AIMS Plus
EPS
AIMS
ANC
Ancillary Impairment
ASA
AWA
bid
Twice a day
BP
Blood pressure
BPRS
BUN
COPD
COTE
CT scan
DBT
DL
Dangerousness Level
ECG
Electrocardiogram
ECT
Electroconvulsive therapy
EEG
Electroencephalogram
EPS
FBS
GAF Eq
GAF Equivalent
GAF Scale
HS
Hour of sleep
Hx
History
Hz
IPP
K Axis
Kennedy Axis V
LTG
Long-Term Goal
MED
Medical Impairment
meds
Medications
MHA
MHW
Introduction
MRI
MTP
NCP
Nsg.
Nursing
po
By mouth, orally
prn
As needed
PSY
Psychological Impairment
Every
R/O
Rule out
SAb
Substance Abuse
SNF
SOC
Social Skills
SSDI
SSRI
STD
STG
Short-Term Goal
Sx
Symptoms
TLE
TPR
Tx
Treatment
VIO
Violence
WBC
WNL
Intro7
Online Support
Visit www.kennedymd.com for support and updates of the Kennedy Approach to Psychiatric Treatment
Planning and outcome measurement using the Kennedy Axis V questionnaire. Additional sample plans,
training opportunities, updates of blank forms, and other materials are also available at the website. You
can contact the author at the website and you are encouraged to make comments or ask questions
about psychiatric treatment planning.
Intro8
Psychological Impairment
Social Skills
Violence
ADLOccupational Skills
These categories are not new theoretical areas. The areas are well known to clinicians and they
make a lot of clinical, intuitive sense. The areas are consistent with much of the training
received by clinicians. Because of the universal nature of the categories, they can be easily used
across disciplines. Minimal training is required to understand the categories.
By going step by step through these seven categories, practitioners can take a systematic
approach to identifying the problems. When one has proceeded through these seven
categories, one is very unlikely to have overlooked significant clinical areas.
Many symptoms and behaviors cluster together in syndromes that can be found within each of
the seven areas. Therefore, treatment can be directed at the syndrome within a problem area,
rather than at several individual problems. For example, use depressive symptoms rather
than sadness, loss of appetite, insomnia, and lethargy.
Training can be directed toward the individual categories as well as toward the categories as an
interactive system.
Finally, the Kennedy Axis V can be used to measure baseline functioning and the outcome of
treatment.
The Kennedy Axis V Categorization System allows the clinician to set a reasonable balance
between being too broad when defining problems and being too specific. Problem Lists that are broken
up into a lot of individual, discrete problems often lead to treatment plans and progress notes that are
choppy and disconnected. Defining a problem somewhat broadly allows clinicians to more easily
integrate what is happening in a clinically meaningful way. Progress notes tracking treatment and its
outcome are often more coherent and useful when directed at syndromes consisting of discrete
problems. However, the use of very discrete problems can tighten up ones thinking and planning.
There are certainly advantages to directing treatment toward individual, discrete problems as opposed
to very broad groups of problems. Again, the Kennedy Axis V Categorization System allows clinicians to
set a reasonable balance between discrete versus broad problem names based on ones clinical
judgment.
The system discourages collapsing problems from separate subscale areas into a single problem,
even though there may be a clear relationship between the problems. For example, depressive
symptoms and suicidal ideation should not be collapsed into a single problem, nor should cocaine
Introduction
Intro9
abuse and assaultiveness be collapsed into a single problem, even if there is a clear relationship
between the problems.
If a problem area consists of a single, specific symptom or behavior, a broad problem name should
not be used. For example, psychotic symptoms should not be used if the patients only symptom of
psychosis is paranoia.
No Perfect Fit
Any classification system that attempts to divide human behaviors into their component parts will
quickly run into areas in which the components do not fit cleanly into one problem area or box. In
such systems, ambiguity and disagreement about where particular symptoms and behaviors should be
placed is unavoidable. Despite the drawbacks and difficulties of classifying human behavior, use of the
Kennedy Axis V Categorization System serves to organize the complexity of clinical features that
patients present.
As indicated earlier, if a syndrome does not fit into one problem area, the syndrome should be
broken down so its components can fit into the appropriate problem areas. For example, suicidal
ideation should be removed from depressive symptoms and placed under the subscale area of
Violence. Lack of motivation should be removed from the problem of poor job skills and placed
under the subscale of Psychological Impairment. Further, lack of motivation may be placed under the
problem name of depressive symptoms or psychotic symptoms.
Intro10
1.
Psychological Impairment
Psychotic symptoms
Poor motivation
Mood disturbance
Personality disturbance
Poor focal attention
Eating disturbance
2.
Social Skills
Limited interpersonal skills
Poor communication skills
Lack of awareness of social norms
Sexually inappropriate behavior
3.
Violence
Threatening and assaultive
Suicidal
Homicidal
Sexually violent
Arsonist
4.
ADLOccupational Skills
Poor job skills
Lack of skills to care for self
Poor workmanship
Lack of basic survival skills
Poor personal hygiene skills
5.
Substance Abuse
Alcohol abuse
Cocaine abuse
Polysubstance abuse
Nicotine addiction
6.
Medical Impairment
Hypertension
Allergy to penicillin
Diabetes
Family planning concerns
Tardive dyskinesia
Dental problems
7.
Ancillary Impairment
Homelessness
Financial problems
Abusive spouse (domestic violence)
Legal problems
Incarceration
Need for guardianship
Permission granted by American Psychiatric Publishing, Inc., and James A. Kennedy, MD, to copy this page.
Introduction
Intro11
Database Assessments
Psychological
Tests
Consults
&
Laboratory Tests
Progress Notes
&
Legal
Physicians
Orders
Figure 1. Treatment plans do not stand alone. The treatment plan, including the Nursing Care Plan, is the engine that
drives the treatment process; however, it must work in conjunction with the rest of the patients record. Only when the
treatment plan is working effectively with the other sections of the patients record will it be acceptable to the accreditors
as well as to the clinicians who use the plan.
Intro12
clinicians are not using the systematic approach and forms in this manual. The audience to which this
manual is addressed includes staff at psychiatric hospitals, halfway houses, and community mental
health centers and students in academic programsthat is, anyone working where treatment planning
or nursing care planning is practiced or taught.
Problem List
Problem
Description
&
Treatment
Modalities
&
Discharge
Planning
Introduction
Intro13
These formal Treatment Plan Reviews are generally used to review, summarize, and update changes.
These formal reviews are also used to ensure that changes in treatment are added or have been added to
the MTP itself.
Scheduling team meetings to immediately review changes is often impossible. The inability to hold
a treatment team meeting each time a review is needed or a change is made in the treatment plan is
often dealt with in one of two ways:
1. A team member who wants a change in the treatment plan discusses the change with available,
relevant team members. The patient should also be included in this process to the degree that
is clinically appropriate. If it is decided that the plan should be changed, the team member
enters the change on the MTP and dates and initials the change. The team member enters
details of the change and the rationale for the change in the progress notes. At the next
treatment team review, the change is discussed with the entire treatment team.
2. The same as #1, except no entry is made on the treatment plan until the next Treatment Plan
Review meeting. As in #1, a team member enters details of the change and the rationale for the
change in the progress notes.
When a change in the plan occurs, it is unacceptable not to make an entry in one of the following: the
Master Treatment Plan, the Treatment Plan Review, or the Progress Notes.
Finally, the clinical team may be so conservative in its definition of major changes or
reasonable clinical care that few, if any, formal Treatment Plan Reviews occur. Therefore, to ensure
that treatment reviews occur at least with some minimal frequency, it is recommended to use a
combination of reviews according to the four clinical requirements mentioned earlier, as well as
scheduled periodic reviews. For example, for a very stable patient, Treatment Plan Reviews might be
scheduled for every 3 months. If a review were done before 3 months, then the next review would be
rescheduled for 3 months following the last completed review. This schedule would ensure that a
review is done at least every 3 months, as well as when clinically indicated by the clinical criteria.
Intro14
The minimal frequency for formal Treatment Plan Reviews should be based on the usual rate of
change in the patients clinical treatment/status within a particular facility or unit within the facility.
For many facilities, it seems reasonable to have a scheduled review every month for the first 6 months
to 1 year and every 2 to 4 months thereafter. One may also want to make allowances for patients
readmitted after only a short time out of the hospital.
Integration of the Nursing Care Plan Into the Master Treatment Plan
There is tremendous overlap between the MTP and the Nursing Care Plan (NCP). The description of the
problems (nursing diagnoses), including response to previous treatments, should be identical. The
nursing interventions on the NCP and the MTP should be essentially identical; therefore, simply
consolidating them into the MTP can eliminate the redundancy. All members of the team should be
working toward the same long-term goals and short-term goals (objectives), even though specific team
members may be more focused on particular goals. Therefore, it is recommended that nursing staff
integrate the NCP into the MTP rather than have separate plans.
Because the nursing interventions (nursing treatment modalities) often form the main component
that differentiates the MTP from the NCP, it is suggested that the nursing interventions (treatment
modalities) in the MTP be labeled as the Nursing Care Plan.
Another equally important reason for integrating the NCP into the MTP is to encourage nursing
staff to be more actively involved with the development and implementation of the MTP. It is not
unusual for nursing staff members to complete their NCP and feel they have met their obligations to
the treatment planning process. They may then move forward with implementing their plan with
minimal investment in the MTPthat is, they feel little ownership of the MTP because they already
have their own plan.
Nursing staff may even see the NCP as a means of separating themselves from the problems,
difficulties, and even at times the chaos that can be associated with poorly developed MTPs. With their
own plan, nursing staff members may not have to worry about the difficulties of becoming an
integrated member of the team process. They have their separate, defined role as outlined in their NCP.
If there are problems with the MTP, those problems can be seen as problems for other team members.
Because they have their own plan, nursing staff members may have little vested interest in the MTP.
Finally, it is suggested that the inclusion of the NCP in the MTP be the standard of care.
Throughout this manual, it is assumed that the NCP has been integrated into the MTP. Often in this
manual, you will see that the NCP has been clearly indicated as part of the MTP; however, even when
not clearly indicated, it should be understood that the NCP has been integrated into the MTP.
Introduction
Intro15
maintenance, and so on. This is the treatment plan, not the problem plan; therefore, important areas
involving treatment should not be omitted from the treatment plan simply because they are not seen as
a problem.
Figure 3.
In these examples, except for laceration of left forearm, various arguments could be put forth as
to which date to include as the date of onset. These arguments can be very time consuming. Including
this information in the problem description allows the clinicians the opportunity to explain the
progression of the development of a problem and often eliminates the arguments and confusion.
Intro16
Use of either pair of outcome measures is acceptable; however, the use of long-term goals and
short-term goals has several advantages.
The phrases long-term goals and short-term goals are unambiguous. Little or no training is
needed to have at least some working understanding as to the meaning of these phrases.
However, the term objective has a wide range of commonly used meanings. Due to its wide
range of definitions, the introduction of objective can be confusing to the writer and anyone
who reads the plan. This confusion leads to the need for additional training, which can be timeconsuming and expensive.
The concepts of long-term goals and short-term goals fit very well along a continuum. However,
goals and objectives do not intuitively fall along a continuum. The terms imply much more of a
qualitative difference than should exist between them.
Separate categories of possible long- and short-term goals are not necessary. Depending on the
clinical situation, a long-term goal can be a short-term goal and vice versa. For example,
patient will be free of assaultive behavior for a 1-week period can be a long-term goal in an
acute setting if freedom from assaultive behavior for 1 week is determined to indicate that the
problem is no longer active or is adequately treated so that the patient can be discharged from
the acute setting. The same goal may be a short-term goal in a chronically assaultive patient if it
is determined that being assault-free for 1 week simply indicates improvement; however, a
much longer assault-free period is felt necessary to indicate that the problem is no longer active
or that adequate improvement has occurred for discharge.
As a rule of thumb, long-term goals are essentially the same as goals, and short-term goals are
essentially the same as objectives. Of course, all outcome measures, regardless of how they are named,
need to comply with rules that ensure they are observable and measurable. See Master Treatment Plan
Forms (Step-by-Step Instructions) later in this chapter for further information on long- and short-term
goals and target dates.
Introduction
Intro17
treatments for various problems. Though certainly important, goals have never seemed to gain the
clinical usefulness to the staff that treatment modalities have.
Further, if the goals are reached, but the treatment modalities are unclear, it may appear as if one
accidentally stumbled into attaining the goals. Finally, it is much easier to defend inaccurate goals and
inaccurate target dates than to defend inaccuracies in the treatment modalities. Predicting the future is
difficult; however, failing to accurately represent what is happening in the present, such as treatment
modalities, can leave one open to criticism.
Working Backward From Treatment Modalities to Goals
In filling out treatment planning forms, one major argument concerning the sequence is often raised.
That argument relates to whether one should enter the treatment modalities before the goals. Logically,
it seems to make a lot of sense to start with the goals; however, clinically, it is sometimes much more
useful to start with the treatment modalities. It is not unusual for the availability of resources to drive
treatment to a greater degree than the goals do. This is especially true for the long-term patient who has
exhausted many of his or her resources, including family supports. The availability of specific
treatments, including the expertise needed for those treatments, can markedly affect the development
of realistic goals and realistic target dates. Therefore, once treatment modalities have been determined,
the modalities can be surprisingly helpful when attempting to write realistic treatment goals.
Intro18
2. Behavior expected
[observable/measurable]
3. Target frequency
4. Time period
twice a week
for 1 month.
for 1 month.
once daily
for 1 week.
for 1 month.
for 1 month.
[not needed]
[not needed]
[not needed]
[not needed]
Figure 4.
Introduction
Intro19
2. Time period
3. Frequency
4. Modality
Nurse will meet with pt. for at least 15 minutes once weekly
1 hour
once weekly
[time necessary]
for 1 hour
twice weekly
[time necessary]
once every
6 months
[as needed]
Figure 5.
[on an ongoing
basis]
Intro20
that clinical process. A benefit of including the IPP forms in this manual is their ability to reflect these
shifts in the clinical process. As a result, IPPs can allow a clinician to quickly determine the current
status of treatment for particular problems. The clinician can also quickly review the progress of the
treatment that has led to the current IPPs. It is not necessary to move back and forth between the
original MTP, Treatment Plan Reviews, and progress notes to determine the general progress and
current standing of the treatment.
Sharing of IPPs
IPPs are critical to the sharing and exchange of ideas on treatments for individual problems. If a good
plan is developed for a particular problem, then the IPP for that problem can be removed from the MTP
and copied and distributed as a guide for members of other treatment teams. Also, as indicated earlier,
IPPs could be written by experts in various areas and made available to users of the manual. These new
IPPs and shared plans can be added to the manual for quick reference.
Training
Training can be done for problem areas using IPPs. For example, IPPs on suicide and suicidal ideation
could form the basis for training related to treatment planning for the suicidal patient. IPPs on
symptoms and behaviors of the psychotic patient could be used for training related to treatment
planning for the psychotic patient.
No Increase in Documentation
Finally, there should be no significant increase in the amount of documentation. The information
required by the accreditors is the same regardless of whether the documentation is collapsed into one
central document or organized in a different manner. There may be more pages in a plan that requires a
page for each active problem; however, because both systems contain the same required information,
there should be no difference in the amount of documentation needed. This can create a problem
because there is a tendency by clinicians to want to completely fill any blank areas based on the size of
the blank area rather than the amount of information needed. Staff members need to be trained to
write briefly and concisely, regardless of the size of the blank areas.
Introduction
Intro21
A major contributor to this knee-jerk reaction is the fact that many clinicians falsely believe that
treatment planning has no clinical value. These are often responsible clinicians who think treatment
planning is necessary for satisfying accreditors but for little else. This attitude is fueled by years of
frustration with the poor results of even genuine attempts to generate good, useful treatment plans.
One of the primary purposes of this manual is to assist clinicians in their attempts to quickly generate
clinically effective treatment plans. If successful, it will help to reduce some of the frustration, anger,
and cost of treatment planning, while helping to improve the quality of care.
Situations in Which Cuts Are Recommended
There are certainly many ways to achieve direct compromises and cost-cutting measures. There are
situations in which such cuts and compromises can lead to better staff acceptance and more appropriate
treatment plans.
Anticipated length of hospitalization. Certainly there may be less need for a comprehensive
treatment plan in an acute setting in which the average stay of the patient is only 8 to 10 days.
Many treatment decisions may be fresh in the minds of the clinicians; therefore, there may be
less of a need to refer to a comprehensive treatment plan. This is especially true if the treatment
team relies almost exclusively on other parts of the record for clinical information and
documentation of the clinical progress, for example, the progress notes.
The opposite is often true of the long-term-care patient. In the long-term-care patient,
treatment may be no more complicated than treatment for the acute-care patient; however, the
treatment is often much more unconventional and individualized. These patients have
generally failed to respond to the initial, somewhat standardized treatment strategies. As plans
get increasingly individualized, comprehensive treatment plans become increasingly important
to keep the team informed and working together. Also, as the length of hospitalization
increases, treatment planning decisions will no longer be fresh in the minds of the clinicians;
therefore, a comprehensive treatment plan can be helpful to remind staff of their roles with a
particular patient.
Problems in the long-term-care setting that are often deferred in the acute-care setting also
have to be addressed. For example, deficits in work skills may not be addressed at all in an
acute-care setting. However, these same deficits in work skills may be the primary focus of
treatment in a long-term-care facility.
Degree to which the rest of the record effectively reflects treatment and its progress. If the
treatment planning information is well organized and easily accessed in the rest of the record,
the team may be less dependent on having a very comprehensive treatment plan. However, if
information about the teams treatment plan and its outcome is buried in the record and
difficult to locate, then a comprehensive treatment plan can be extremely helpful with keeping
the team focused on their common goals and the methods to achieve those goals.
Clinical style of the treatment team. Clinical styles vary greatly in the development and use
of MTPs. Some clinical styles may work better with an abbreviated, short plan. This manual and
its forms do not limit the use of the system to clinicians with a particular style. Therefore, if the
clinician wants to do a short, quick MTP, the system will allow for it. If the clinician wishes to
write a comprehensive plan, the system will continue to satisfy the needs of the clinician. The
system also allows clinicians and the quality assurance department a lot of flexibility to impose
their clinical judgments and standards onto what should be included in the treatment plan.
Time constraints for a hurried treatment team. Obviously, if the team is not provided with
adequate time to prepare a reasonable treatment plan, the plan may lack many critical elements
or the plans may be extremely canned as clinicians take desperate steps to meet various
deadlines. It has been my experience that it is not unusual for clinicians to be expected to write
comprehensive treatment plans without the minimal time and staff needed to write reasonable
plans. I have seen this lead to anger and frustration among the staff.
Intro22
Introduction
Intro23
done directly on the electronic version and then stored, printed, or both. I also recommend that
IPPs created within your facility be categorized by the Kennedy Axis V and placed in a binder
for later reference. As more IPPs are added, this binder can be an invaluable resource for writing
future plans.
Intro24
I.
Date of Admission
Enter the date of the current admission.
B.
C.
Problem Number
Enter the number of the problem. A suggested numbering system is a categorization in which
all problems are placed into one of seven categories (based on the Kennedy Axis V subscales).
This is the numbering system used in this manual:
1.
2.
3.
4.
5.
6.
7.
Psychological Impairment
Social Skills
Violence
ADLOccupational skills
Substance Abuse
Medical Impairment
Ancillary Impairment
Depressive Symptoms
Suicidal Ideation
Homicidal Ideation
Health Maintenance
Diabetes
Hypertension
Kidney Failure
Placement
In the above numbering system the period (.) separates the problem area from the designation of a specific, individual problem within that problem area. The problem numbers
should be entered in numerical order when developing the Problem List. As additional
problems are added, they would be added in the next available row at the bottom of the list
and assigned the next available number within that problem area.
In the Problem List example, if all the problems were active, seven IPPs would have to be
completed. However, in two subscale areas, there is more than a single problem number:
3.1
3.2
6.0
6.1
Suicidal Ideation
Homicidal Ideation
Health Maintenance
Diabetes
Introduction
Intro25
6.2 Hypertension
6.3 Kidney Failure
Whenever clinically reasonable, problems within a subscale area should be covered under a
single problem number. This can reduce the complexity of the MTP by decreasing the
number of IPPs that have to be tracked separately. Therefore, if it is clinically reasonable to
collapse the above problems into a single number within their respective subscale areas, the
list may appear as follows:
1.1
3.1
6.0
6.0a
6.0b
6.0c
Depressive Symptoms
Suicidal and Homicidal Ideation
Health Maintenance
Diabetes
Hypertension
Kidney Failure
Even if all the problems listed were active, only three IPPs would need to be completed for
this list. Because the hypertension and kidney failure may be secondary to diabetes, the list
could also be collapsed as follows:
1.1
3.1
6.0
6.1
6.1a
6.1b
Depressive Symptoms
Suicidal and Homicidal Ideation
Health Maintenance
Diabetes
Hypertension
Kidney Failure
In this example, four IPPs would be needed. Problems 6.1a and 6.1b would be collapsed into
problem 6.1 Diabetes. The .0 position, as illustrated in the example, is reserved for a special
problem within a problem area. No other problem would be assigned the .0 position, even
if it were not used on a particular plan. Currently two such problem names are often
associated with the .0 position:
6.0 Health Maintenance
7.0 Placement
It is common for a 6.0 to be entered into the Problem List of every patient being treated at a
particular facility and given an active status, even when a patient has no significant medical
problems. This listing allows for tracking of routine health issues, as well as relatively minor
health problems. Serious health problems should generally be given a separate problem
number, for example, a serious case of diabetes could be assigned 6.1 Diabetes, rather than
being collapsed under 6.0. A case of diabetes that is stable and well controlled by diet and an
oral hypoglycemic medication may be easily tracked under 6.0 Health Maintenance.
The problem number should follow revisions of the problem name, if it continues to be
essentially the same problem. For example, in the original MTP psychotic symptoms may
have been identified; however, later the patient was determined to have bipolar symptoms.
This would lead to the following changes in the Problem List:
Problem
Number
1.1
1.1
Problem Name
Psychotic Symptoms
Bipolar Symptoms
Discharge
Barrier
Yes
01/15/03
02/15/03
Active
Revised to 1.1
Yes
01/15/03
Active
Date Changed
& New Status
Intro26
Problem Name
Discharge
Barrier
Date Changed
& New Status
02/15/03
Revised to 3.1
3.1
Yes
01/15/03
Active
3.1
Assaultive
Yes
01/15/03
Active
Discharge
Barrier
Date Changed
& New Status
02/15/03
Revised to 6.1
Another example:
Problem
Number
Problem Name
6.1
Hypothyroidism
No
01/15/03
Active
6.1
No
01/15/03
Active
At the time of a rewrite of the MTP (often annually), it may be reasonable to redo the
problem numbers to allow the most prominent problem in a problem area to be moved to
the numerical top of the problem area. For example, at the time of the rewrite on 01/15/04,
the old Problem List for the Violence area would appear as follows:
Problem
Number
Problem Name
Discharge
Barrier
Date Changed
& New Status
3.1
Hx of Suicidal Attempt
No
01/15/03
Noted
01/15/04
Revised to 3.2
3.2
Assaultive Behavior
Yes
02/15/03
Active
01/15/04
Revised to 3.1
In the new MTP on 01/15/04, assaultive behavior can be moved to the numerical top:
Problem
Number
Problem Name
Discharge
Barrier
3.1
Assaultive Behavior
Yes
02/15/03
Active
3.2
Hx of Suicidal Attempt
No
01/15/03
Noted
Date Changed
& New Status
Similarly, if information was gathered concerning the patients suicide attempt and on
04/15/03 it was determined to have been fabricated by family to get needed treatment for
their mentally ill family member, then on 04/15/03, Hx of suicidal attempt could be
canceled:
Introduction
Problem
Number
Problem Name
Intro27
Discharge
Barrier
Date Changed
& New Status
04/15/03
Canceled
3.1
Hx of Suicidal Attempt
No
01/15/03
Noted
3.2
Assaultive Behavior
Yes
02/15/03
Active
In the annual rewrite of the MTP on 01/15/04, assaultive behavior can be moved to the
numerical top and Hx of suicidal attempt, which was canceled, would not appear on the
Problem List:
Problem
Number
3.1
D.
Problem Name
Assaultive Behavior
Discharge
Barrier
Yes
02/15/03
Active
Date Changed
& New Status
Problem Name
Write the name of the problem in this column. The name should be brief, generally no
longer than three words. The name is intended to be a quick, concise way of identifying the
problem. For example, use suicidal ideation rather than suicidal ideation because of recent
job loss. Document descriptive and interpretive statements related to the problem, such as
because of recent job loss, in the problem description section on the IPP sheets.
As indicated earlier, to help ensure that significant problems are not overlooked, when
determining the Problem List work your way systematically through each problem area,
starting with Problem Area 1 (Psychological Impairment) and ending with Problem Area 7
(Ancillary Impairment).
The Problem List should contain all significant clinical problems. In addition to the
obvious problems, the Problem List should contain items such as history of assaultive
behavior, history of suicidal attempt, allergy to penicillin, single kidney, and so on. These
problems should not be listed if they are thought to be of no clinical significance (e.g., if the
suicidal attempt was an isolated incident that occurred years ago and is of no future clinical
relevance to the case). Problems should not be listed if they are already incorporated into an
active problem. Allergies do not need to be included on the Problem List if there is already a
system in place to prominently display allergies in the patients record.
Also, in addition to problems, the Problem List should contain other clinical factors that
require treatment or clinical resources, such as pregnancy, criminal charges, Tarasoff warning,
placement, health maintenance, and so on. This is the treatment plan, not the problem plan;
therefore, important areas involving treatment should not be omitted from the MTP simply
because they are not seen as a problem.
If the Problem List is complete, clinicians will not be surprised by significant clinical
issues or problems lost or buried in the patients chart. Generally, the Problem List is the only
place in the chart where there is a comprehensive, condensed, and updated outline of all
significant clinical issues. This is a key part of any clinical chart and is one of the first places
clinicians should go when attempting to get an overview of the patients clinical situation.
Intro28
E.
Discharge Barrier
Enter Yes or No as appropriate:
YesThis problem is a significant barrier to discharge.
NoThis problem is not a significant barrier to discharge.
There is no column to indicate a status change in the discharge barrier. When the
problem is no longer active, it is assumed to no longer be a discharge barrier. If needed, one
can revise the problem on the Problem List to the same problem number and enter the
revised problem on the next available row on the Problem List. You can then indicate that
the problem is no longer a discharge barrier or indicate that it is now a discharge barrier.
Finally, it is important to note that if a problem is not a barrier to discharge, funding
sources may mandate that any treatment of that problem be deferred.
F.
G.
H.
be noted because it is likely that it may become active or it could have some significant
impact on treatment. Some examples include history of homicidal attempt, history of
suicidal attempts, allergy to penicillin, only one functioning kidney, abnormal ECG. No
IPP is required.
3. Inactive With Tx: A problem that is inactive; however, continued treatment is required to
prevent the recurrence of the problem. An example includes assaultiveness under control
with lithium and present when lithium is withdrawn. Therefore, continued treatment
would be indicated for this inactive problem. An active problem should not be changed to
Inactive With Tx until you are fairly certain that the change in status is real and not just
a fairly temporary state. The IPP for the active problem would continue to be used;
however, all goals, including long-term goals, would have been Attained or Canceled. Any
changes in treatment would be documented in the same way that changes were documented for the active state for the problem, including writing progress notes to document
the continued treatment and with hope, continued control of symptoms.
Introduction
Intro29
4. Noted Problem: Similar to an inactive problem; however, it is even less likely to become
active or to require treatment. Noted problems fit along the following continuum:
Active or Inactive With Tx
Inactive
Noted
Resolved
For example, a fractured arm will be an Active problem while it is in the cast
healing and being followed up. After a few weeks, when the arm is taken out of the cast
and appears to have healed and no follow-up is recommended, the problem may be
changed to Inactive. After a few months, if there is a rewrite of the MTP, the problem
may be Noted on a treatment plan. After about 6 months or longer, if the arm continues
to appear to have healed well and the patient does not appear to be at risk for another
fracture, the problem may be listed as Resolved. If Resolved, it would be taken off the
Problem List at the next rewrite of the MTP.
Of course, no IPP is needed for a Noted problem.
5. Resolved Problem: This status is used when a problem has reached a state whereby it is felt
or in rare cases the discharge barrier. This revision is intended to clear up any confusion or
misunderstanding in the present problem name or number. Revisions in the problem
name include better wording for clarity, changes in the name to reflect changes in the
nature of the problem itself, and so on. For example, allergy to Risperdal could be
revised to severe EPS on Risperdal, if it were determined that rather than an allergy, the
patient had severe EPS when on Risperdal.
If the problem is revised for inclusion with one or more other problems, the resultant
problem could be assigned a number already held by one of the problems or it could be
assigned a new number. Problems losing their numbers would be Revised to the chosen
number.
If there were a change in the status of the revised problem, the need for an IPP would
depend on the final status assigned to the problem. For example, if the Revised status was
an Active status, an IPP would be required. If the problem were revised to an Inactive
status, no IPP would be needed.
7. Deferred Problem: An active problem whose assessment, treatment, or both have been
postponed until a later time or another place. For example, treatment of a learning
disability may be deferred in an acutely psychotic or acutely suicidal individual. A deferred
problem could also be an active problem that for various reasons would probably never be
treated or require further assessment. In addition, a deferred problem could be a problem
that is being actively treated; however, a decision to stop treatment is made for various
reasons and any further treatment is deferred until a later time or another place.
As indicated earlier, it is important to note that if a problem is not a barrier to
discharge, funding sources may mandate that any treatment of the problem be deferred.
No IPP is required on deferred problems; however, a partial IPP can be completed at
the discretion of the treatment team. On such a partial IPP, one would enter the
description of the problem. Deferred problem and the reason for deferral could then be
written in the area for the long-term goal. Later, if the problem changes to an Active status, a line could be drawn through Deferred problem and the rest of the form could
then be updated and completed.
Intro30
8. Canceled Problem: This status should be used to cancel out a problem that may have been
incorrectly identified as a problem for the patient. For example, suicidal ideation would
be canceled if it were determined that the patient is not and has never been suicidal or
self-abusive. Of course, no IPP would be needed for a canceled problem.
II.
Patients Strengths
Enter either a list of the patients strengths or a narrative statement listing and integrating the
patients strengths. These strengths should be related to treatment and discharge. As with the
Problem List, to help ensure that significant strengths are not overlooked, it is suggested that
you work systematically through each strength area as defined by the Kennedy Axis V subscale
problem areas as shown in Table 1.
Table 1.
PROBLEMS
STRENGTHS
1. Psychological Impairment
1. Psychological Strengths
3. Violence
3. Nonviolence
5. Substance Abuse
5. Sobriety
6. Medical Impairment
6. Medical Strengths
7. Ancillary Impairment
7. Ancillary Strengths
As with the problems, once you have gone through the strengths areas it is unlikely that
significant strengths will be overlooked.
B.
Discharge Criteria/Planning
Discharge criteria are often equated with the long-term goals of the problems that are
discharge barriers; therefore, you may want to work backward from the long-term goals to the
discharge criteria.
Prediction of placement should be realistic (i.e., based on the patients strengths and
weaknesses and the availability of resources in the community). Enter here the realistic
placement plans, rather than the idealistic ones. Also enter concerns about the lack of
availability of appropriate community resources. If needed, complete an IPP on placement.
Such a problem plan helps the social workers to document in the progress notes their efforts
to place the patient. This also makes it easier to locate information in the progress notes
concerning placement that has been written by social work staff, as well as nonsocial work
staff.
Enter the target discharge date here. It is rare for the target discharge date to be beyond
1 year; however, if realistic, it is acceptable to indicate a discharge date of 2 or 3 years or even
indefinite. Be sure to document ones clinical reasons for such an extensive length of stay.
Introduction
C.
Intro31
Psychiatric Diagnosis
Enter the patients DSM-IV-TR diagnosis at the time of the MTP. The Kennedy Axis V should
be used for both Axis IV and Axis V (Kennedy 2003). Figure 6 shows an example of a
psychiatric diagnosis.
Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
AXIS II:
AXIS III:
AXIS IV:
AXIS V:
Figure 6.
Psychiatric diagnosis.
B.
Nursing Diagnosis
As a part of the integration of the NCP into the MTP, enter the nursing diagnosis below the
problem name. To assist with this task, nursing diagnoses have been categorized by the
Kennedy Axis V (see Appendix).
C.
D.
Problem Description
Enter a brief description of the problem. The following six components are often seen in
problem descriptions:
1.
2.
3.
4.
Nursing Diagnoses: Definitions and Classifications 20012002. Philadelphia, PA, North American Nursing Diagnosis
Association, 2001.
Intro32
5.
6.
These components should relate to goals, treatment modalities, and target dates.
E.
Pt.s psychotic symptoms will decrease such that she can participate in full-time program
activities for 1 month without serious disruption by psychotic process.
Pt.s Kennedy Axis V for Psychological Impairment will improve from a score of 30 to
50.
At a minimum, the long-term goal(s) should reflect the intention of preventing further
deterioration in the patients mental or physical condition. One exception would be a
problem that is part of a progressive disease process. In such a disease, there may be no
treatment that will fully stop the progressive nature of the illness (e.g., the cognitive
deterioration associated with Alzheimers disease). The goals for these progressive problems
should reflect realistic attempts to minimize the deterioration.
No active problem should be without a long-term goal.
F.
Target Date
Indicate the anticipated date when the long-term goal(s) or the short-term goal(s) will be
achieved. Attempt to make these dates realistic. The treatment team should take into account
the various expected delays and difficulties. The date should not reflect an ideal date or a
best-case scenario. Generally the treatment team should set up long-term goals that are
thought to be achievable before discharge or within 1 year for patients who are expected to
remain in the hospital for 1 year or longer. The target date for the short-term goals may vary
widely depending on many clinical factors. Generally, the date should not be longer than
6 months for short-term goals.
If a target date has to be extended, draw a line through the target date and place the new
target date below the old target date. Initial the change and document the reason for the
change in the progress notes, the Treatment Plan Review, or both.
Ongoing as a target date for an attained goal can be useful. Ongoing reflects that the
goal has been attained; however, the team does not want to eliminate the goal from the plan
because it helps to convey that the patient has achieved a specific level of functioning. An
additional goal would not have to be added to the plan to replace this attained goal if the
team is satisfied that the level of functioning achieved is adequate for discharge. The team
would work on at least maintaining the patient at the level of the ongoing goal. For
example, if an assaultive patient has attained a goal of being assault free for 6 months and
this is adequate for discharge, the team may want to simply indicate ongoing as the target
date. At the time of the MTP rewrite, the ongoing goal could be moved forward or
Introduction
Intro33
incorporated into the problem description to document the current level of functioning for
the problem.
Ongoing can also be useful for problems that are Inactive With Tx because use of the
term allows the level of functioning necessary for the patient to have achieved the Inactive
With Tx status to be clearly documented, as well as the level of functioning needed to
maintain the status of Inactive With Tx.
G.
Date/Status
Indicate status change and date of that change in this column. The status changes include
Attained, Canceled, and Revised (see Section J). Draw a line through the long-term goal when
its status has changed. If this is the only long-term goal and the problem is not Inactive,
Inactive With Tx, Deferred, or Resolved, then another long-term goal or a revised long-term
goal should be added.
H.
I.
Intro34
J.
Status
The goals may be Attained, Canceled, or Revised, depending on the patients response to
treatment and additional information obtained. A treatment modality can be Completed,
Canceled, or Revised. Draw a line through a goal or treatment that has been Attained,
Completed, Canceled, or Revised:
1.
2.
3.
K.
Attained goal or completed treatment: This status indicates that the goal or treatment has
been reached or completed. Enter a date and status change and draw a line through the
goal or treatment. If appropriate, enter another goal or treatment, along with a target
date for each new goal.
Revised goal or treatment: This status indicates that a change has been made in the goal or
treatment. Enter a date and status change and draw a line through the goal or treatment
to be revised. In the appropriate column, enter the revised goal or treatment. If a goal is
being revised, enter a target date in the column next to the new goal.
Canceled goal or treatment: This status indicates that a goal or treatment has been
canceled. At this time, enter the appropriate date and status change and draw a line
through the goal or treatment that is being canceled.
V.
A.
B.
B.
Introduction
Intro35
C.
D.
E.
F.
G.
H.
Continuation/Comments Section
This area provides additional space if adequate space is not available in the previous sections.
Patient or staff comments can also be entered here.
I.
Level of Care
This section can be useful for Medicare and Medicaid billing purposes by indicating the
following:
Active Treatment [ ]
Extended [ ]
Awaiting SNF [ ]
Refer to the Centers for Medicare and Medicaid Services (formerly HCFA) for details and help
with Medicare and Medicaid billing (SNF, skilled nursing facility).
J.
Notes
MTP1
MTP3
MTP4
19862003
#: 12345
Age:
26
Instructions: For each subscale, enter the rating followed by a brief description of the relevant symptoms and behaviors. Round off
intermediate codes, e.g., 43, 62, 78, to the nearest multiple of 5, e.g., 45, 60, 80. Enter NR if Not Rated. The numbers for deriving the
Dangerousness Level are located directly below the subscale scores and are automatically indicated as one checks each subscale score.
FUNCTIONAL
DYSFUNCTIONAL
1. Psychological Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Primarily (check one):
Not Impaired___
Antisocially Impaired___
Other Impairment X
Both___
Dereks current depression is characterized by feelings of hopelessness and worthlessness. He is anxious, lethargic, socially
isolated, and frequently up most of the night. His depression is also associated with self-deprecating and command
hallucinations.
2. Social Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
70
65
65
60
55
45
40
30
25
20
15
5
50
Dereks attempts to be pleasant and engaging are usually awkward. He has a couple of friends; however, he does see them often.
He often gets into conflicts due to inappropriate social behavior.
3. Violence
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 X 40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
Primarily (check one):
Nonviolent___
Violent to Self X
Violent to Others___
Violent to Self and Others___
Derek has a long history of suicidal attempts, gestures, and manipulations. He has made serious attempts to hurt himself in
response to command hallucinations, including taking overdoses of meds and attempting to hang himself. Since he stopped
drinking 2 years ago, he has not acted on any suicidal impulses. Currently he continues to have command hallucinations and
suicidal ideation; however, he reports that he would not actually attempt to harm himself.
4. ADLOccupational Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Derek is a high school graduate with average intelligence. He has some mild difficulty following instructions on his job as an
office assistant. He has a drivers license and has no more than mild difficulty maintaining his own apartment. Overall he has
fairly good independent living skills.
5. Substance Abuse
100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
Primarily (check one):
Nonabuser___
Alcohol Abuser X
Drug Abuser___
Both___
Derek began using alcohol as a senior in high school as a means of fitting in with his peer group and self-medicating his
depression. He had some very serious problems with alcohol that led to serious attempts to hurt himself when intoxicated,
including taking overdoses of meds and attempting to hang himself. Generally, since he stopped drinking 2 years ago, he has had
much better control of these impulses. He goes to AA on a weekly basis and is committed to continued sobriety. Derek smokes
one pack of cigarettes a day.
6. Medical Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 X 60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Derek is in fairly good physical health, even though he has mild reflux esophagitis secondary to a hiatal hernia. This disorder is
fairly well controlled with a prescription med to reduce stomach secretions; however, currently he drinks 8 to 12 carbonated
beverages every day and eats other foods that exacerbate his heartburn.
GAF Equivalent:
#1
40
+ #2
60
+ #3
45
+ #4
70
Victor Dyson, MD
215
55
45
Date:
01/05/03
MTP5
Problem List
ID #: 12345
Lakeview Hospital
Name of Facility
Problem Name
Date: 01/15/03
Discharge
Barrier*
1.1
Yes
01/15/03
Active
2.1
No
01/15/03
Deferred
3.1
Suicidal Ideation
Yes
01/15/03
Active
5.1
Alcohol Abuse
No
01/15/03
Inactive With Tx
6.0
Health Maintenance
No
01/15/03
Active
6.0a
Reflux Esophagitis
No
01/15/03
Active
Date Changed
& New Status***
02/12/03
Inactive With Tx
*DISCHARGE BARRIER: YES = Significant barrier to discharge; NO = Not a significant barrier to discharge
**ESTAB. STATUS: Active, Inactive, Inactive With Tx, Deferred, Noted
***CHANGED STATUS: Resolved, Active, Inactive With Tx, Revised, Canceled, Noted
Check if list is continued [ ]
MTP6
ID #: 12345
Strengths/Discharge Plan/Diagnosis
Area: West Unit
Date: 01/15/03
Patients Strengths (related to treatment and discharge):
Discharge Criteria/Planning (Include anticipated placement environment, criteria for discharge, long-term goals
needed for discharge, and anticipated target date. If a problem exists with placement, complete an Individual Problem Plan on
Placement.):
Derek Rossi will be free of any suicidal ideation or any command hallucinations to harm himself for 4 weeks. Derek
will be able to participate in a full schedule of program activities for 2 weeks. Plans will be in effect for Derek to
return to his job in the community immediately following discharge. Derek will complete three overnight passes
back to his apartment without any return of suicidal ideation. Derek will continue to participate in community AA
meetings after discharge.
Discharge Coordinated By: Brenda St. Martin, MSW
AXIS II:
No diagnosis
AXIS III:
AXIS IV:
Ancillary Impairment =
AXIS V:
PSY =
40
SOC =
GAF Equivalent =
70
60
55
VIO =
45
ADL =
70
SAb =
70
Dangerousness Level =
MED =
65
45
Significant changes have been made in the diagnosis and those changes have been documented on the
Treatment Plan Review dated:
/ /
/ /
/ /
/ /__
MTP7
Date: 01/15/03
Problem Description:
Derek has a long history of depressive symptoms that began during his senior year of high school following a
breakup with a girlfriend. His current depression appears to be associated with his stopping his meds and his
perception that he was not doing a good job at work. However, his employer reports being satisfied with Dereks
performance. Pt. reports being a loner with lots of feelings of hopelessness and worthlessness. He is anxious,
lethargic, and frequently up most of the night. His depression is also associated with self-deprecating and
command hallucinations. The hallucinations generally occur only during periods of decompensation and disappear
when he is doing fairly well. Dereks compliance with aftercare is poor, despite his having a reasonable
understanding of his meds. Last week, he started taking his meds as prescribed. Social isolation is felt to be a
significant contributor to his depressive symptoms and associated noncompliance with his meds. In the past, Derek
has responded well to a combination of Risperdal and Effexor. His hospitalizations usually last about 2 to 3 months
before he has recompensated to the point that he is ready for discharge.
Target Date
1.
04/15/03
2.
04/15/03
1.
Derek will accept prescribed meds and lab work for 2 weeks.
Date/Status*
Target Date
Date/Status*
01/29/03
01/29/03
Attained
2.
02/29/03
3.
02/29/03
4.
02/29/03
5.
02/29/03
6.
03/15/03
7.
03/15/03
02/12/03
Attained
02/05/03
Attained
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
MTP8
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with Derek for at least 35 minutes once weekly to monitor any
changes in Dereks psychotic and depressive symptoms in order to monitor Dereks
response to being restarted on a combinations of antipsychotic meds such as
Risperdal and an antidepressant such as Effexor. Labs will be ordered as needed.
Victor Dyson, MD
Social Work:
1.
Social worker will meet with Derek twice weekly for 30 minutes to discuss his
depression and psychotic symptoms and the effect on his discharge. She will evaluate
Dereks readiness for discharge and discuss discharge options with Derek. She will also
help Derek work on a list of activities to help structure his life.
Psychology:
1.
Psychologist will meet with Derek one-to-one twice weekly for 45-minute cognitive
therapy sessions to direct Derek back to reality and to help improve Dereks ability to
identify stressors, including dispelling stressors that are not real, and helping improve
his ability to better cope with those stressors that are real.
Rehab:
1.
Rehab staff will meet with Derek one-to-one for 30 minutes at least once weekly to
review his daily treatment schedule and refer him to appropriate groups to improve
his contact with reality and self-esteem, increase his social interactions, and develop
structure in his daily routine. His groups will include stress management group and
socialization group (see weekly Rehab Schedule for details).
Nsg. staff will redirect and refocus Derek to reality issues. When derogatory
hallucinations are present, nsg. staff will express an understanding of Dereks distress,
give reassurance, suggest interventions, and if indicated, offer prn meds to help
relieve his distress. Nsg. staff will provide support and praise for reality-based
statements.
2.
Nsg. staff will encourage Derek to attend morning meeting, other on-ward activities,
and rehab groups; staff will provide escort, if needed.
3.
Building on Dereks understanding of the need to take his meds, nsg. staff will
explore with Derek his difficulty continuing his meds in the community and help pt.
develop a plan for him to work with his community case manager to correct this
problem.
4.
Nsg. staff will rate the Kennedy NOSIE once per week to help track Dereks response
to treatment.
5.
*Status:
Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
MTP9
Date: 01/15/03
Problem Description:
Derek has a long history of suicidal attempts, gestures, and manipulations beginning at age 17 when he was a
senior in high school. When decompensated, he has command hallucinations to hurt himself. In the past, when
intoxicated, he has made serious attempts to hurt himself in response to command hallucinations, including taking
overdoses of meds and attempting to hang himself. Since he stopped drinking 2 years ago, Derek has not attempted
to hurt himself and overall has had much better control of these impulses. Immediately before this hospitalization,
Derek was having command hallucinations to harm himself, including commands to jump from the fourth floor at
work. He was concerned that he was losing control of these impulses. Currently he continues to have command
hallucinations and suicidal ideation; however, he reports that he would not actually attempt to harm himself.
Target Date
1.
04/15/03
2.
04/15/03
1.
2.
3.
4.
02/19/03
5. Derek will be able to go safely on three independent day passes into the community during
1 week.
VD
Date/Status*
Target Date
Date/Status*
02/29/03
02/05/03
Attained
02/29/03
02/29/03
02/19/03
Attained
02/29/03
03/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
MTP10
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with Derek for at least 35 minutes once weekly to monitor any
changes in Dereks suicidal impulses, including command hallucinations to hurt
himself. This will allow the psychiatrist to assess the need for special precautions.
This meeting will also allow the psychiatrist to prescribe treatment with antipsychotic
meds such as Risperdal and an antidepressant such as Effexor (as outlined under
Problem 1.1).
Victor Dyson, MD
Social Work:
1.
Social worker will meet with Derek twice weekly for 30 minutes to discuss his suicidal
impulses and the effect on his discharge. Social worker will evaluate Dereks readiness
for discharge, discuss discharge options with Derek, and help him to locate
community supports that will help him to remain free of suicidal ideation following
his discharge.
Psychology:
1.
Psychologist will meet with Derek one-to-one twice weekly for 45-minute cognitive
therapy sessions to help Derek develop strategies to more effectively cope with
stressors rather than becoming suicidal.
2.
Psychologist will lead the suicide prevention group once weekly for 45 minutes to
help pt. reduce feelings of hopelessness and worthlessness and more effectively deal
with stress.
Rehab:
1.
Rehab staff will meet with Derek one-to-one for 30 minutes at least once weekly to
review his daily treatment schedule and refer him to appropriate groups to decrease
his self-destructive impulses and frustration tolerance, including stress management
group and anger management group (see weekly Rehab Schedule for details).
Nsg. staff will immediately redirect and refocus Derek away from self-destructive
impulses and discuss appropriate alternative means of coping.
2.
Nsg. staff will question Derek at least once each shift to determine whether he is
having impulses to hurt himself.
3.
When command hallucinations are directing him to harm himself, nsg. staff will give
reassurance, suggest interventions, and if indicated, offer prn meds to help relieve his
impulses to harm himself.
4.
If there are any concerns about Derek attempting to hurt himself, at a minimum, nsg.
staff will have him verbally contract for safety each time he goes off the ward. For
safety reasons, pt. may be restricted to the ward and placed on special precautions
until the psychiatrist can evaluate him.
5.
Nsg. staff will provide support and praise when Derek is demonstrating appropriate
coping skills to maintain safe behaviors.
*Status:
Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
MTP11
Date: 01/15/03
Problem Description:
Derek began using alcohol as a senior in high school as a means of fitting in with his peer group and selfmedicating his depression. He had some very serious problems with alcohol that led to serious attempts to hurt
himself when intoxicated, including taking overdoses of meds and attempting to hang himself. Generally, since he
stopped drinking 2 years ago he has had much better control of these impulses. He goes to AA on a weekly basis
and is committed to continued sobriety. Derek smokes one pack of cigarettes a day; however, he has no interest in
quitting smoking.
1.
1.
Target Date
Date/Status*
Ongoing
Target Date
Date/Status*
Ongoing
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
MTP12
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with Derek weekly and as needed to monitor for any evidence
of intoxication and any changes in intensity of impulses to abuse alcohol. If needed,
psychiatrist will order Breathalyzer to ensure that pt. has not been abusing alcohol.
Victor Dyson, MD
Rehab:
1.
Derek will attend AA meetings once weekly to help support his continued sobriety.
Derek will start the AA meetings in the hospital; however, when it is safe for him to
go into the community, rehab staff will take him to AA meetings in the community.
Nsg. staff will monitor Derek for any evidence of intoxication and report any
significant findings to the psychiatrist.
2.
3.
Nsg. staff will be alert to a return of any impulses to abuse alcohol and, if present, will
assist him to deal with these in an appropriate, sober manner.
4.
Nsg. staff will give encouragement and verbal praise for Dereks involvement in
non-drug-related social activities.
*Status:
Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
MTP13
Date: 01/15/03
Problem Description:
Dereks physical exam revealed no significant abnormality. Dereks medical history reveals that he has mild
heartburn due to reflux esophagitis, which is fairly well controlled with Zantac (ranitidine) 150 mg po bid.
However, currently he drinks 8 to 12 carbonated beverages every day and eats other foods that exacerbate his
heartburn.
1.
1.
Derek will eat a diet that will help promote control of his reflux
esophagitis, AEB no heartburn for 2 weeks.
Target Date
Date/Status*
02/29/03
Ongoing
Target Date
Date/Status*
02/29/03
Attained
02/12/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
MTP14
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Medical:
1.
MD will treat Dereks reflux esophagitis with Zantac (ranitidine) and monitor him as
needed for any burning in his stomach. MD will request a dietary consult to assess
Dereks diet and make needed recommendations.
Virginia Coleman, MD
Nsg. staff will monitor Derek daily and follow up on any signs and symptoms of
illness.
2.
Nsg. staff will work with Derek and the dietician on developing a dietary plan to help
control Dereks heartburn.
3.
Nsg. staff will administer all prescribed meds and treatments as ordered, including
dietary recommendations, and will document Dereks compliance.
4.
Nsg. staff will assess and document pt.s level of understanding of prescribed
treatments, including diet, and will provide necessary teaching at Dereks level of
understanding.
5.
Nsg. staff will prompt Derek to comply with treatments, diet, lab work, and any other
medical procedures. If needed, nsg. staff will support and accompany Derek to
procedures. Staff will offer praise for compliance and document compliance.
*Status:
Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
MTP15
ID #: 12345
Signature Page
Lakeview Hospital
Name of Facility
Date: 01/15/03
Patient Participation in Treatment Planning (check as appropriate):
Contributed to goals and plan
Aware of plan content
Present at team meeting
Refused to participate
Unable to participate
Refused to sign plan
X
X
X
Derek Rossi
01/15/03
Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Victor Dyson, MD
Date:
01/15/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
01/15/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
01/15/03
Print Name:
Psychologist:
Date:
01/15/03
Print Name:
Rehabilitation:
Date:
01/15/03
Print Name:
Other:
Date:
Print Name:
Note: The above signatures document that the participants have reviewed the Master Treatment Plan on the date
signed and that they agree with the plan, unless indicated otherwise under Staff Members Comments.
ALL SUBSEQUENT CHANGES ON THIS PLAN SHOULD BE DATED, INITIALED, and supported by associated progress
note(s) and/or Treatment Plan Review(s).
Notes
MTP17
MTP18
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Area: West Unit
Lakeview Hospital
Name of Facility
Date: 01/22/03
3. Evaluation of Progress and Plans Effectiveness in Achieving Goals for Active Problems:
Problem 1.1. Derek is continuing to take his meds. Yesterday he started going to some program activities. However,
he continues to have lots of feelings of hopelessness and low self-esteem.
Problem 3.1. Derek continues to have suicidal ideation and associated command hallucinations to hurt himself;
however, they may be decreasing somewhat. Derek continues to feel that he has control of the impulses to hurt
himself.
Problem 6.0. Nsg. staff and the dietitian are working with Derek on getting him to cooperate with moving toward a
bland diet to help control his heartburn.
Awaiting SNF [ ]
8. Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Victor Dyson, MD
Date:
01/22/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
01/22/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
01/22/03
Print Name:
Psychologist:
Date:
01/22/03
Print Name:
Rehabilitation:
Date:
01/22/03
Print Name:
Other:
Date:
Derek Rossi
Print Name:
Date:
01/22/03
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
Check if review is continued on reverse [ ]
MTP19
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Area: West Unit
Lakeview Hospital
Name of Facility
Date: 01/29/03
3. Evaluation of Progress and Plans Effectiveness in Achieving Goals for Active Problems:
Problem 1.1. Derek is continuing to cooperate with treatment, including taking his meds and going to at least one
program every day. However, he continues to have lots of feelings of hopelessness and low self-esteem.
Problem 3.1. Derek continues to have suicidal ideation and associated command hallucinations to hurt himself.
Recently Derek has been having problems with feeling that he is losing control of the impulses to hurt himself;
however, he has not made any plans to hurt himself.
Problem 6.0. Dereks heartburn appears to be responding to a bland diet, including cutting back on carbonated
beverages.
Awaiting SNF [ ]
8. Treatment Team Members (All participants in the treatment planning must sign below):
Psychiatrist:
Victor Dyson, MD
Date:
01/29/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
01/29/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
01/29/03
Print Name:
Psychologist:
Date:
01/29/03
Print Name:
Rehabilitation:
Date:
01/29/03
Print Name:
Other:
Date:
Derek Rossi
Print Name:
Date:
01/29/03
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
Check if review is continued on reverse [ ]
MTP20
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Area: West Unit
Lakeview Hospital
Name of Facility
Date: 02/05/03
3. Evaluation of Progress and Plans Effectiveness in Achieving Goals for Active Problems:
Problem 1.1. Derek is continuing to cooperate with treatment and has completed 1 week of at least 4 days/week of
program activities. He is having much fewer feelings of hopelessness and low self-esteem. The hallucinations are
decreasing.
Problem 3.1. Derek has done better for the last few days; however, he continues to have some suicidal ideation. For
the last couple of days, the command hallucinations have stopped, and for the last week, pt. has been able to
identify ways to help direct himself from self-destructive impulses.
Problem 6.0. Dereks heartburn appears to be responding to a bland diet, including cutting back on carbonated
beverages. He denies having any heartburn for about 1 week.
Awaiting SNF [ ]
8. Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Victor Dyson, MD
Date:
02/05/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
02/05/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
02/05/03
Print Name:
Psychologist:
Date:
02/05/03
Print Name:
Rehabilitation:
Date:
02/05/03
Print Name:
Other:
Date:
Derek Rossi
Print Name:
Date:
02/05/03
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
Check if review is continued on reverse [ ]
MTP21
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Area: West Unit
Lakeview Hospital
Name of Facility
Date: 02/12/03
3. Evaluation of Progress and Plans Effectiveness in Achieving Goals for Active Problems:
Problem 1.1. Dereks spirits are improving and he is no longer having feelings of hopelessness and low self-esteem.
Next week, he is expected to participate in a full schedule of program activities. For the last couple of days, all
hallucinations stopped completely.
Problem 3.1. Derek reports that he in now free of both suicidal ideation and command hallucinations.
Problem 6.0. Dereks heartburn appears to have responded very well to a bland diet, including cutting back on
carbonated beverages. He denies having any heartburn for about 2 weeks.
Victor Dyson, MD
Date:
02/12/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
02/12/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
02/12/03
Print Name:
Psychologist:
Date:
02/12/03
Print Name:
Rehabilitation:
Date:
02/12/03
Print Name:
Other:
Date:
Derek Rossi
Print Name:
Date:
02/12/03
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
Check if review is continued on reverse [ ]
MTP22
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Area: West Unit
Lakeview Hospital
Name of Facility
Date: 02/19/03
3. Evaluation of Progress and Plans Effectiveness in Achieving Goals for Active Problems:
Problem 1.1. Dereks spirits continue to be good and he continues to be free of feelings of hopelessness and low
self-esteem. For the last few days, he has participated in a full schedule of program activities. No hallucinations
since 02/10/03.
Problem 3.1. Derek reports that for the last week he has been free of suicidal ideation and impulses to hurt himself.
The command hallucinations to hurt himself stopped more than 2 weeks ago.
Problem 6.0. Derek continues to be free of any heartburn or any other medical complaints.
Victor Dyson, MD
Date:
02/19/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
02/19/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
02/19/03
Print Name:
Psychologist:
Date:
02/19/03
Print Name:
Rehabilitation:
Date:
02/19/03
Print Name:
Other:
Date:
Derek Rossi
Print Name:
Date:
02/19/03
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
Check if review is continued on reverse [ ]
PSYCHOLOGICAL IMPAIRMENT
(Problem Area 1)
11
13
PSYCHOLOGICAL IMPAIRMENT
(Problem Area 1)
CONTENTS
Kennedy Axis V for Psychological Impairment......................................................................................... 14
This rating scale can be used to measure the outcome of treatment. It also helps to define the problems
that fit into the category of Psychological Impairment and can be helpful in composing a short
description of each problem.
Strengths .................................................................................................................................................. 17
Examples of strengths that may be related to treatment and discharge in the area of Psychological
Strengths are listed here.
Goals ......................................................................................................................................................... 17
Examples of treatment goals that may relate to problems in the area of Psychological Impairment are
listed here.
14
70 Some mild symptoms (e.g., depressed mood with mild insomnia, occasional truancy, theft within the
household, difficulty trusting others, mild insensitivity to the feelings and needs of others), but generally
functioning fairly well; however, those who know him/her well might express some concerns about his/her mental
state.
60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks; frequently
preoccupied; moderate impairment in attention span); moderate insensitivity to the feelings and needs of others;
to those who know him/her well it is clear that he/she has mental problems.
50 Serious symptoms (e.g., moderately depressed mood, moderate lethargy, severe obsessional rituals, severe
phobia, severe sexual perversion, moderate problems with anorexia/bulimia, frequent shoplifting, frequent anxiety
attacks, moderately guarded, mild but definite manic syndrome).
40 Major psychological impairment; some impairment in reality testing or communication (e.g., speech is
at times illogical, obscure, or irrelevant; moderate paranoia; may have hallucinations or delusions; however,
probably realizes they are not a part of reality); major impairment in several areas, such as judgment, thinking, or
mood (e.g., depressed man avoids friends, neglects family, and is not motivated to work; or, moderate negative
symptoms of schizophrenia); even those who do not know him/her well would likely consider him/her to have
mental problems.
30 Behavior is considerably influenced by delusions or hallucinations; appears to be responding to
hallucinations; serious impairment in communication or judgment (e.g., sometimes incoherent, thinking is
occasionally grossly inappropriate); severely depressed mood; withdrawn, with few spontaneous communications;
inability to function in almost all areas (e.g., stays in bed all day and does not care for own living space; no job,
home, or friends due to paranoia, poor motivation, social withdrawal, extremely poor insight, or being almost
totally insensitive to the feelings and needs of others); at times attention span is markedly impaired; severe
sociopathic behaviors have led to multiple arrests; severe sexual perversion toward prepubescent children.
20 Thinking and communication are generally grossly impaired; manic excitement or catatonia;
largely incoherent or mute; generally markedly impaired attention span; occasionally fails to maintain minimal
personal hygiene due to severe lethargy or very disorganized, bizarre thinking (e.g., too lethargic to attempt to wipe
food off shirt; smears feces for bizarre, delusional reasons).
10 Thinking is totally disorganized; totally insensitive to the feelings and needs of others; completely
incoherent; completely mute, extremely catatonic; persistent inability to maintain minimal personal hygiene or
minimal safety due to totally disorganized thinking or very severe lethargy; unable to focus attention for even a
few seconds; chronic, self-induced vomiting has led to a very life-threatening situation.
NR Not rated
II.
Sadness
1.
Low self-esteem
2.
Extremely fragile and brittle self-esteem
3.
Depression with persecutory delusions
4.
Difficulty accepting significant loss
5.
Preoccupation with perceived rejection
B.
C.
D.
Other
1.
Insomnia
2.
Disturbance in eating habits
3.
Poor attention span
4.
Rumination or racing thoughts
5.
Mood swings
6.
Manic episodes, elation, grandiosity
B.
15
16
6.
7.
C.
Bizarre behaviors
1.
Bizarre behavior such as lying on the floor or exhibiting constant rocking, head banging, and
stereotypical movements
2.
Bizarre, inappropriate dress
3.
Bizarre compulsive eating or drinking habits (e.g., occasionally drinking from the toilet, eating
feces)
4.
Bizarre episodes of screaming and yelling
D.
Other
1.
Poor attention span
2.
Agitation and restlessness
Personality disturbances
1.
Obsessive-compulsive behaviors
2.
Ritualistic, compulsive mannerisms
3.
Overemphasis on cleanliness and neatness
4.
Psychosomatic symptoms and conversion reactions
5.
Stealing and other antisocial behaviors toward property
6.
Dependent personality style
7.
Overly dependent on others for decision making and support
8.
Resistant to independent functioning
9.
Passive-aggressive manipulation
B.
Eating disturbances
1.
Anorexia (inadequate food or fluid intake or both)
2.
Obesity
3.
Bulimia (gorging and vomiting)
4.
Polydipsia (drinking fluids to dangerous excess)
5.
Pica (persistent and compulsive craving to eat nonfood items such as dirt, clay, coffee grounds, or
cigarettes)
C.
Other
1.
Noncompliance with treatment
2.
Escape risk
3.
Nocturnal enuresis secondary to psychological factors
4.
Gender identity confusion
5.
Manipulative behavior
6.
Nonviolent attention seeking
17
Psychological Strengths
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
Other
Goals
I.
Thought disorder
1.
Pt. will make at least one nondelusional, relevant comment in community meeting twice a week
for 1 month.
2.
Pt. will be able to engage in one 2-minute conversation during the 7-to-3 shift with no evidence of
delusional content three times weekly for 1 month.
3.
Pt. will complete a two-step task successfully without performance being impeded by ritualistic
behavior or delusional speech twice weekly for 1 month.
4.
Pt. will gain insight into delusions and hallucinations so that he or she will suspect that they are a
part of the illness for 1 month.
B.
Mood disturbance
1.
Pt. will consistently verbalize a sense of self-worth and express realistic hopes for his or her future
for 1 week.
2.
Pt. will be able to participate in a program activity without extreme mood swings at least four
times a week for 1 month.
3.
Pt. will be free of depressive or manic symptoms for 1 week.
C.
Focal attention
1.
Pt. will maintain relevance and focus on topics beyond the first two sentences of a conversation
consistently for 1 week.
2.
Pt.s focal attention will improve to the point that pt. will be able to maintain involvement in one
day-program activity each weekday for 1 month.
3.
Pt.s focus will improve such that he or she will consistently carry out three-step tasks with only a
single prompt for 1 week.
18
II.
D.
E.
Social withdrawal
1.
Pt. will initiate at least a one one-word greeting daily for 1 month.
2.
Pt. will initiate and sustain a 5-minute conversation once each shift for 1 week.
3.
Pt. will spontaneously initiate a request to go on buddy privileges with one of the other pts.
F.
Other
1.
Psychosomatic complaints will be reduced such that these complaints will interfere with assigned
program no more than once per week for 1 month.
2.
Pt. will attempt to escape no more than once per month during a 3-month period.
3.
Pt. will be able to go on supervised privileges with staff once a day for 1 week without attempting
to escape.
4.
Pt. will decrease his or her excessive fluid intake, such that his or her blood Na level remains WNL
for 3 months.
5.
Pt.s anorexia will improve, AEB gaining 2 pounds per month for 2 months.
6.
Pt. will cooperate with staff requests to toilet self for 1 week.
7.
Pt.s incidences of nocturnal enuresis will decrease to fewer than three times per week for
1 month.
Reporting of Symptoms
A.
B.
C.
D.
E.
Pt. will consistently remain in the group activity area with minimal redirection for at
least hour per weekday for 1 month.
Pt. will attend two program activities per week for 1 month.
Pt. will attend art therapy twice a week for 1 month to help improve self-esteem.
Pt. will participate in a full-time load of day-program activities for 1 month.
Pt. will start a supportive job in the hospital gift shop.
Pt. will start a job in the community.
Pt. will attend assigned programs (with medical clearance), despite psychosomatic
complaints, at least once per weekday for 1 month.
19
V.
A.
B.
Program activities
1.
Pt. will state the benefits of attending program twice weekly for 2 weeks.
2.
Pt.s level of compliance will improve such that he or she will attend art therapy class twice a week
for 1 month.
C.
Treatment planning
1.
Pt. will cooperate with at least one treatment team member in the treatment planning process for
1 week.
2.
Pt. will be willing to participate in the evaluation process AEB meeting with the psychologist
weekly for 1 hour.
3.
Pt. will demonstrate cooperation with all aspects of the treatment plan, including meds and blood
work, for 1 month.
4.
Pt. will be free of unrealistic, grandiose discharge plans for 1 month.
D.
Consequences of actions
1.
Pt. will demonstrate a realistic orientation toward his or her progress such that the pt. understands
and explains the connections between the following:
a. Rational, trusting behavior; program attendance; medication compliance; and the ability to be
discharged from the hospital
b. Bizarre, paranoid thinking; inconsistent program attendance; medication noncompliance; and
recurring setbacks, including the need for continued care at the hospital
Assessments
1.
Pt. will cooperate so that psychological tests can be completed.
2.
Pt. will cooperate so that rehabilitation assessment for an appropriate day-program referral can be
completed.
B.
C.
Laboratory tests
1.
Pt.s medication compliance will improve so that the medication blood level is in the therapeutic
range for 3 months.
2.
Pt. will control his or her drinking of excessive fluids AEB maintaining a proper electrolyte balance
for 3 months.
110
B.
C.
D.
E.
Treatment Modalities
I.
B.
C.
II.
111
Psychotherapy
1.
Staff will meet with pt. for one-to-one, insight-oriented psychotherapy once a week to help work
through psychological conflicts that result in high levels of anxiety.
2.
Psychologist will provide supportive, problem-solving psychotherapy to help the pt. more
effectively cope with day-to-day problems.
3.
Social worker will provide weekly one-to-one dialectic behavior therapy (DBT) counseling for pt.
and lead weekly DBT skills practice group to help reduce pt.s depressive symptoms.
Positive reinforcement
1.
Staff will give pt. positive feedback and encouragement for coherent, reality-based
communications.
2.
Staff will praise pt. for reality-based speech.
3.
Staff will provide positive verbal reinforcement for independent action when around the ward or
when in program (to reduce apathy and lack of motivation).
4.
Staff will provide constant encouragement to help relieve pt.s lack of motivation to wash face,
comb hair, wipe nose, and so on.
5.
Staff will give positive reinforcement for any spontaneous activity other than going to bed.
6.
Staff will give positive verbal reinforcement for each step toward greater involvement in ward activities.
7.
Staff will encourage pt. to be involved in the treatment-planning process.
8.
Staff will give pt. reinforcement for accumulating points for specific compliant acts (e.g., making
bed, dressing appropriately, going to program). When pt. receives 10 points, he or she will be
given an identified reinforcer. (See attached behavioral plan for details.)
9.
Staff will give pt. money, clothes, and gym activities to richly reinforce independent, self-initiated
behaviors such as getting dressed, making bed, and going to program.
B.
C.
Extinction
1.
All staff will ignore bizarre and delusional speech, thus helping to extinguish this psychotic
behavior.
2.
Staff will acknowledge psychosomatic complaints but will encourage pt. to attend assigned
program.
3.
Staff will disregard delusional speech.
D.
112
E.
Channeling of energies
1.
Staff will channel pt.s high level of anxiety into structured day-program activities, including
exercise group.
F.
Task simplification (reducing confusion and frustration by simplifying tasks and providing
consistency and assistance)
1.
Nsg. staff will use the same person as consistently as possible for redirection.
2.
All staff will be as consistent as possible in redirecting pt. away from inappropriate, bizarre
behavior.
3.
To reduce level of dependency, contact will help pt. write down all basic answers and procedures
to questions and routines that confuse him or her. When appropriate, contact will direct pt. to
these written lists.
B.
C.
Other modalities
1.
DBT
a.
Social worker trained in DBT will meet with pt. for therapy and training on means of
managing his or her impulsive behaviors for 1 hour twice a week.
b.
Because of failure to respond to treatment, the team will refer pt. to the DBT ward for
treatment of his or her problems with borderline personality disorder.
2.
Group therapy
a.
Group therapy to facilitate discussion of problems and to learn means of more appropriately
coping with those problems will be undertaken once weekly for 1 hour.
3.
Psychodrama
a.
Role playing will be used to help reduce pt.s anxiety about talking about his or her illness
once weekly for 1 hour.
4.
Behavioral plan
a.
Psychologist will oversee behavioral plan to change specific behaviors (see attached
behavioral plan).
5.
Desensitization
a.
Psychologist will develop a plan to help desensitize the pt. to his or her fear of driving.
b.
Rehab staff will provide activities that pt. can successfully complete to help relieve pt.s fear
of failure.
c.
Recreational therapist will work with pt. in bowling group to reduce anxiety associated with
participating in groups.
113
V.
A.
Stimulus reduction
1.
Staff will redirect pt. from triggering events or overstimulating areas to reduce level of
hallucinations.
2.
Sound-absorbing material will be added to pt.s dorm area to help reduce noise.
B.
C.
Medication
1.
Psychiatrist will prescribe antipsychotic meds to reduce intensity of persecutory beliefs.
2.
Nsg. staff will give pt. prn meds to relieve pt. from acute episodes of tormenting hallucinations.
B.
Light therapy
a.
Pt.s seasonal depressive symptoms will be treated using light therapy for 1 hour daily.
3.
Psychosurgery
a.
Pt.s severe unremitting depression will be treated using psychosurgery.
b.
Severe, incapacitating obsessive-compulsive symptoms will be treated at a general hospital
by psychosurgery.
4.
Miscellaneous
a.
Restrict fluids to 350 cc following dinner to prevent nocturnal enuresis.
b.
Nsg. staff will toilet pt. every 2 A.M. to help reduce nocturnal enuresis.
c.
Staff will provide wheelchair to increase pt.s independence around the ward.
Mental illness
1.
Staff will discuss ways to cope with mental illness with pt. for 1 hour once weekly.
2.
Staff will teach pt. and the family ways to recognize the signs of manic decompensation.
3.
Staff will discuss the nature of pt.s mental illness and its prognosis with the pt. and family.
B.
Medication
1.
Psychiatrist will discuss the risks and benefits of meds with pt. once weekly for hour.
2.
Nsg. staff will point out concrete benefits of taking meds (e.g., There is a decrease in the
hallucinations, You are more focused on tasks, You are less paranoid).
3.
Pt.s psychiatrist will discuss with pt.s family the reasons pt. needs to take meds.
114
C.
D.
Miscellaneous
1.
Staff will involve pt.s family in a psychoeducational program to improve their ability to cope with
pt.s psychotic symptoms.
2.
Psychologist will meet to educate pt.s parents about the effect that lack of monitoring and lack of
discipline has on the pt. for 1 hour once a month.
B.
Psychiatric evaluations
1.
Psychiatric diagnostic evaluation
2.
Psychiatric medication evaluation
3.
Neuropsychiatric evaluation
4.
AIMS or AIMS Plus EPS exam, as needed
C.
D.
9.
115
Conduct religious assessment to evaluate validity of pt.s guilt feelings from a religious
perspective.
Court commitment
1.
Psychiatrist will seek court commitment under Sections 7 and 8 for a period of up to 6 months
because pt. is unable to safely function in the community due to her poor insight and judgment.
2.
Psychiatrist will initiate petition for mandatory outpatient commitment and treatment under
Section 23c.
B.
Treatment of related problems (optional and can be included with the treatment
modalities or in the problem description)
1.
Treat pt.s problem with suicidal ideation as indicated under Problem 3.1 (Suicidal Ideation).
2.
Treat pt.s problem with assaultiveness as indicated under Problem 3.1 (Violence Secondary to
Paranoia).
3.
Treat pt.s problem with substance abuse as indicated under Problem 5.1 (Polysubstance Abuse).
116
Date: 01/15/03
Problem Description:
1.
2.
3.
4.
Make sure that the above relate to goals and treatment modalities.
If the treatment of a particular problem is very complicated or lengthy, the practitioner may want to divide it
into two problems, for example, 1.1 Psychotic Symptoms and 1.2 Noncompliance With Treatment.
Indicate psychotic impulses to hurt self or others or command hallucinations to hurt self or others in Problem
Area 3, Violence.
1.
2.
3.
4.
Pt. will accept prescribed meds and lab work for a ___-week/month
period.
5.
6.
Pt. will cooperate with a least one treatment team member in the
treatment planning process.
7.
Pt. will be able to explain the nature of his or her illness and its
treatment in a fairly rational, fairly accurate manner.
8.
9.
Target Date
Date/Status*
10. Pt.s score on the Kennedy NOSIEs Manifest Psychosis and Social
Interest will improve from the current score of ___ to ___.
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
117
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for ____ minutes at least ______ time(s) weekly/monthly to
monitor any changes in psychosis to prescribe treatment with antipsychotic meds,
______________, and _____________ for EPS. Lab (blood levels, WBCs). AIMS q 6 months.
Victor Dyson, MD
Social Work:
1.
Social worker will meet with pt. for ___ minutes at least ___ time(s) weekly/monthly to
discuss the effect of pt.s psychosis on discharge, to evaluate pt.s readiness for
discharge, and to discuss discharge options with pt.
Psychologist (social worker) will meet one-to-one with pt. for ___ minutes at least ___
times weekly/monthly in supportive, problem-solving, cognitive therapy to direct pt.
back to reality or help pt. function, even if psychotic symptoms persist.
2.
Rehab:
1.
Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ time(s)
weekly/monthly to review and revise the daily treatment schedule. Staff will refer pt. to
appropriate groups working to improve contact with reality, self-image, motivation,
and focal attention and to develop structure in pt.s daily routine.
2.
Staff will work with pt. in _____________________ group program for ___ hour(s) a
day/week to help improve pt.s (contact with reality, self-image, motivation, focal
attention, ____________________).
Nsg. staff will provide decreased stimulation, verbal redirection, and refocusing to
reality issues. If tormenting hallucinations or paranoid thoughts are present, nsg. staff
will express understanding of pt.s distress, give reassurance, suggest interventions and,
if indicated, offer prn meds to help relieve pt.s distress.
2.
Nsg. staff will encourage attendance at morning meeting (staff will encourage role
modeling of appropriate behavior), other on-ward activities, and rehab groups. Staff
will provide escort if needed. Nsg. staff will document frequency of attendance.
3.
Nsg. staff will offer support and praise for appropriate, reality-based interactions.
4.
Nsg. staff will begin to assess pt.s level of understanding of antipsychotic meds and his
or her readiness to learn before educating pt.
5.
Nsg. staff will meet with pt. for ___ minutes at least ___ time(s) a week/month to
educate pt. about his or her illness and the importance of taking his or her meds. This
process will be simple, clear, concrete, and according to pt.s ability to understand.
Nsg. staff will request feedback from pt. to validate pt.s level of comprehension.
6.
7.
Nsg. staff will prompt pt. to perform ADLs and will document compliance.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
118
Date: 01/15/03
Problem Description:
1.
2.
3.
4.
Make sure that the above relate to goals and treatment modalities.
If the treatment of a particular problem is very complicated or lengthy, the practitioner may want to divide it
into two problems, for example, 1.1 Psychotic Symptoms and 1.2 Noncompliance With Treatment.
Indicate psychotic impulses to hurt self or others or command hallucinations to hurt self or others in Problem
Area 3, Violence.
1.
2.
Pt. will be able to discuss options for the future beyond feelings
of helplessness and hopelessness for a _____-day/week period.
3.
4.
Pt.s motivation will improve to the point that pt. will get out of
bed and have his or her dorm area in acceptable order at least ___
weekdays per week for a ___-week/month/period.
5.
6.
7.
8.
9.
Target Date
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
119
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for ____ minutes at least ______ times weekly/monthly to
monitor any changes in depression to prescribe treatment with antidepressant meds,
such as _______________________ . Labs as ordered, including antidepressant levels.
Victor Dyson, MD
Social Work:
1.
Social worker will meet with pt. for ___ minutes at least ___ time(s) weekly/monthly to
discuss pt.s depressions affect on discharge, to evaluate pt.s readiness for discharge,
and to discuss discharge options with pt.
Psychologist (social worker) will meet one-to-one with pt. for ___ minutes at least ___
time(s) weekly/monthly in supportive, problem-solving cognitive therapy to improve
pt.s mood and/or help pt. function, even if depressive symptoms persist.
2.
During these meetings, drops in pt.s self-esteem will be treated by helping pt. focus on
his or her assets and accomplishments (e.g., career accomplishments, relatives who
care for pt., hobbies, memories of happy experiences).
Rehab:
1.
Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ time(s)
weekly/monthly to review and revise pt.s daily treatment schedule. Staff will refer pt.
to appropriate groups working to improve his or her contact with reality, self-image,
motivation, and sense of helplessness or hopelessness (see weekly schedule).
2.
Staff will work with pt. in _____________________ group program for ___ hour(s) a
day/week to help improve pt.s ______________ (self-esteem, self-image, motivation, and
sense of helplessness or hopelessness).
Nsg. staff will provide support and reassurance and will verbally refocus pt. to positive
aspects of his or her life. Nsg. staff will help pt. learn ways to resolve or cope with
negative aspects of his or her life.
2.
Nsg. staff will begin to assess pt.s level of understanding of antidepressant meds and
his or her readiness to learn before educating pt.
3.
Nsg. staff will meet with pt. for __ minutes at least ___ time(s) weekly/monthly to
educate pt. about his or her illness and the fact that pt.s meds can help to reduce his
or her sadness and sense of hopelessness or helplessness. Nsg. staff will request
feedback from pt. to validate pt.s level of comprehension.
4.
Nsg. staff will begin to assess pt.s level of understanding of antipsychotic meds and his
or her readiness to learn prior to educating pt.
5.
Nsg. staff will offer support and praise for realistic, positive interactions or statements
about self or about pt.s future.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
121
122
Date: 01/15/03
Problem Description:
Pt. presents with consistent attitude of hopelessness and helplessness about situation. She has no plans for future
and views her immediate situation as totally beyond her control. Behavior has adolescent quality in that negative
behaviors are used as retaliatory measures against others and to keep others at a distance. Pt. will be able to discuss
options for future.
1.
Target Date
Date/Status*
07/15/03
Target Date
1.
04/15/03
2.
04/15/03
3.
Pt. score on the Beck Depression Inventory will improve from the
current 30 to 18.
04/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
123
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for at least hour once weekly to monitor any changes
in depression to prescribe treatment with antidepressants, such as Zoloft (sertraline).
Order labs, including antidepressant levels.
Victor Dyson, MD
Psychology:
1.
2.
Psychologist will meet one-to-one with pt. for 45 minutes once weekly in supportive,
problem-solving therapy to improve pt.s mood and help her function even if
depressive symptoms persist.
Social Work:
1.
Social worker will meet with pt. for hour once weekly to evaluate pt.s readiness for
discharge.
2.
Social worker will consistently offer pt. the opportunity for treatment planning
involvement.
Rehab:
1.
Rehab staff will meet with pt. as needed to review and revise her daily treatment
schedule and will refer her to appropriate groups working to improve her self-image,
motivation, and sense of helplessness and hopelessness (see weekly schedule).
Staff will verbally reward pt. for cooperative acts on ward and toward other pts.
2.
Staff will discuss with pt. the fact that the meds reduce her sense of hopelessness and
helplessness.
3.
Nsg. staff will offer support and praise for positive interactions, positive statements
about herself, or positive statements about her future.
Ronald Donahue, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
124
Date: 01/15/03
Problem Description:
For the last several years, pt. has been having increasing problems with mood swings, which occur every few
months. During the depressive phase, pt. experiences motor retardation and low self-esteem and becomes
withdrawn. During the manic episodes, pt. experiences euphoric mood, marked insomnia, hyperactivity,
intrusiveness, marked irritability, and assaultiveness. Pt. often feels that the moods are related to external events,
and he is reluctant to take his lithium on a regular basis. When pt. takes his lithium as prescribed, there is a marked
reduction in the severity of his mood swings. Tremors appear to be the only significant side effect of the lithium.
Treatment of irritability as outlined under Problem 3.1 Assaultive, Irritable Behavior.
1.
Target Date
Date/Status*
07/15/03
Target Date
1.
Pt.s mood will stabilize such that he gets at least 6 hours of sleep
each night for 1 month.
03/15/03
2.
03/15/03
3.
04/15/03
4.
Pt. will be free of any significant side effects from the lithium for
1 month.
03/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
125
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for at least 1 hour and 35 minutes monthly to monitor
any changes in manic-depressive symptoms and to prescribe treatment with mood
stabilizer (such as lithium or Depakote) and beta-blockers (such as Inderal) to help
relieve tremors secondary to the lithium therapy.
2.
Psychiatrist will conduct periodic lab tests to monitor lithium levels and to detect
possible adverse effects of lithium on the thyroid gland, kidney, and the like.
Victor Dyson, MD
Nsg. staff will lead medication group once weekly to help pt. understand the nature of
his cyclic mood disturbance, to help him monitor signs of changing mood, and to help
him recognize the benefits of medication for relieving his symptoms.
2.
Nsg. staff will encourage attendance at morning meeting and program activities. Nsg.
staff will document frequency of attendance.
Ronald Donahue, RN
Rehab:
1.
Staff will engage pt. in meaningful activities to redirect excessive energy when pt. is
manic and to minimize withdrawal and drifting when pt. is depressed.
Social Work:
1.
Social worker will hold a family meeting once weekly to address pt.s brothers
concerns about pt. illness, to educate them regarding his cyclic mood disturbance, and
to support them in coping with his behavior.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
126
Date: 01/15/03
Problem Description:
Pt. has a long history of depressive and psychotic symptoms, including persecutory delusions, constant auditory
hallucinations, disorganized thinking, marked sadness, and marked apathy. Exacerbation of depressive and
psychotic symptoms often occurs in association with stress, noncompliance with his meds, or both. Currently pt. is
actively psychotic and very unmotivated. He rejects most interpersonal contact, including that of family members.
Pt. often appears depressed and at times self-reports feelings of depression. The depression is reflected in his lack of
motivation to attend to personal hygiene and his appearance, as well as a generalized appearance of sadness.
Target Date
1.
Pt. will improve to the extent that he can participate in two offward groups per day for 1 month.
01/15/04
2.
01/15/04
Target Date
1.
Pt. apathy and poor motivation will diminish such that he is out
of bed for at least 2 hours per shift for 2 weeks.
04/15/03
2.
Pt. will use unsupervised privileges at least hour per shift for
2 weeks without significant interference from his psychotic
symptoms.
04/15/03
3.
04/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
127
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for hour once a week to monitor pt. for any changes
in his depressive and psychotic symptoms. Antipsychotic and antidepressant meds as
prescribed. Labs as needed and AIMS Plus EPS exam q 6 months.
Virginia Coleman, MD
Social Work:
1.
Social worker will hold weekly meetings with pt. for 45 minutes (family to be included
monthly) to assess and address individual and family issues.
2.
Social worker will hold weekly meetings with pt. to assess readiness for discharge and
to determine obstacles to his discharge.
Psychology:
1.
Psychologist will hold weekly reality testing for hour to determine obstacles to
improved level of functioning.
Nsg. staff will provide positive feedback to pt. for spontaneous attendance to his
appearance.
2.
Nsg. staff will engage pt. in one-to-one contact two to three times per day to encourage
interpersonal contact in on- and off-ward supervised activities.
3.
Nsg. staff will provide support and praise for appropriate, reality-based interactions.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
128
Date: 01/15/03
Problem Description:
For more than 10 years, pt. has been almost constantly experiencing auditory hallucinations, persecutory
delusions, and bizarre behavior. Because of interference from her thought disorder, she currently is unable to
engage in meaningful conversation for more than 30 seconds. Pt. is becoming increasingly apathetic and does not
participate in any structured activities. Numerous treatment interventions have failed to bring about significant
improvement in her psychosis. These treatments have included trials of several different antipsychotics. Pt. has
recently been approved for a trial on clozapine. Pt. has a borderline abnormal ECG and tardive dyskinesia.
Target Date
1.
01/15/04
2.
01/15/04
Target Date
1.
Pt.s thought disorder will improve to the extent that she is able
to participate in supervised groups for 1 hour, twice weekly for
1 month.
04/15/03
2.
04/15/03
3.
04/15/03
4.
Pt.s score on the BPRS will improve from current 61 to less than
40.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
129
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. to monitor any changes in pt.s psychotic symptoms to
prescribe antipsychotic meds, such as clozapine.
2.
3.
Psychiatrist will order weekly WBC for first 6 months of treatment with clozapine,
then WBC twice a month.
4.
Virginia Coleman, MD
Nsg. staff will monitor pt.s pulse, BP, and temp weekly for the first month of clozapine
treatment, then monitor her as needed.
2.
Nsg. staff will give positive verbal reinforcement for staying focused on the topic of a
conversation.
3.
Nsg. staff will provide one-to-one contact to encourage pt. to participate in program
activities two to three times per day.
4.
Nsg. staff will provide positive feedback to pt. for spontaneous participation in any
structured activity.
5.
Nsg. staff will monitor pt.s weight monthly for possible excessive weight gain
secondary to clozapine.
Rehab:
1.
Rehab staff will meet one-to-one with pt. to refer pt. to appropriate groups to increase
her motivation and develop structure in her daily routine.
2.
Rehab staff will work with pt. to develop and update her weekly program schedule (see
attached weekly schedule).
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
130
Date: 01/15/03
Problem Description:
Pt. thinking is often disorganized and she is easily overwhelmed by external stimuli. Pt. demonstrates moderate to
marked lethargy and frequently spends much of the day in bed. Pt. has a history of active psychosis; however,
currently she isnt delusional and she does not appear to be hallucinating. Pt.s insight and judgment are
moderately impaired. Care has to be taken when planning activities for pt. because she often, at a superficial level,
appears able to function higher than her actual skills will allow. Recently pt. has been able to function well several
days a week in a community day program.
Target Date
1.
01/15/04
2.
Ongoing
Target Date
1.
04/15/03
2.
04/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
131
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for hour once a month to monitor pt. for any return
of delusions or hallucinations and adjust pt.s antipsychotic meds accordingly. Lab
work as needed and AIMS Plus EPS q 6 months.
Victor Dyson, MD
Social Work:
1.
Social worker will conduct weekly one-to-one meeting with pt. for 1 hour to discuss
methods of coping with and tolerating group interactions in daily ward and program
routine.
2.
Social worker will conduct weekly one-to-one meeting with pt. to evaluate pt.s
readiness for discharge.
Rehab:
1.
Rehab staff will encourage pt. to participate in hospital and community programs.
2.
Rehab staff will make ongoing assessments of pt.s actual abilities through observation
of her ability to perform specific ward and program tasks.
Nsg. staff will encourage pt. to attend morning meeting and rehab groups.
2.
Nsg. staff will provide positive feedback to pt. for staying out of bed during the day for
periods of 2 hours or more.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
132
Date: 01/15/03
Problem Description:
Pt. has a lifelong history of noninvolvement in productive activities. He spends the bulk of the day lying in bed,
preoccupied with internal thoughts. Hospital staff has consistently been unsuccessful during previous hospitalizations in getting pt. involved in on- or off-ward activities. Recently pt. has expressed some interest in earning
money for extra cigarettes. Pt. has been tried on a number of antipsychotic meds, including typical and atypical
meds. Pt. has not had a trial on Clozaril.
1.
Target Date
Date/Status*
01/15/04
Target Date
1.
03/15/03
2.
03/15/03
3.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
133
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for hour once a week to prescribe antipsychotics, such
as Clozaril, to help relieve the negative symptoms of pt.s psychotic process. Lab as
needed, such as weekly WBC and periodic Clozaril blood levels.
Virginia Coleman, MD
Rehab:
1.
Rehab staff will arrange for pt. to participate in the Patient Wage Program.
2.
Rehab staff will schedule pt. for activities that he can complete successfully and that
lead to increased self-esteem and motivation to continue with the activities (see pt.s
weekly schedule).
Nsg. staff will provide encouragement for pt. to participate in structured work
activities, such as washing windows or cleaning the dayroom.
2.
Nsg. staff will provide support and praise for pt.s involvement in any program
activity.
Social Work:
1.
When pt. is able to consistently participate in program activities, social worker will
begin meeting with pt. for hour once weekly to evaluate his readiness for discharge
and to discuss discharge options.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
134
Date: 01/15/03
Problem Description:
Pt. has a very short attention span; however, with frequent staff redirection, he is able to complete assigned
program tasks. This has been a long-standing problem for pt.; however, he does appear to respond to staff
members attention and verbal praise.
Implementation of treatment of Problem 1.1 Psychotic Symptoms to help relieve the contribution of pt.s
psychotic symptoms to pt.s poor focal attention.
Target Date
1.
01/15/04
2.
01/15/04
Target Date
1.
07/15/03
2.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
135
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Rehab:
1.
Staff will increase focal attention through the use of graded activities designed to meet
his needs and interests.
2.
Staff will give verbal reinforcement for incremental increases in focal attention during
tasks.
Nsg. staff will give positive verbal reinforcement for staying focused on the topic of a
conversation.
2.
When nsg. staff members observe pt. wandering off task or off verbal focus, they will
immediately redirect pt. back to task, with immediate reinforcement for returning to
task, even though it requires guided redirection.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
136
Date: 01/15/03
Problem Description:
Pt. has a long history of noncompliance with her meds, despite being under a court order to take her psychotropic
meds. When she stops her meds, she gradually decompensates over a few weeks to a few months. Once
decompensated, she is very slow to recompensate after being restarted on her meds. There are concerns that after a
period of decompensation she never fully recovers back to her baseline. Currently she continues to be very resistant
to taking her meds. Pt. also refuses blood work and often refuses to go to program.
1.
Target Date
Date/Status*
01/15/04
Target Date
1.
04/15/03
2.
Pt. will attend assigned programs at least three times weekly for
3 months.
07/15/03
3.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
137
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Virginia Coleman, MD
Psychology:
1.
Psychologist will inventory reinforcing events, activities, and objects specific to this pt.
2.
Pt. will receive second-level reinforcement by accumulating one point for each
compliant action (e.g., allowing blood to be drawn or attending assigned group). When
pt. accumulates five points, she will receive a previously identified reinforcer (see
attached behavioral plan).
Staff will discuss with pt. the importance of blood work and meds.
2.
Staff will give verbal reinforcement for all aspects of treatment compliance, such as
taking meds, complying with blood work, and going to program.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
138
Date: 01/15/03
Problem Description:
Since adolescence, pt. has had difficulty functioning independently of her family or institutions. She is terrified of
growing up and separating from caregivers. However, she denies these fears and expresses a desire to leave the
hospital to live on her own. To avoid independence, she gets herself restricted by breaking the rules, assaulting
others, dressing inappropriately, making somatic complaints that have no physical basis, going AWA (away
without authorization), and refusing to go to programs or social activities that she has identified as interesting. Pt.s
family often does things that increase pt.s dependence, such as interrupting treatment despite their agreement to
schedule visits when she is not involved in program activities.
1.
Target Date
Date/Status*
01/15/04
Target Date
1.
04/15/03
2.
07/15/03
3.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
139
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nsg. staff will give pt. immediate verbal reinforcement for any significant independent
functioning, such as getting out of bed without cues, going to program with no more
than one cue, and independently preparing to go to program without any cues (see
attached behavioral plan).
2.
Nsg. staff will remind pt. to get ready for program activities with minimal verbal cues
(e.g., she will be reminded to get ready for her DBT group only once, 15 minutes before
the group).
Psychology:
1.
Psychologist will use DBT techniques to work with pt. one-to-one and in the DBT
group for 1 hour twice a week.
2.
Psychologist will inventory reinforcing events, activities, and objects specific to the pt.
and make modifications in the DBT plan as indicated by the results of the inventory.
Social Work:
1.
Family education meetings will be held once weekly for hour to engage parents in
pt. treatment, to help them identify and modify behaviors they contribute that slow
pt.s improvement, and to teach them to identify and reward small improvements in
pt.s independent functioning.
2.
Social worker will meet with pt. hour once weekly to help pt. see the advantages of
living in the community and how her acting-out behaviors sabotage her transition into
the community.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
140
Date: 01/15/03
Problem Description:
Pt. has an extensive history of escaping from the hospital while on independent privileges. While on such
unauthorized passes, pt. has abused alcohol and attempted to break into houses. His escaping appears to be related
to his impulsivity and disorganized thinking. Pt. may put himself and others in dangerous situations while on
escape because of his poor judgment, especially when intoxicated.
Implementation of treatment of Problems 1.1 Psychotic Symptoms and 5.1 Alcohol Abuse to help lower pt.s
escape risk.
1.
Target Date
Date/Status*
01/15/04
Target Date
1.
04/15/03
2.
04/15/03
3.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
141
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Pt.s supervised privileges will be held for at least 1 week following his return from
escape. During this week, he will be assessed as to whether he is safe to restart
supervised privileges.
Virginia Coleman, MD
Social Work:
1.
Social worker will meet with pt. for 45 minutes once weekly to help pt. understand
how escaping from his treatment leads to increased loss of freedom and increased
difficulty with placing him in the community.
Rehab:
1.
Rehab staff will closely monitor pt.s whereabouts while he is off-ward in scheduled
groups.
Psychology:
1.
Staff will provide one-to-one to assistance pt. to develop appropriate alternative means
of gaining freedom and independence.
Nsg. staff will monitor pt. for evidence that he is planning an escape (e.g., hoarding
money, wearing a coat while going to in-hospital activities).
2.
If suspicious behavior is noted, nsg. staff will discuss it with pt. to assess his rationale
for the behavior. If suspicions continue, staff will be very conscientious about
monitoring pt. and will notify psychiatrist of concerns.
3.
Prior to pt.s going on privileges, nsg. staff will caution him against attempting to
escape. Upon his return from successful privileges, nsg. staff will praise pt. for his not
having attempted to escape.
4.
Nsg. staff will provide verbal praise and reinforcement for comments and behaviors
that suggest that he is working on alternatives to gain freedom, rather than escaping.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
142
Date: 01/15/03
Problem Description:
Pt. steals a wide variety of items, most frequently cosmetics. While on pass in the community, she has been
arrested twice during the last year. No charges were filed. Pt. could easily buy the items that she steals. Because of
her psychotic process, it is very difficult to understand why she steals; however, there does appear to be a
compulsive quality to her stealing. Her stealing makes it very difficult to give her unsupervised passes. Her family is
very interested in having pt. return home to live with them; however, her stealing makes it very difficult to allow
her to go unsupervised in the community. Rewarding her for not stealing with weekly trips to visit her family has
decreased the frequency of the stealing. Generally pt. does not steal when at home. Prozac has been helpful with
reducing pt.s compulsion to steal.
1.
Target Date
Date/Status*
01/15/04
Target Date
1.
04/15/03
2.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
143
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
On each day there is an absence of conclusive evidence that she has stolen, staff will
take pt. to the canteen for a snack.
2.
In association with taking pt. on an earned trip to the canteen, staff will verbally
reinforce her appropriate (nonstealing) behavior. For example, saying, with smiling
approval, You did such a good job controlling your impulse to steal that I want to
take you to the canteen.
3.
Pt. will be rewarded with a day pass to home once weekly, if she is able to control her
urge to steal on the ward or in the community during the preceding week. This control
will be measured by the absence of conclusive evidence that she has stolen during the
last week.
Social Work:
1.
Social worker will arrange the schedule for passes with pt. family.
2.
Social worker will meet with pt.s family for 1 hour once a month for supporting,
problem-solving family therapy.
Psychology:
1.
Psychologist will meet with pt. once a week for hour to attempt to understand her
stealing and to develop strategies that will help decrease her stealing.
Psychiatry:
1.
Psychiatrist will meet with pt. in treatment team for 1 hour once a month to monitor
any changes in pt.s stealing and to prescribe treatments with SSRIs, such as Prozac
(fluoxetine).
Virginia Coleman, MD
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
144
Date: 01/15/03
Problem Description:
Pt. has a long history of somatic complaints that are related to attention seeking and avoidance of involvement in
activities. Complaints include problems with stomach, bowel, broken bones, and headaches. Only rarely is there a
physical basis for the complaint.
1.
1.
Target Date
Date/Status*
01/15/04
Target Date
Date/Status*
07/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
145
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will assess medical aspects of all somatic complaints and treat or arrange
for treatment of actual physical problems. Psychiatrist will give staff feedback
concerning the medical safety of pt.s participation in various activities.
Victor Dyson, MD
Following medical assessment of complaints and reasonable assurance that pt. is not at
risk, nsg. staff will provide strong support and encouragement to patient for
functioning in program despite complaints.
2.
Nsg. staff will discuss health issues with pt. and teach healthy lifestyle changes for
hour once weekly.
3.
Nsg. staff will provide support and praise for any reductions in pt.s seeking medical
attention for his psychosomatic complaints; for example, staff will praise pt. for being
able to go for a day without any significant attention obtained through the use of
psychosomatic complaints.
Psychology:
1.
Psychologist will discuss stress reduction training with pt. and initiate if appropriate.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
146
Date: 01/15/03
Problem Description:
Two years ago, pt. developed temporal lobe epilepsy (TLE) syndrome. With treatment, he still has an episode about
once a month that is characterized by confused, disorganized thinking. The episodes are preceded by a weird
feeling and last only a few minutes. Since the development of TLE, pt. has not been involved in any productive
activity. Pt. states that his confidence is low and he is afraid of having an episode of TLE in front of customers in a
work setting. Pt. had been a very successful computer programmer before the onset of TLE, and the TLE should not
have significantly impaired his work performance.
Implementation of the medical treatment of Problem 6.1 Temporal Lobe Epilepsy.
1.
Target Date
Date/Status*
01/15/04
Target Date
1.
03/15/03
2.
Pt. will able to participate in the sports and fitness club three
times weekly for 1 month.
04/15/03
3.
07/15/03
4.
10/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
147
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Rehab:
1.
Pt. will participate in exercise group three times weekly for 20 minutes to engage pt. in
a structured social activity to reduce anxiety in group activities.
2.
Pt. will participate in sports and fitness club three times weekly for 2 hours to engage
pt. in a structured social activity that will help reduce anxiety in group activities.
Albert Sanchez, RT
3.
Pt. will participate in vocational counseling for 1 hour once weekly to develop stepwise plan of engagement in vocational activities.
Thomas Parker, OT
4.
Pt. will participate in hospital industries program 5 hours weekly to assess and renew
his confidence in his work skills and to develop means of coping with the episodes of
TLE.
5.
Pt. will participate in vocational group for 1 hour once weekly to explore and
encourage vocational adjustment activities and to develop a means to cope with
occasional episodes of TLE while on the job.
Jane Hoover, OT
Psychology/Rehab:
1.
Pt. will participate in behavioral treatment to reduce anxiety correlated with the
initiation of structured activities (see Behavioral Plan).
Psychiatry:
1.
Pt. will take anxiolytics as prescribed for job-related anxiety and panic.
Victor Dyson, MD
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
148
Date: 01/15/03
Problem Description:
Pt. is a 23-year-old gay male. He is HIV+ by history and appears to have a good understanding of being HIV+. He
presents with an adjustment disorder, which is apparently secondary to the stress of being labeled as an AIDS
patient. Despite no physical evidence of illness or any evidence of danger of transmitting the disease to others, he
has lost his job and his health insurance. He feels shunned by many of the people in his community. He is having
increasing financial difficulties and often wonders whether life is worth living; however, pt. is not believed to be
suicidal.
Implement treatment of medical aspects of being HIV+ and AIDS precautions as outlined under Problem 6.1 HIV+
(including an appointment with an infectious disease specialist).
1.
1.
Target Date
Date/Status*
07/15/03
Target Date
Date/Status*
04/15/03
2.
Pt. will use legal and social supports consistently for a 1-month
period.
04/15/03
3.
04/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
149
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Victor Dyson, MD
Social Work:
1.
Social worker will discuss and introduce the pt. to the notion of group psychotherapy
and community support groups. These can lessen sense of being the only one. The
theme of the group is that some choices have been taken away by the nature of the
illness but that other choices remain and should be used and appreciated.
2.
Social worker will help pt. see how other gay men cope and ideally will stick with pt.
when healthy and when hospitalized.
Social worker will explain to pt. that job and insurance discrimination is illegal and
refer pt. to community advocacy groups (both gay and HIV). Advise pt. that asserting
his rights can be psychologically therapeutic.
Nsg. staff will conduct ongoing assessment of pt.s sexual practices with regard to
encouraging safe ways to have physical intimacy. Staff will provide extensive teaching
of safer sex practices, as well as reassurance that the need for intimacy increases when
people are faced with the HIV diagnosis.
2.
Nsg. staff will provide support and reassurance and will verbally refocus pt. to positive
aspects of his life. Staff will support him in learning ways to cope with being HIV+.
Marilyn Davis, RN
Psychology:
1.
Rehab:
1.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
SOCIAL SKILLS
(Problem Area 2)
21
23
SOCIAL SKILLS
(Problem Area 2)
CONTENTS
Kennedy Axis V for Social Skills ................................................................................................................ 24
This rating scale can be used to measure the outcome of treatment. It also helps to define the problems
that fit into the category of Social Skills and can be helpful in composing a short description of each
problem.
Strengths .................................................................................................................................................. 25
Examples of strengths that may be related to treatment and discharge in the area of Social Skills are
listed here.
Goals ......................................................................................................................................................... 26
Examples of treatment goals that may relate to problems in the area of Social Skills are listed here.
24
Superior social skills, sought out by others because of his/her outstanding social/communication skills,
has many friends and no difficulty making new friends. No symptoms.
90 Good social skills, no difficulty being pleasant and engaging, good communication skills, socially
effective.
80 No more than slight impairment in social skills, slightly inappropriate social behavior leads to
infrequent interpersonal conflicts, no more than slight difficulty maintaining several friendships.
70 Some difficulty with social skills (e.g., mild difficulty knowing how to share with others, show
sympathy for others, and/or understand feelings of others), social skills are not obviously impaired, generally
functioning fairly well, has some meaningful interpersonal relationships.
60 Moderate difficulty with social skills (e.g., conflicts with peers due to inappropriate teasing or other
inappropriate social behavior; attempts to be pleasant and engaging are usually moderately awkward; moderate
difficulty knowing what to say even when talking with friends; moderate difficulty knowing how to share with
others, show sympathy toward others, and/or understand feelings of others); hardly any friends because of
problems with social skills; communications are understandable but vague.
50 Serious impairment in social skills; has no friends because of clearly impaired social skills;
however, has some peer relationships, despite social skills being clearly impaired; frequent conflicts with peers
or co-workers because of inappropriate social behavior; conversations are often socially inappropriate; great
difficulty communicating thoughts and feelings; unable to introduce self and a second person without clear
difficulty; frequently intrusive; inappropriate, nonsexual touching.
40 Major impairment in social skills; attempts to approach others quickly lead to embarrassing
situations; no friends and virtually no peer relationships because of poor social skills; unable to appropriately
engage in almost any social activity; continually intrusive with little understanding of the inappropriateness of the
behavior; major acts of socially inappropriate behavior lead to being assaulted, fired from work, or expelled from
school; great difficulty recognizing or coping with inappropriate sexual or aggressive advances by others;
great difficulty recognizing that his/her sexual advances are not welcome.
30 Acts grossly inappropriately toward others; virtually no understanding of the feelings of others, how
to share with others, and/or how to show sympathy toward others; conversations with others are grossly
inappropriate; unaware of or ignores most social norms as manifested by open masturbation, inappropriate sexual
touching, and the like.
20 Very few social skills; generally unable to communicate in an organized, understandable way; uses short
phrases or gestures to get basic needs met; acts with shocking inappropriateness in front of others, such as
smearing of feces or making sexual advances toward young children; however, may have some understanding that
such behavior is inappropriate.
10 Few if any social skills; unable to communicate in an organized, understandable way; shows no apparent
awareness of social norms (e.g., doesnt realize that it is inappropriate to grab food or cigarettes from others);
extremely vulnerable to victimization (e.g., has no understanding of the inappropriateness and/or dangers of
approaching strangers or assaulting others, needs constant care and supervision to not get into dangerous social
situations).
NR Not rated
25
II.
Nonsexual
1.
Limited interpersonal skills
2.
Extremely impoverished social skills secondary to social isolation
3.
Socially inappropriate behavior due to lack of awareness of social norms
4.
Lack of consideration for others due to poor interpersonal skills
5.
Demanding, intrusive behavior
6.
Teasing, pestering, or agitation of peers due to poor social skills
7.
Poor communication skills
B.
Sexual
1.
Overly affectionate
2.
Inappropriate seductive dress and sexual actions with little or no understanding that these actions
are inappropriate
3.
Frequent, inappropriate masturbation without an understanding of the social and legal
consequences of such behavior
4.
Inappropriate sexual advances without awareness that the behavior is inappropriate
5.
Inappropriate hugging or inappropriate touching of other without an understanding of the
inappropriate nature of these acts
Other
A.
No examples given
26
Goals
I.
II.
B.
Reporting of Symptoms
A.
Pt. will consistently discuss any problems that he or she is having in social interactions
for 1 month.
Pt. will participate in on-ward group activities for 5 minutes a day for 1 month.
Pt. will attend morning ward meeting twice per week for 1 month.
Pt. will attend one off-ward group activity per week for 1 month.
Pt. will engage in one independent off-ward social activity with a peer at least once a
week for 3 months.
B.
Program activities
1.
Pt. will consistently express the benefits of attending program activities focused on improving
social skills for 3 months.
2.
Pt.s level of compliance will improve such that he or she will attend the group social activities
twice a week for 4 weeks.
V.
27
C.
Treatment planning
1.
Pt. will consistently cooperate with at least one treatment team member in the treatment
planning process for 1 month.
2.
Pt. will be willing to participate in the evaluation process.
3.
Pt. will demonstrate cooperation with all aspects of his or her treatment plan, including meds and
blood work, for 2 weeks.
D.
Assessments
1.
Pt. will cooperate with rehabilitation assessment for appropriate day-program referral so that it
can be completed.
2.
Pt. will cooperate so that an assessment can be made as to whether cultural factors significantly
interfere with the demonstration of pt.s social skills.
B.
C.
Laboratory tests
1.
No examples given.
Kennedy Axis V
1.
Pt.s Kennedy Axis V subscale score on Social Skills will improve from a current score of 30 to 40.
B.
VII. Miscellaneous
A.
No examples given
28
Treatment Modalities
I.
II.
B.
C.
Psychotherapy
1.
Staff will conduct weekly one-to-one interview to encourage and help increase social involvement
as a means of improving pt.s social skills.
2.
Rehab staff will provide supportive, problem-solving psychotherapy to help pt. better understand
how his or her behavior impacts others and how to modify behavior to more effectively meet pt.s
needs.
3.
Rehab staff will provide supportive, problem-solving psychotherapy to help pt. better understand
and cope with conflicts in pt.s relationships.
Positive reinforcement
1.
Staff will praise pt. for improvements in social skills.
2.
Staff will give positive verbal feedback to pt. for appropriate social interactions, such as asking for
things wanted, rather than grabbing them.
3.
Staff will reinforce alternative, appropriate attention-seeking behaviors, such as pt. playing guitar.
4.
Nsg. staff will praise pt. when pt. makes appropriate statements and requests to peers.
5.
Nsg. staff will give pt. one extra cigarette, token, or quarter as a reward for appropriate social
interactions during community meeting.
6.
Staff will positively reinforce pt. with trips to the canteen for attending social skills group.
7.
Nsg. staff will give encouragement and praise when patient knows the daily schedule.
B.
C.
Extinction
1.
All staff will ignore inappropriate social behavior, thus helping to extinguish it.
2.
Nsg. staff will interact with pt. as little as possible during screaming incidences in the hope of
extinguishing this behavior.
3.
Staff will ignore incoherent communications in an attempt to get pt. to try to communicate more
clearly.
29
D.
E.
Channeling of energies
1.
Staff will help pt. sublimate his or her sexual energies into more appropriate social activities.
F.
B.
C.
Other modalities
1.
Group therapy
a.
Staff will hold group therapy once weekly to facilitate discussions of problems with forming
relationships.
b.
Group leader will regularly attempt to engage pt. in topics being discussed.
2.
Psychodrama
a.
Psychologist will provide role playing to assist pt. in understanding and dealing with
complicated social interactions.
3.
Rehabilitation
a.
Rehab counselor will lead social skills building group for 1 hour once a week to help pt.
learn more appropriate social interactions.
210
4.
V.
A.
Stimulus reduction
1.
Staff will redirect pt. to a quiet environment to allow pt. to practice appropriate social interaction
with fewer distractions.
2.
Staff will remove pt. from overwhelming social situations and place pt. in supportive,
nonthreatening social situations until his or her skills improve to allow pt. to interact in these
more demanding situations.
B.
C.
Medication
1.
Meds will be taken as prescribed.
B.
B.
Medication
1.
Staff will discuss with the pt. the risks and benefits of meds.
2.
Staff will conduct one-to-one discussion for hour once weekly about the need to take meds as
prescribed.
3.
Staff will show the concrete benefits of taking meds (e.g., You seem more relaxed in social
situations, You act more appropriately toward others, You have more friends).
C.
D.
211
B.
Psychiatric evaluations
1.
Pt. will receive psychotropic medication evaluation to help determine whether psychotropic meds
will enhance his or her ability to participate in social skills training.
C.
D.
No examples given
Treatment of related problems (This is optional and can be included with the treatment modalities
or in the problem description.)
1.
Staff will treat pt.s bizarre behavior as indicated under Problem 1.1 Psychotic Symptoms.
2.
Staff will treat pt.s social withdrawal as indicated under Problem 1.1 Psychotic Symptoms.
3.
Staff will treat pt.s sexually assaultive behavior as indicated under Problem 3.1 Sexually Assaultive
Behavior.
Notes
213
214
Date: 01/15/03
Problem Description:
Pt. has a 15-year history of mental illness. Skills acquired before the onset of her illness have decreased
dramatically. Most of her interactions are with family members, and her skills demonstrated with her family are
often very awkward and ineffective. Her verbal responses are passive and monosyllabic. She generally avoids others
and has no close friends because of her impaired social skills. Pt. has only a minimal awareness of social norms;
however, she doesnt act grossly inappropriately toward others, such as by initiating inappropriate sexual touching.
Target Date
1.
01/15/04
2.
01/15/04
1.
2.
3.
Pt. will ask for materials that she needs about 50% of the time
for 1 month.
Pt. will ask for things that she needs about four out of five times
for 1 month.
Pt. will be able to consistently interact with her peers in social
skills group without the interactions leading to very awkward
situations for 1 month.
Target Date
Date/Status*
Date/Status*
07/15/03
10/15/03
10/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
215
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work:
1.
Staff will provide psychoeducational counseling of family with focus on helping the
family to model effective social interaction skills.
Rehab:
1.
Staff will focus on feedback of basic social skills, cooperative behavior, approximation
to the group, discrimination, and demand for minimal interaction with group leader
(e.g., asking for materials and instructions).
2.
Rehab programs will allow pt. to observe and practice social skills, including leisure
awareness, leisure exploration, recreational groups, and the like (see Program
Schedule).
3.
Staff will redirect her through modeling for more functional alternatives when pt.s
social behaviors are ineffective.
Staff will interact with pt. one-to-one for at least 5 minutes for a minimum of three
times per shift to model effective social behaviors (e.g., addressing pt. by her first
name, maintaining eye contact, asking for things needed).
2.
Staff will provide pt. with daily encouragement and praise for keeping track of her
daily schedule of activities.
3.
Staff will provide support and praise for appropriate social interactions on the ward.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
216
Date: 01/15/03
Problem Description:
Pt. has markedly impaired social skills that prevent her from having any friends or peer relationships. Her skills are
not so impaired that she displays grossly inappropriate social acts. As indicated under Problem 1.1 Psychotic
Symptoms, pt. is withdrawn and has great difficulty trusting others.
Target Date
Date/Status*
Target Date
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
217
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
Social Work:
Psychology:
Rehab:
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
218
Date: 01/15/03
Problem Description:
Pt. is generally pleasant and engaging; however, she will often attempt to inappropriately kiss others. About once a
month, she will attempt to touch others in private areas. She does not appear to be aware of the inappropriateness
of her behaviors. She appears to be looking for love, affection, and acceptance. Her inappropriate advances
generally turn people off instead of meeting her needs for a caring, affectionate relationship. However, because of
her desperateness for affection, strangers could easily take advantage of her.
Target Date
1.
01/15/04
2.
01/15/04
Target Date
1.
04/15/03
2.
Pt. will touch others on their private areas no more that once
during 3 months.
07/15/03
3.
04/15/03
4.
05/15/03
5.
06/15/03
6.
07/15/03
7.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
219
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Rehab:
1.
Pt. will participate in relationships group for 1 hour once weekly to review and learn
appropriate social interactions, especially with someone with whom she may develop
a relationship.
2.
Pt. will have one-to-one daily modeling of appropriate interactions with others,
including appropriate expressions of affection.
3.
Pt. will participate in leisure activity group for 1 hour three times weekly to help her
develop interests and skills in activities that would allow her to appropriately interact
with others at a social, affectionate, friendship level, such as going for a walk, meal,
or movie with a friend or playing board games or a physical sport with a friend.
Pt. will participate in womens group for 1 hour once weekly to explore the issues of
relationships and the skills related to these issues.
2.
Staff will provide stern one-to-one redirection when pt. inappropriately touches
others on private areas.
3.
Staff will redirect pt. with a minimum of attention to avoid reinforcing inappropriate
sexual behaviors that do not involve sexual touching.
4.
Staff will encourage and praise pt. for appropriate expression of affection.
5.
Staff will provide one-to-one skill teaching regarding the recognition of inappropriate
sexual impulses and development of alternative behaviors for 1 hour once weekly.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
VIOLENCE
(Problem Area 3)
31
33
VIOLENCE
(Problem Area 3)
CONTENTS
Kennedy Axis V for Violence..................................................................................................................... 34
This rating scale can be used to measure the outcome of treatment. It also helps to define the problems
that fit into the category of Violence and can be helpful in composing a short description of each
problem.
Strengths .................................................................................................................................................. 36
Examples of strengths that may be related to treatment and discharge in the area of Nonviolence are
listed here.
Goals ......................................................................................................................................................... 36
Examples of treatment goals that may relate to problems in the area of Violence are listed here.
34
35
I.
II.
B.
C.
D.
Suicide (general)
1.
Suicidal ideation or attempts
2.
Self-abuse in response to hallucinations
3.
Self-abuse (due to obvious secondary gain)
4.
Noncontingent self-abuse
5.
Self-mutilation
III. Other
1.
No examples given
36
Nonviolent Strengths
A.
B.
C.
D.
E.
F.
G.
Goals
I.
Assaultiveness
1.
General
a.
Pt. will be able to converse with staff for 1 minute once per shift without threatening or
attempting to assault staff.
b.
Pt.s threatening behavior will decrease to no more than once per week for 1 month.
c.
Pt.s frequency of explosive episodes (e.g., throwing chairs, ripping curtains) will be reduced
to no more than one time per week for 1 month.
d.
Pt. will be able to control his or her behavior such that other pts. complaints of his or her
aggression toward them will diminish to a maximum of one per week.
e.
Pt.s assaultive behavior will decrease such that no incidences of assault occur for 2 months.
f.
Pt. will be able to demonstrate control of hostility by being able to apologize to anyone he or
she threatens.
g.
Pt. will maintain current status of no evidence of threatening or assaultive behavior.
h.
Pt. will be able to consistently express an understanding of the connection between his or
her paranoia and hostility and his or her assaultive behaviors for 1 month.
2.
3.
4.
B.
5.
6.
Miscellaneous
a.
Pt. will be prevented from acting on aggressive, homicidal impulses directed at his or her
parent for 6 months.
II.
37
Reporting of Symptoms
A.
Pt. will remain in the group activity area with minimal redirection for 15 minutes per
day for 1 week.
Pt. will attend two program activities per week for 1 month.
Pt. will attend full-day programs 3 days a week for 1 month.
Pt. will start a Corps Services job.
Pt. will start a job in the community.
Pt. will participate in the anger management group once a week for 1 month.
Pt. will attend the self-abuse prevention group once weekly for 4 weeks.
38
B.
Treatment planning
1.
Pt. will consistently cooperate with at least one treatment team member in the treatment
planning process for 1 month.
2.
Pt. will demonstrate cooperation with all aspects of his or her treatment plan, including meds and
blood work, for 4 weeks.
3.
Pt. will express a willingness to participate in the evaluation process.
C.
Program activities
1.
Pt. will verbalize the reasons for attending program.
2.
Pt.s level of compliance will improve such that pt. will attend art therapy class twice a week for
1 month.
D.
V.
Pt.s statements will reflect a clear understanding of how others feel threatened and intimidated by
pt.s aggressive, erotic attachments.
Pt. will express an understanding as to the association between pt.s use of drugs and alcohol and
violent behavior.
Pt. will express an understanding as to the connection between pt.s paranoia and his or her
violent behavior.
Pt. will express an understanding of the connection between possessing a gun and the pt. not
being allowed to live in the community.
Pt. will agree not to purchase a gun, despite his or her failure to understand that owning a gun
would pose a serious danger to pt. and others.
Assessments
1.
Pt. will allow needed psychological tests to be completed.
2.
Pt. will cooperate with rehabilitation assessment for appropriate day-program referral so that it
can be completed.
3.
Pt. will cooperate with psychological assessment to determine whether low self-esteem leads to an
expectation of failure to which pt. reacts with hostility and suicidal ideation.
4.
Pt. will cooperate with the assessment to determine whether pt.s irritability reflects his or her
attempts to avoid communicating with anyone.
B.
Kennedy Axis V
1.
Pt.s Kennedy Axis V subscale score on Violence will improve from a current score of 40 to 60.
B.
VII. Miscellaneous
A.
No examples given
39
Treatment Modalities
I. Verbal Treatment Modalities (emphasis on verbal interactions)
II.
A.
B.
C.
Psychotherapy
1.
Staff will provide pt. with one-to-one insight-oriented psychotherapy once a week to help reduce
psychological conflicts that result in periods of uncontrollable anger and hostility.
2.
Psychologist will provide supportive, problem-solving psychotherapy to help pt. better cope with
lifes day-to-day frustrations and thus lessen pt.s anger.
3.
Social worker will provide one-to-one DBT counseling for pt. and lead DBT skills practice group to
help reduce pt.s level of self-abusive behavior.
Positive reinforcement
1.
Nsg. staff members will verbally reinforce pt. for informing them of his or her suicidal feelings and
then suggest interventions
2.
Ward staff will provide positive feedback to pt. for appropriate control of pt.s hostile impulses.
3.
Staff will praise pt. for completion of 1 hour of program without any evidence of anger or
hostility.
4.
Staff will positively reinforce pt. with canteen and cafeteria privileges for nonassaultive behaviors.
B.
C.
Extinction
1.
Following a suicidal gesture, staff will carry out all necessary medical procedures with minimal
dialogue and conversation with pt.
D.
310
E.
Channeling energies
1.
Pt. will participate in weekly group therapy to facilitate expression of anger in a more appropriate
manner.
2.
Pt. will talk with staff or go for a short walk with staff to reduce the level of frustration.
3.
Staff will increase structured periods to appropriately channel potentially aggressive behavior into
various activities; for example, maximize pt.s involvement in structured day program, including
open workshop, patient wage program, leisure interest group, and community meeting.
4.
Staff will encourage pt. to verbalize his or her agitation rather than become oppositional or
unreasonable.
5.
Staff will divert pt. into acceptable channels to reduce chronic hypersexual arousal and associated
sexual assaults.
F.
B.
C.
Other modalities
1.
Group therapy
a.
Pt. will participate in group therapy for 1 hour once weekly to facilitate discussions of
suicidal impulses.
b.
Pt. will participate in relapse prevention group to help pt. understand the importance of his
or her meds and of continuing DBT treatments.
2.
Psychodrama
a.
Pt. will participate in role playing to allow pt. to see alternative ways of responding to
frustrations and disappointments in life.
3.
4.
Empowerment
a.
Staff will empower pt. with the opportunity to make choices as to which activities to pursue
to reduce his or her anger and frustration of feeling unimportant and helpless.
Stimulus reduction
1.
Staff will redirect pt. to a quiet environment if the pt. is agitated or expresses threats.
2.
Staff will redirect pt. to a quiet room when necessary to decrease stimulation and agitation.
3.
4.
5.
B.
C.
V.
311
When pt. makes threats, staff will redirect him or her to the quiet room for 15 minutes or until pt.
is no longer threatening.
Staff will redirect pt. from triggering events or overstimulating areas.
Staff will remove pt. from overwhelming situations to reduce his or her level of frustration.
Medication
1.
Staff will prescribe antipsychotic meds to reduce the intensity of pt.s anger and irritability.
2.
Psychiatrist will prescribe mood stabilizers, such Depakote, to help control pt.s explosive
episodes.
3.
Prn meds, such as a combination of Haldol and Ativan, will be used to relieve acute explosive
episodes.
4.
Psychiatrist will prescribe an SSRI, such as Zoloft, or hormonal therapy, such as Depo-Provera, to
reduce pt.s libido and associated hostile, sexual impulses.
B.
Mental illness
1.
Psychologist will discuss the association between the pt.s paranoia and his or her assaultiveness.
2.
Social worker will discuss with the pt. and family the association between pt.s feelings of
hopelessness and suicidal impulses.
B.
Medication
1.
Psychiatrist will discuss with pt. the risks and benefits of meds.
2.
Nsg. staff will meet one-to-one to educate pt. about the fact that the meds decrease pt.s level of
anger and irritability.
312
3.
Staff will show concrete benefits of taking meds (such as, You are less angry and irritable, Your
suicidal impulses are decreased, You spend less time in restraints, People are less fearful of
you).
C.
D.
B.
Psychiatric evaluations
1.
Psychopharmacology staff will consult for recommendations of meds that may reduce pt.s
explosive behavior.
2.
Staff will conduct a psychiatric assessment of pt.s violent behavior.
C.
D.
E.
313
Court commitment
1.
Staff will seek court commitment for 6 months because of the dangers to self and others due to
mental illness.
B.
Guardianship
1.
Staff will seek court approval of the forced use of antipsychotics to control pt.s assaultive
behavior.
C.
Implementation of other treatment plans (This step is optional; instead, this information may
be included in the problem description.)
1.
Staff will implement treatment of Problem 1.1 Psychotic Symptoms to reduce the level of Bills
paranoia.
2.
Staff will implement treatment of Problem 1.1 Depressive Symptoms to relieve the depression that
is driving Angelas suicidal impulses.
314
Date: 01/15/03
Problem Description:
1.
Precipitants (e.g., noncompliance with meds, substance abuse, command hallucinations, stress, poor
frustration tolerance)
Response to previous and current treatments and expected response to any proposed treatments
Current level of threats and assaults
Barriers to treatment, such as poor insight into the need for treatment, including meds
Presence or need for psychotropic medication guardianship, guardianship of person and/or estate
Current level of symptoms and activity level, including frequency of attendance at therapeutic activities
2.
Make sure that the above relate to goals and treatment modalities.
3.
The description and treatment of any psychotic or depressive symptoms that may be driving pt.s hostility
should be addressed in Problem Area 1 Psychological Impairment.
Target Date
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
315
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for ____ minutes at least ______ times weekly/monthly to
monitor any changes in intensity of agitation and out-of-control behavior. This will
allow the psychiatrist to assess the need for special precautions and level of privileges
and to prescribe treatment with antipsychotic meds such as __________________,
beta-blockers such as ____________________, anticonvulsants such as ____________,
lithium, or other meds such as __________________. Lab will be as ordered, including
blood levels.
Victor Dyson, MD
Social Work:
1. Social worker will meet with pt. for ___ minutes at least ___ times weekly/monthly to
help pt. understand how his or her violent behavior acts as a barrier to discharge.
Brenda St. Martin, MSW
Rehab:
1. Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ times
weekly/monthly to review and revise his or her daily treatment schedule, will refer pt.
to appropriate groups, and will work to improve his or her frustration tolerance.
2. Pt. will attend relapse prevention group ___ time(s) a week/month to learn more about
risk factors and how to avoid them. See weekly schedule for programs.
Jane Hoover, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
316
Date: 01/15/03
Problem Description:
1.
2.
Make sure that the above relate to goals and treatment modalities.
3.
The description and treatment of any psychotic or depressive symptoms that may be driving pt.s hostility,
should be addressed in Problem Area 1 Psychological Impairment.
Target Date
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
317
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for __ minutes at least ___ time(s) weekly/monthly to
monitor any changes in intensity of suicidal/self-abusive impulses. This monitoring
will allow the psychiatrist to assess the need for special precautions and to prescribe
treatment with antidepressant meds such as _______________________ or other meds
such as _________________. Lab will be as ordered, including antidepressant levels.
Victor Dyson, MD
Social Work:
1. Social worker will meet with pt. for __ minutes at least ___ time(s) weekly/monthly to
help pt. understand how his or her suicidal/self-abusive behaviors act as a barrier to
discharge.
Brenda St. Martin, MSW
Rehab:
1. Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ time(s)
weekly/monthly to review and revise pt.s daily treatment schedule and will refer pt. to
appropriate groups to work to improve his or her self-esteem/frustration tolerance.
2. Pt. will attend relapse prevention group ___ time(s) a week/month to learn more about
risk factors and how to avoid them. See weekly schedule for programs.
Jane Hoover, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
319
320
Date: 01/15/03
Problem Description:
Pt. has a long history of attention-seeking suicidal ideation and dangerous suicidal attempts, including attempts to
hang himself, suffocate himself with a plastic bag, and, recently, to poison himself by drinking an insecticide.
Precipitants to suicidal attempts include 1) improvement with associated increased cognitive ability to appreciate
the tragedy of his illness and difficulties making real progress (reality depression) and 2) desire to escape
tormenting auditory hallucinations. Treatment should emphasize controlling hallucinations and helping pt. to
accept slow, gradual improvements in his progress toward goals. In the past, focusing on suicidal ideation has
increased pt.s attention-seeking gestures.
Implement treatment of Problem 1.1 Psychotic and Depressive Symptoms, including regular and prn meds to
reduce the level of tormenting hallucinations.
Target Date
01/15/04
2. Pt. will verbalize self-worth and express realistic hopes for his
future consistently for 6 months.
01/15/04
01/15/04
Target Date
07/15/03
07/15/03
07/15/03
10/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
321
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for at least 1 hours a month to assess pt.s response to
treatment, including monitoring any changes in intensity of suicidal ideation, place pt. on
special precautions as needed, and allow increased privileges when pt. is assessed to be safe.
Victor Dyson, MD
Psychology:
1. Psychologist will meet with pt. for 45 minutes once weekly to discuss connections
between daily behavior (being out of bed, attending program) and progress toward pt.s
goals, including discharge.
2. Staff will encourage pt. to inform staff of suicidal feelings when they occur and to help
pt. learn interventions, such as 1) focusing on his realistic goals (e.g., passes with
family, shopping trips, and discharge planning), 2) focusing on ward activities, and
3) focusing on his assets and accomplishments (e.g., hobbies, program attendance,
relatives who care for him, memories of happy experiences).
Susan Green, Psychologist
Social Work:
1. Social worker will meet with pt. for hour once weekly to evaluate pt.s readiness for
discharge.
2. Social worker will consistently offer pt. the opportunity for treatment planning
involvement.
Brenda St. Martin, MSW
Rehab:
1. Rehab staff will meet with pt. for at least hour once a week to review and revise his
daily program schedule and refer him to appropriate groups to improve his self-esteem,
coping skills, and frustration tolerance.
2. Rehab staff will ensure that pt. is actively engaged in creative art therapy, an area of
strength for pt.
Albert Sanchez, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
322
Date: 01/15/03
Problem Description:
Two weeks following the loss of her job, pt. was found by neighbors with her wrist deeply cut. Pt. required 3 days
of medical hospitalization for treatment of blood loss and nerve injuries sustained during the suicidal attempt;
however, there appears to have been no permanent functional damage. She felt that she would not be able to get
another job. She felt that suicide was the only way to avoid her mounting bills and problems. Pt. now denies
suicidal ideation; however, she is felt to still be a serious risk of a suicidal attempt. In the past, pt. had attempted
suicide twice before by taking overdoses. The previous attempts were also associated with difficulty coping with
stress in her life.
Implement treatment of Problem 1.1 Depressive Symptoms, including meds to reduce the level of hopelessness and
helplessness.
Target Date
04/15/03
04/15/03
Target Date
02/15/03
02/15/03
02/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
323
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work:
1. Staff will provide family counseling to help pt.s family understand her suicidal
attempts and help them to cope with fears that she will again attempt suicide.
Brenda St. Martin, MSW
Psychology:
1. Psychologist will meet with pt. for 1 hour once a week 1) to help pt. understand the
association between her hopelessness and helplessness and her suicidal attempts, 2) to
help pt. to verbalize her self-destructive thoughts rather than acting on them, 3) to
help her reduce feelings of hopelessness and helplessness, and 4) to help her more
effectively deal with stress in her life.
2. Staff will use psychological testing to help assess pt.s level of dangerousness.
Susan Green, Psychologist
Rehab:
1. Staff will assess pt.s skills and work interests to determine whether pt. has a problem
that would interfere with her getting and keeping a job.
2. Staff will assign pt. to appropriate groups to work to improve her self-esteem and selfconfidence, including suicidal prevention group.
Jane Hoover, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
324
Date: 01/15/03
Problem Description:
Pt. has a long history of poor control over hostile impulses. Currently she is often angry, hostile, and threatening;
however, it has been more than 6 months since pt. was physically assaultive. Pt. is very likely to become angry
when demands are placed on her, especially concerning programs or her meds. She generally takes her anger out
on others; however, she has a history of breaking a window when angry, resulting in a serious laceration of her
hand. Pt. has been treated with a number of meds with some degree of success.
Target Date
07/15/03
07/15/03
Target Date
04/15/03
Ongoing
04/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
325
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will prescribe meds to help control anger and hostility, such as Clozaril,
Depakote, lithium, beta-blockers, and the like.
Victor Dyson, MD
Social Work:
1. Social worker will meet with pt. one-to-one weekly to give pt. the opportunity to
discuss personal issues.
Brenda St. Martin, MSW
Psychology:
1. Psychologist will encourage pt. to appropriately verbalize anger to staff.
2. Psychologist will lead pt. in relaxation exercises.
3. Psychologist will assess pt.s appropriateness for referral to the DTB Program.
Joseph LeBlanc, Psychologist
Rehab:
1. Staff will train pt. to improve frustration tolerance via involvement in groups such as
anger management group.
2. Staff will provide pt. with opportunities to feel empowered (i.e., give her choices as to
the activities she would like to pursue).
Albert Sanchez, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
326
Date: 01/15/03
Problem Description:
Pt. has a long history of being assaultive and threatening. The assaultiveness has been reduced to about once a
month. Generally the assaults are no more than pushing someone or hitting someone on the arm; however, about
a year ago he attacked and injured an attendant. The assaultiveness is associated with periods of being angry and
irritable. Recently the pt. has been moderately angry and irritable because of conflicts with his family.
Implement treatment of Problem 1.1 Psychotic Symptoms to reduce paranoid feelings.
Target Date
01/15/04
01/15/04
Target Date
07/15/03
2. Pt. will be able to converse with staff for 10 minutes each shift
without threatening or attempting to assault staff for 1 month.
04/15/03
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
327
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will restrict pt. to supervised privileges for at least 1 week if he is assaultive
to others.
2. Psychiatrist will administer meds as prescribed to reduce pt.s anger and irritability.
Victor Dyson, MD
Psychology:
1. Psychologist will discuss with pt. the association between pt.s paranoia and
assaultiveness.
2. Psychologist will discuss with pt. Stress Reduction Training and will initiate it if
appropriate.
Susan Green, Psychologist
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
328
Date: 01/15/03
Problem Description:
In August 2001, pt. made an attempt to kill his mother. At that time, pt. had a knife at his mothers throat, but was
pulled away by his brother. Since August 2001, patient has continued to make threats to kill his mother; however,
since the attempt in August 2001, he has not had the opportunity to harm his mother. Currently pt. is supervised
whenever he is off the ward; there is a restraining order to prevent him from going to the area where his mother
lives.
Implement treatment of Problem 1.1 Psychotic Symptoms and Problem 3.1 Anger and Explosiveness to help reduce
the danger toward pt.s mother.
Target Date
01/15/04
2. Pt. will be free of any homicidal impulses toward his mother for
6 months.
01/15/04
Target Date
07/15/03
07/15/03
3. Pt. will not attempt to act on his impulses to hurt his mother for
3 months.
07/15/03
10/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
329
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work:
1. Social worker will maintain contact with his mother to clarify any conflicts that she
may have with pt. and discuss possible resolution.
2. Social worker will keep pt.s mother informed of any potential danger from pt. as
indicated under the hospital duty-to-warn policy.
Roger Sing, MSW
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
330
Date: 01/15/03
Problem Description:
Pt. has a long history of assaultive, threatening behavior in association with paranoid thoughts. Pt. has had an
ongoing fascination with weapons and police work. Prior to the current hospitalization, pt. threatened his father
with a knife because he felt that his father was conspiring with the Mafia to have him assassinated.
Implement treatment of Problem 1.1 Psychotic Symptoms to reduce pt.s level of paranoia.
Target Date
10/15/03
10/15/03
Target Date
07/15/03
07/15/03
07/15/03
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
331
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for at least 1 hours a month to monitor any changes in
his violent impulses to make decisions concerning the need for special precautions and
level of privileges and to prescribe prn meds to help control angry impulses.
Victor Dyson, MD
Social Work:
1. Social worker will provide family counseling for 1 hour twice monthly to help pt.s
family understand and learn to cope with pt.s hostile, threatening episodes.
2. Social worker will encourage family members to remove all weapons from their home.
Roger Sing, MSW
Psychology:
1. Psychologist will provide one-to-one therapy for 1 hour once weekly to help pt.
understand the association between his paranoia, hostility, weapons, and
dangerousness.
2. Psychologist will encourage pt. to verbalize his hostile impulses rather than assaulting
others.
3. Psychologist will use psychological testing to help assess pt.s level of dangerousness.
Joseph LeBlanc, Psychologist
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
332
Date: 01/15/03
Problem Description:
Pt. has a long history of inappropriate sexual behaviors, including public nudity, sexually inappropriate touching
of females, and masturbating in public. Pt.s sexually assaultive behavior appeared to be under fairly good control;
however, recently pt. began openly masturbating in front of the social worker while having an individual therapy
session in her office. Pt. barred her from leaving the room until he had reached a climax. This attack was felt to
have been more of an inappropriate attempt at sexual gratification, rather than an act of hostility. Pt. appears to
have very little insight into the hostile, frightening nature of his acts toward females. Pt. has been resistive to
taking meds to help control his sexual impulses.
Target Date
Date/Status*
01/15/04
Target Date
07/15/03
07/15/03
3. Pt. will cooperate with treatments to lower his libido AEB his
frequency of masturbating decreasing from twice a day to no
more than twice a week for 3 months.
10/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
333
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will activate an assessment process for transfer to the Intensive Treatment
Unit in the event of further sexually assaultive behavior.
2. Psychiatrist will encourage pt. to consider a trial on an SSRI, such as Paxil, or hormonal
treatment, such as Depo-Provera, to help pt. maintain better control over his sexual
impulses.
Virginia Coleman, MD
Rehab/Psychology:
1. Staff will initiate cognitive-behavioral training for socially appropriate responses to
women in a variety of heterosexual situations, using modeling and role-playing.
2. Psychologist will help pt. to understand the legal consequences of sexually assaultive
behavior.
Joseph LeBlanc, Psychologist
Albert Sanchez, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
334
Date: 01/15/03
Problem Description:
Patient has been obsessed with one of the social workers at the hospital (Anne Stevens) since 12/01. He has been
making threatening comments to her by letter, calling her at home, and waiting for her outside her office and by
her car. Patient appears to have no insight into the threatening nature of his acts. Currently, he seems less
preoccupied by this social worker and less convinced that they share something special; however, these thoughts
do occur at times. In the past, pt. has not been able to have any significant relationship with a member of the
opposite sex.
Target Date
1. Pt. will not harm anyone, including Anne Stevens, for 6 months.
01/15/04
01/15/04
Target Date
1. Pt. will not harm anyone, including Anne Stevens, for 3 months.
07/15/03
07/15/03
3. Pt. will not make any threats toward anyone for 3 months.
07/15/03
07/15/03
10/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
335
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychology:
1. Psychologist will meet one-to-one with pt. for 1 hour weekly in cognitive therapy to
help pt. resolve his obsession with Anne Stevens.
2. Psychologist will lead the sex offenders group once weekly to help pt. gain insight into
the inappropriateness of his behaviors through the group process, as well as to help
him understand the legal consequences of his stalking behaviors.
Joseph LeBlanc, Psychologist
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
ADLOCCUPATIONAL SKILLS
(Problem Area 4)
41
43
ADLOCCUPATIONAL SKILLS
(Problem Area 4)
CONTENTS
Kennedy Axis V for ADLOccupational Skills............................................................................................ 44
This rating scale can be used to measure the outcome of treatment. It also helps to define which
problems fit into the category of ADLOccupational Skills and can be helpful in composing a short
description of each problem.
Strengths .................................................................................................................................................. 46
Examples of strengths that may be related to treatment and discharge in the area of ADLOccupational
Skills are listed here.
Goals ......................................................................................................................................................... 46
Examples of treatment goals that may relate to problems in the area of ADLOccupational Skills are listed
here.
44
II.
B.
C.
Other
1.
No examples given
General
1.
Lacks ability to perform self-preservation skills
2.
Lacks basic life survival skills
3.
Is unable to care for self
4.
Has dependent patient status
5.
Appears incapable of recognizing dangers
B.
Specific
1.
Eats in a manner that would lead to choking
2.
Has hazardous smoking habits
3.
Walks in front of cars due to a lack of understanding of the danger
4.
Wanders away
45
46
ADLOccupational Strengths
A.
B.
C.
D.
E.
F.
G.
H.
I.
Goals
I.
II.
Reporting of Symptoms
A.
Pt. will become more aware of ADL limitations AEB asking for help in areas where
needed for 1 month.
Pt. will participate in on-ward group activities for 5 minutes a day for 1 month.
Pt. will attend morning ward meetings twice per week for 1 month.
Pt. will attend one off-ward group activity per week for 4 weeks.
V.
47
B.
Treatment planning
1.
Pt. will cooperate with at least one treatment team member in the treatment planning process for
1 month.
2.
Pt. will cooperate with treatment plans, such as IQ testing and vocational evaluations.
3.
Pt. will consistently accept realistic plans for employment for 3 months.
C.
Program activities
1.
Pt. will gain insight into the need to attend program, AEB being able to consistently explain the
reasons for attending, for 1 month.
2.
Pt.s level of compliance will improve such that pt. will attend art therapy class twice a week for
1 month.
3.
Pt. will attend the programs recommended by the treatment plan on a regular basis for 1 month.
D.
Assessments
1.
Staff will complete rehabilitation assessment for appropriate day-program referral.
2.
Pt. will cooperate so that rehab staff can assess the degree to which apathy, lack of motivation, or
poor focal attention obscure ADL skills.
3.
Pt. will cooperate so that psychological testing can be completed.
B.
Kennedy Axis V
1.
Pt.s Kennedy Axis V score for ADLOccupational Skills will improve from a current score of 30 to
40.
B.
C.
VII. Miscellaneous
A.
Staff will maintain a safe, secure environment for (dependent) pt. while attempting to
maximize his or her functional ability.
48
Treatment Modalities
I.
II.
B.
C.
Psychotherapy
1.
Rehab staff will provide supportive, problem-solving psychotherapy to help pt. better cope with
problems on the job.
Positive reinforcement
1.
Nsg. staff will encourage pt. and provide verbal praise for performing on-ward work activities.
2.
Staff will reinforce with positive verbal praise pt.s positive behaviors, such as following through
with daily ADL requirements.
3.
Staff will give pt. encouragement for completion of multistep tasks in the absence of ritualistic or
other bizarre behavior.
4.
Staff will spend one-to-one time daily to encourage pt.s participation in vocational groups.
5.
Nsg. staff will accompany pt. into the bathroom to encourage and reinforce appropriate personal
hygiene habits.
6.
Staff will give pt. one extra cigarette as a reward for learning the steps of a fairly complicated
multistep task.
7.
Staff will positively reinforce pt. with canteen and cafeteria privileges for regular attendance at the
vocational training group.
B.
C.
Extinction
1.
Nsg. staff will limit their interactions with pt. when he or she fails to work on learning how to do
multistep tasks, such as making the bed and washing clothes.
D.
49
E.
Channeling energies
1.
Rehab staff will assist pt. to learn vocational skills so that pt. can get a job that will help pt.
channel potentially aggressive behavior into work.
2.
Rehab staff will assist pt. to learn vocational skills so that pt. can get a job that will help divert
pt.s energies into acceptable channels to reduce chronic hypersexual arousal and associated sexual
assaults.
F.
B.
C.
Other modalities
1.
Group therapy
a.
Group therapy will facilitate discussions of job-related problems.
2.
Psychodrama
a.
Role-playing for 1 hour once weekly will assist pt. in dealing with situational conflicts on the
job.
b.
Role-playing for 1 hour once weekly will teach pt. how to act during a job interview.
3.
Rehabilitation
a.
Staff will provide weekly counseling to identify work goals, to identify deficits in work skills,
and to develop plans for education and training needed to meet goals.
b.
Staff will involve pt. in the on-ward rehabilitation group at least once weekly.
c.
Staff will involve pt. in money management group for 1 hour once weekly, including
community banking.
d.
Assigned staff will redirect this dependent pt. away from decisions, plans, and actions that
place pt. in danger.
410
V.
A.
Stimulus reduction
1.
Rehab training should be in a quiet area because of pt.s easy distractibility.
B.
C.
Medication
1.
Staff will administer meds as prescribed.
2.
Staff will use prn meds to relieve pt. from acute episodes of tormenting hallucinations so pt. can
participate in prevocational training.
B.
Mental illness
1.
Staff will discuss with pt. ways of coping with mental illness while working.
B.
Medication
1.
Staff will discuss the risks and benefits of meds with the pt. and family.
2.
Staff will discuss one-to-one the need to take meds as prescribed, including how meds can
facilitate pt.s ability to participate in vocational programs.
3.
Staff will show concrete benefits of taking meds (e.g., You are able to stay focused and, therefore,
better able to benefit from vocational training, You are less paranoid on the job; therefore, you
are able to participate in on-the-job training).
C.
D.
411
Rehabilitation assessment
1.
Staff will assess pt.s work preferences and work skills.
2.
Staff will assess pt.s areas of greatest interests and motivation to begin occupational training
congruent with pt.s interests.
3.
Rehab staff will assess the degree that apathy, lack of motivation, and poor focal attention obscure
ADL skills.
4.
Staff will refer pt. to occupational therapist for formal assessment of ADL skills and interests.
5.
Pt. will participate in trial job period to assess pt.s job skills.
6.
Staff will use work hardening (slowly increasing hours and difficulty of task) to determine
endurance and skill level.
B.
C.
Psychiatric evaluations
1.
Staff will conduct psychotropic medication evaluation to assess the potential for medication to
facilitate pt.s ability to learn new ADL skills.
2.
Staff will conduct psychiatric evaluation to assess the degree that side effects of pt.s psychotropic
medication might be impairing pt.s ADL skills.
3.
Staff will provide neuropsychiatric consultation to assess the degree that factors related to pt.s
abnormal EEG might impair job performance.
D.
E.
Commitment
1.
Psychiatrist will seek court commitment under Sections 7 and 8 for a period up to 6 months
because of pt.s inability to care for self because of limited ADL skills.
B.
Guardianship
1.
Psychiatrist will seek permanent legal guardian to make decisions for pt. related to his or her
medical and psychiatric condition and estate.
Treatment of problems affecting ADLoccupational skills (This step is optional; instead, this
information may be included in the problem description.)
1.
Staff will treat pt.s lack of motivation to get out of bed and attend to personal hygiene, as
indicated under Problem 1.1 Psychotic Symptoms.
2.
Staff, as indicated, will treat pt.s marked lack of motivation and apathy under Problem 1.2 Lack of
Motivation.
3.
Staff will treat pt.s problems with interpersonal relations on the job as indicated under Problem
2.1 Poor Social Skills.
Notes
413
414
Date: 01/15/03
Problem Description:
Pt. has a history of many years of severe impairment of ADL skills due to long stays in institutions. Pt. needs
constant supervision to complete almost any task (e.g., dressing, preparing a simple meal, and returning from short
errands).
Implement treatment of withdrawn apathetic behavior and poor focal attention under Problem 1.1 Psychotic
Symptoms and Problem 1.2 Poor Focal Attention.
Target Date
1.
01/15/04
2.
01/15/04
Target Date
1.
Pt. will ask for things that he needs for his morning routine about
50% of the time for 1 month.
07/15/03
2.
10/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
415
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Staff will prepare the environment before the time of the ADL activities (e.g., have
clothes and self-care utensils ready).
2.
Staff will provide one-to-one modeling of ADL tasks (e.g., making his bed, choosing
clothes, and looking for utensils).
3.
Staff will encourage and praise pt. for successful completion of various ADL tasks.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
416
Date: 01/15/03
Problem Description:
Pt. has marked impaired ADL skills and needs supervision to perform even basic self-care skills; however, the
impairment appears to be mostly due to her apathy and disorganized thinking. With encouragement, she is able to
perform basic ADLs in self-care and housekeeping, such as preparing a small, simple meal, sewing on buttons, or
mending a tear.
Implement treatment of apathy and disorganized thinking under Problem 1.1 Psychotic Symptoms.
Target Date
Date/Status*
Target Date
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
417
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
Social Work:
Psychology:
Rehab:
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
418
Date: 01/15/03
Problem Description:
Pt. has held three jobs in the past 6 years; however, he was unable to keep any of the jobs for more than 1 month.
He was fired from one job for poor performance and quit the other two jobs because he didnt like them. Pt.
appears to lack many of the basic skills necessary to keep a job. Pt. has difficulty following instructions and
difficulty performing somewhat complicated tasks, such as running the copier, filing, and stocking shelves. Pt. also
has difficulty taking public transportation and is unable to drive a car.
Implement treatment of Problems 1.2 Lack of Motivation and 1.3 Poor Focal Attention.
Target Date
1.
Pt. will get and keep a part-time job (l6 to 20 hours per week) in a
competitive work environment for at least 6 months.
01/15/04
2.
01/15/04
Target Date
1.
02/15/03
2.
Pt. will be able to file 50 letters with no more than one misfile.
04/15/03
3.
04/15/03
4.
Pt. will work 10 hours per week in a work program of his choice
and will keep the job for at least 1 month.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
419
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Rehab:
1.
Pt. will participate in weekly individual and group counseling to identify deficits in
work adjustment in order to
a. Address deficits in work skills
b. Identify and plan for vocational goals
c. Determine education and training needed to meet goals
2.
Staff will identify job interests to help pt. choose an appropriate work program to
increase the probability of pt. keeping a job and developing needed work skills.
a. Pt. will complete interest testing to aid in vocational decision making.
b. Pt. will participate in a 2-week trial in a job of his choice for situational
assessment.
c. Individual vocational rehab counselor will assign work according to pt.s choice.
d. Vocational rehab counselor will monitor, address, and document work adjustment
issues on a daily basis.
3.
Work supervisor and peers will use role modeling and verbal praise to increase desired
work behaviors, such as using the copier and filing correspondence.
4.
Staff will use work hardening (slowly increasing hours and difficulty of task) to
determine pt.s endurance and skill level.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
420
Date: 01/15/03
Problem Description:
Pt. is generally unable to find her way around the hospital. If lost, it is felt that she may not be able to identify
herself or tell where she is from. It is feared that if given the opportunity she may wander away from the hospital.
Pt. appears to be able to safely cross streets; however, it is believed she is vulnerable to advances of strangers.
Without supervision, pt. does not respond to emergencies, such as fire alarms.
Implement treatment of Problem 2.1 Poor Social Skills.
Target Date
1.
01/15/05
2.
01/15/04
Target Date
1.
Pt. will be able to identify herself and her location once per day
for 1 month.
07/15/03
2.
Pt. will be able to lead staff to the hospital store and back to the
ward three times weekly for 1 month.
07/15/03
3.
01/15/04
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
421
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nsg. staff will maintain a safe, secure environment while attempting to maximize pt.s
functional ability.
2.
Nsg. staff will follow hospital procedure for dependent patients, including labeling the
outside of pt.s chart, notifying the proper authorities if pt. is missing, and the like.
3.
Nsg. staff will ensure that pt. wears an identification bracelet or tag at all times.
4.
Pt. contact will conduct off-ward training trips twice daily to teach pt. the route to the
hospital store and back.
5.
Pt. contact will spend 5 to 10 minutes per shift working with pt. to self-identify and to
give correct ward address.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
422
Date: 01/15/03
Problem Description:
Pt. has been a careless smoker for years. He often burns holes in his clothes, thus posing a health hazard.
1.
Target Date
Date/Status*
01/15/04
Target Date
1.
Pt. will use ashtray three out of five times he smokes without staff
cues for 1 month.
04/15/03
2.
Pt.s smoking will improve such that he will be able to wear one
set of clothes each day for 1 month without burning holes in
them.
04/15/03
3.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
423
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nsg. staff will reinforce the need for and use of an ashtray each time a cigarette is
given.
2.
Nsg. staff will remind patient not to burn holes in his clothes.
3.
If patient does not use an ashtray or if he reports for the next scheduled cigarette with
a hole in his clothes, his cigarettes will be withheld for 1 hour.
4.
If cigarettes are withheld, nsg. staff will explain why they are being held and will
remind pt. what smoking behaviors are necessary to continue hourly cigarette
schedule.
5.
Nsg. staff will educate pt. for hour once weekly to help pt. understand the dangers
associated with his careless use of cigarettes.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
SUBSTANCE ABUSE
(Problem Area 5)
51
53
SUBSTANCE ABUSE
(Problem Area 5)
CONTENTS
Kennedy Axis V for Substance Abuse ....................................................................................................... 54
This rating scale can be used to measure the outcome of treatment. It also helps to define which
problems fit into the category of Substance Abuse and can be helpful in composing a short description
of each problem.
Strengths .................................................................................................................................................. 55
Examples of strengths that may be related to treatment and discharge in the area of Sobriety are listed
here.
Goals ......................................................................................................................................................... 55
Examples of treatment goals that may relate to problems in the area of Substance Abuse are listed here.
54
40 Major impairment in several areas because of substance abuse (e.g., alcoholic man avoids
friends, neglects family, and is unable to get a job; student is failing in school and having serious conflicts with his
family or roommate due to substance abuse); occasionally injects heroin or cocaine into his/her veins; occasionally
has an accidental drug overdose; severe alcohol or drug abuser with less than 1 month of sobriety.
30 Drugs or alcohol pervade his/her thinking and behavior; his/her behavior is considerably
impaired by substance abuse; injects heroin or cocaine into his/her veins once or twice a day; abuses substances
without regard for personal safety (e.g., some accidental overdoses and/or auto accidents resulting in medical
hospitalizations); blackout spells; prostitutes self for drugs/alcohol; multiple alcohol- or drug-related arrests; serious
neglect of children due to substance abuse.
20 Functioning is extremely impaired by daily use of drugs such as LSD, PCP, cocaine, heroin,
or inhalants; unable to go for more than a few hours without significant physical and/or psychological craving
for drugs or alcohol; continued use of alcohol or drugs (other than cigarettes) is beginning to cause very
serious medical complications (e.g., liver failure, overt brain damage, AIDS or high risk for AIDS); injects drugs
into his/her veins more than twice a day.
55
II.
Examples
1.
Abuse of drugs, cigarettes, or alcohol
2.
Lack of insight into acute and chronic alcoholism
3.
Inability to quit the use of drugs, cigarettes, or alcohol despite desire to do so
4.
Addiction to caffeine
B.
Other
1.
Addiction to drinking excessive fluids (this problem is often included under Problem 1.1
Polydipsia, Problem 6.1 Hyponatremia Secondary to Polydipsia, or both)
Problems Associated With Substance Abuse (substance abuse often leads to other acute
or chronic problems that might be addressed under their particular problem area[s])
A.
Examples
1.
Continued abuse of drugs, cigarettes, or alcohol despite acute or chronic medical problems caused
by them
2.
Inability to quit cigarettes despite physical damage from cigarettes
3.
Multiple accidental overdoses of drugs or alcohol
4.
Hypomania triggered by excessive caffeine intake
5.
Depression and suicidal ideation secondary to chronic alcohol abuse
Goals
I.
56
II.
Reporting of Symptoms
A.
B.
C.
Pt. will consistently discuss with staff his or her impulse to use drugs or alcohol for
1 month.
Pt. will consistently disclose to staff occasions on which pt. broke his or her agreement
not to abuse drugs or alcohol for 3 months.
Pt. will agree to sign a contract that pt. will not abuse alcohol when on pass.
Pt. will attend the programs recommended by the treatment plan, including AA
meetings, 4 out of 5 weekdays for 3 months.
Pt. will participate in weekly AA and substance abuse discussion groups within the
hospital for 1 month.
V.
A.
B.
Treatment planning
1.
Pt. will cooperate with at least one treatment team member in the treatment planning process
consistently for 1 month.
2.
Pt. will be willing to participate in the evaluation process.
3.
Pt. will explore potential resources and support systems available in the community.
4.
Pt. will verbalize that participation in the work program will help to improve self-esteem, reduce
boredom, and channel excess energy away from alcohol.
C.
Program activities
1.
Pt. will verbalize the benefits of attending program activities.
D.
Consequences of actions
1.
Pt. will be able to verbalize an understanding of the connections among the following:
a.
Continued drug or alcohol abuse and continued deterioration of ones lifestyle and rejection
by family and friends;
b.
Continued abuse of illegal drugs and continued conflicts with the law;
c.
Continued abuse and neglect of basic health needs and reoccurring physical illnesses;
d.
Substance abuse, AIDS, and other serious health problems;
e.
Substance abuse and inability to retain a job; and
f.
Alcohol abuse and worsening of depression.
Assessments
1.
Pt. will cooperate with the evaluation process.
2.
Pt. will consistently cooperate with urine toxicology screens when substance abuse is suspected for
3 months.
3.
Pt. will complete rehabilitation assessment for appropriate day-program referral.
B.
57
Kennedy Axis V
1.
Pt.s Kennedy Axis V score for Substance Abuse will improve from a current score of 50 to 70.
VII. Miscellaneous
A.
B.
Pt. will seek a discharge environment free of street drugs and alcohol.
Pt. will work for a company that stresses employee health, including smoking cessation
and abstinence of alcohol for those with an alcohol problem.
Treatment Modalities
I.
B.
Cognitive refocusing (redirect focus away from things that support substance abuse and
toward things that support sobriety)
1.
Psychologist will meet with pt. once a week to direct pt. toward considering methods other than
drinking for dealing with depression and anxiety.
2.
Staff will help pt. recognize and express self-worth (e.g., compliment pt. when his or her
appearance improves to bolster self-esteem and engage pt. in activities that pt. can succeed in and
feel comfortable doing without needing alcohol).
3.
Staff will maximize structured activities to minimize preoccupation with drugs and to help pt. stay
focused on alternative behaviors. This refocusing can be done by maximizing pt.s involvement in
structured day programs, including open workshop, patient wage program, leisure interest group,
and community meeting.
C.
Psychotherapy
1.
Staff will provide pt. with one-to-one, insight-oriented psychotherapy once a week to help pt.
uncover the reasons why he or she turns to alcohol to cope with problems.
2.
Psychologist will provide supportive, problem-solving psychotherapy to help pt. find alternatives
to substance abuse for coping with lifes problems.
58
II.
Positive reinforcement
1.
Ward staff will encourage and give verbal praise for pt.s involvement in non-drug-related social
activities.
2.
Staff will provide ongoing verbal reinforcement for pt.s decision to stop drinking.
3.
Staff will reinforce with positive verbal praise pt.s positive behaviors, such as taking on
responsibilities and attempting self-discipline.
4.
Staff will positively reinforce pt. with trips to the canteen for involvement in the treatment
planning process.
5.
Nsg. staff will provide frequent encouragement for pt. to attend to personal hygiene and
appearance.
B.
C.
Extinction
1.
Nsg. staff members will limit their interactions with pt. when pt. fails to work on means of
controlling impulses to abuse drugs and alcohol.
D.
E.
Channeling energies
1.
Pt. will be placed in a job as a salesperson at a retail store to divert pt.s hyperactivity and high
level of energy from drug dealing to more socially acceptable behaviors.
2.
Staff will encourage pt. to spontaneously report urges to drink and will discuss alternatives to help
manage these urges.
F.
B.
C.
D.
59
Other modalities
1.
Psychodrama
a.
Staff will use psychodrama to assist pt. to be able to say No when pressured by peers to use
drugs.
2.
Termination
a.
Pt. will be terminated from the program if, after 1 week, pt. shows no significant motivation
for change.
b.
Pt will be readmitted when his or her drug lifestyle is painful enough for pt. to want to
change.
3.
Significant other
a.
Staff will explore whether a significant other, such as pt.s fianc(e), will help pt. follow
through with a commitment to stopping drinking.
V.
A.
Stimulus reduction
1.
Staff will restrict pt. from associates and areas that have triggered drug use in the past.
2.
Staff will work at identifying and reducing triggering cues.
3.
Dietitian will work with pt. to identify eating habits that trigger smoking (or drinking).
4.
Staff will work with pt. for 1 hour once weekly to reduce cues that trigger substance abuse.
B.
C.
Medical Treatments
A.
Medication
1.
Staff will gradually reduce medication doses as prescribed to detox pt. off drugs and alcohol.
2.
Staff will administer vitamin supplement as prescribed.
3.
Staff will place pt. on methadone maintenance.
4.
Staff will place pt. on Antabuse (disulfiram) to help prevent relapse back into alcohol use.
5.
Staff will place pt. on nicotine gum or nicotine patch to reduce craving for cigarettes.
B.
510
Mental illness
1.
Staff will discuss with pt. his or her addiction to drugs and alcohol.
2.
Staff will discuss with pt.s family the nature of pt.s addiction and the fact that pt. will not be able
to stop the abuse of drugs by himself or herself.
B.
Medication
1.
Staff will discuss with pt. the process of detoxification using methadone.
2.
Staff will discuss with the pt. and family the use of drugs like methadone and Antabuse
(disulfiram) in an aftercare program.
C.
D.
B.
Psychiatric evaluations
1.
Staff will conduct a psychiatric diagnostic evaluation to R/O an underlying psychiatric illness that
pt. is self-medicating with drug abuse.
2.
Staff will conduct a psychiatric evaluation to help determine whether pt. would be better treated
in a psychiatric facility or in a drug treatment program.
C.
D.
511
Court commitment
1.
Staff will initiate petition for mandatory substance abuse treatment.
Treatment of related problems (This is optional and can be included with the treatment
modalities or in the problem description.)
1.
Staff will treat the hopelessness and despair associated with pt.s alcoholism as indicated under
Problem 1.1 Depressive Symptoms.
2.
Staff will treat pt.s chronic hepatitis as outlined under Problem 6.1 Chronic Hepatitis.
512
Date: 01/15/03
Problem Description:
1.
Response to previous and current treatments and expected response to any proposed treatments
Precipitants (e.g., lifestyle, peer pressure, depression, anxiety, losses, other stress, boredom)
Characteristics, frequency, intensity, and variance of substance abuse behavior, including types, quantities,
and frequency of use of drugs or alcohol
Current level of substance abuse, urges to abuse substances, preoccupation with substance abuse
Barriers to treatment, such as minimizing ones problem with substance abuse, poor motivation
2.
Make sure that the above relate to goals and treatment modalities.
3.
The description and treatment of any depressive or anxious symptoms that may be driving pt.s impulses to
abuse drugs or alcohol should be addressed in Problem Area 1 Psychological Impairment and violence
secondary to substance abuse in Problem Area 3 Violence.
Target Date
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
513
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for ___ minutes at least ___ time(s) weekly/monthly to
monitor any changes in intensity of impulses to abuse drugs/alcohol and to prescribe
treatments that may help reduce the craving or sense of need for drugs/alcohol such as
___________________________. Labs as ordered, including urine toxicology screens.
Virginia Coleman, MD
Social Work:
1. Social worker will meet with pt. for ___ minutes at least ___ time(s) weekly/monthly to
help pt. understand how his or her impulses to abuse drugs or alcohol act as a barrier
to pt.s discharge.
Brenda St. Martin, MSW
Rehab:
1. Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ time(s)
weekly/monthly to review and revise pt.s daily treatment schedule and will refer pt.
to appropriate groups working to improve his or her problem with drugs/alcohol.
2. Pt. will attend AA/Narcotics Anonymous meetings ___ time(s) a week/month to learn
more about substance abuse risk factors and how to avoid them. See weekly schedule
for substance abuse programs.
Jane Hoover, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
515
516
Date: 01/15/03
Problem Description:
Pt. has a history of several years of abusing substances, including alcohol, marijuana, and cocaine. At first, patient
denied abuse of drugs and alcohol; however, her extensive substance abuse problem quickly became apparent.
Abuse of drugs and alcohol appears to pervade her thinking and behavior. When given privileges, pt. would
frequently go AWA to get alcohol. During these periods, pt. places herself in potentially dangerous situations. Staff
feels that if given the opportunity, pt. would abuse drugs and alcohol on a daily basis. Pt.s drivers license was
revoked last year because of driving under the influence. In part, pt.s substance abuse is seen as a method of
blocking out her feelings of low self-esteem. She has not used any drugs IV.
Pt.s low self-esteem, which appears to be a factor in her substance abuse, will be treated as indicated under
Problem Area 1.1 Depressive Symptoms.
Target Date
07/15/03
2. The pt.s Kennedy Axis V score for Substance Abuse will improve
from a current score of 35 to 55.
07/15/03
Target Date
1. Pt. will accurately discuss with staff her impulses to use drugs and
alcohol for 1 month.
04/15/03
04/15/03
04/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
517
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for at least 1 hours each month to monitor any
changes in intensity of impulses to abuse drugs and alcohol.
2. Staff will consider prescribing medication to reduce craving for substance abuse, such
as naltrexone.
3. Psychiatrist will order urine toxicology screens to help ensure that pt. is not abusing
substances.
4. Pt. will be restricted to supervised privileges for 1 week if she returns to the ward
intoxicated or if she has a positive urine toxicology screen. During that period, staff
will reassess pt.s commitment to sobriety, the treatment plan, and her level of
dangerousness in the community.
Victor Dyson, MD
Psychology:
1. Psychologist will meet one-to-one with pt. to direct her toward methods other than
substance abuse for relieving her depression and anxiety.
2. Staff will refer pt. to and encourage her to attend AA meetings and substance abuse
disorders group at least twice weekly in the hospital.
Joseph LeBlanc, Psychologist
Rehab:
1. Pt. will work in hospital cafe 4 hours each workday to help pt. stay focused on
alternatives to substance abuse and to improve her self-esteem.
2. Rehab staff will lead the relapse prevention group for 1 hour weekly to help pt. learn
about substance abuse risk factors and how to avoid them.
Jane Hoover, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
518
Date: 01/15/03
Problem Description:
Pt. was recently transferred from our Psychiatric Acute Treatment Unit to our Substance Abuse Treatment Unit. Pt.
began abusing alcohol and marijuana around age 15. His episodic but persistent abuse of alcohol and marijuana
invariably leads to a worsening of his psychiatric symptoms. This abuse clearly impairs his functioning in his
community residence and his day treatment program. This abuse has led to multiple psychiatric hospitalizations,
including the present.
Target Date
Date/Status*
01/15/04
Target Date
04/15/03
07/15/03
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
519
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will lead medication and mental illness education group weekly to help pt.
to learn about the interaction between mental illness and substance abuse disorder.
2. Psychiatrist will monitor and document episodes of substance abuse and provide
medical/detox interventions as ordered.
Victor Dyson, MD
Social Work:
1. Social worker will lead weekly community transition group to help pt. develop plans
around living in the community and to identify support systems and resources that he
can use when he is out of the hospital.
Brenda St. Martin, MSW
Psychology/Social Work:
1. Psychologist and social worker will lead twice-weekly on-ward substance abuse group
to help pt. learn about problems created by substance abuse and to develop supports,
strategies, and alternatives to substance abuse.
2. Psychologist and social worker will lead weekly relapse prevention group for pt. to
learn ways of preventing relapse of both mental illness and substance abuse.
Joseph LeBlanc, Psychologist
Brenda St. Martin, MSW
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
520
Date: 01/15/03
Problem Description:
Pt. has been smoking one to two packs of cigarettes per day for the past 10 years. Pt. has recently begun to
experience shortness of breath. Pt. has also begun to experience a persistent, dry cough, and she occasionally
experiences upset stomach and chest tightness on days when her smoking is especially heavy (two packs per day).
Pt. has expressed a strong desire to cut down or stop smoking, but past attempts have been unsuccessful.
Target Date
Date/Status*
07/15/03
Target Date
1. Pt. will begin eating meals and snacks that are less likely to be
connected with previous patterns of smoking for 1 month.
04/15/03
2. Pt. will increase her interest in and awareness of health issues AEB
her participation in an exercise group three times a week for
1 month.
04/15/03
3. Pt. will work with a significant other for at least 1 month to help
ensure that she will follow through with stopping smoking.
04/15/03
04/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
521
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for 15 minutes once weekly to assess any changes in
pt.s craving for cigarettes and to prescribe treatments, such as nicotine gum or
nicotine patch, that will help to reduce episodes of cigarette craving.
Victor Dyson, MD
Psychology:
1. Psychologist will meet with pt. for hour once a week to identify sources of potential
relapse (e.g., cues and triggers for smoking) and to develop coping strategies to reduce
risks of returning to smoking.
2. Psychologist will run the clinic self-help group, where pt. can obtain further
information regarding the problems associated with cigarette smoking and also obtain
peer reinforcement around the decision to stop smoking and to not restart.
Joseph LeBlanc, Psychologist
Social Work:
1. Staff will explore whether a significant other, such as her fianc, will help pt. follow
through with her commitment to stop smoking.
Brenda St. Martin, MSW
Rehab:
1. Staff will work with pt. to plan and implement an individualized program to focus on
good health maintenance, including physical fitness exercises and smoking cessation.
Jane Hoover, Rehab
Dietitian:
1. Dietitian will work with pt. to identify eating habits that trigger smoking. As the
triggers are identified, the dietitian will help pt. develop eating habits that are less
connected with previous patterns of cigarette smoking.
Louise Tallo, Dietitian
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
MEDICAL IMPAIRMENT
(Problem Area 6)
61
63
MEDICAL IMPAIRMENT
(Problem Area 6)
CONTENTS
Kennedy Axis V for Medical Impairment.................................................................................................. 64
This rating scale can be used to measure the outcome of treatment. It also helps to define the problems
that fit into the category of Medical Impairment and can be helpful in composing a short description of
each problem.
Strengths .................................................................................................................................................. 66
Examples of strengths that may be related to treatment and discharge in the area of Medical Strengths
are listed here.
Goals ......................................................................................................................................................... 66
Examples of treatment goals that may relate to problems in the area of Medical Impairment are
listed here.
64
70 Mild medical problems which may cause some difficulty in social, occupational, or school
functioning; however, generally functioning fairly well; missing no more than about 1 to 2 weeks a year from
work or school due to medical problems; mild impairment in mobility, speech, use of hands, vision, or hearing
despite use of prosthesis, glasses, hearing aids, and the like; has chronic illness but has few if any overt signs or
symptoms of the illness (e.g., mild asthma, mild hypertension, mild diabetes, mild arthritis; mild dysphagia;
epilepsy easily controlled with medication; mild tardive dyskinesia); requires medical follow-up several times a
year; takes prescription medication on a daily basis.
40 Major impairment in several areas (such as work or school or family relations) because of medical
problems; missing about 2 months a year or more from work or school due to medical problems; medical problems
result in major impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses,
hearing aids, and the like; frequently confined to bed or wheelchair because of chronic medical problems.
30 Behavior and/or lifestyle is considerably impaired by medical problems; very serious medical
problems confine him/her to bed or wheelchair most of the time (e.g., very symptomatic cases of diseases such as
metastatic cancer, multiple sclerosis, cerebral palsy, or AIDS); chronic failure of a major body system (e.g., heart,
lung, kidney, liver); on dialysis for kidney failure.
20 Major medical problems confine him/her to bed all of the time and intensive, continuous
medical treatment is required without which he/she would rapidly progress to death (e.g., late stages of metastatic
cancer, multiple sclerosis, AIDS, and the like); chronic, near terminal failure of a major body system (e.g., heart,
lung, kidney, liver); quadriplegic.
10 Chronic medical incapacity requiring basic life support (e.g., ventilator); removal of life support
would rapidly lead to death; he/she is in chronic vegetative or near vegetative state; persistent delirium or coma.
NR Not rated
65
II.
B.
C.
Pt.
Pt.
Pt.
Pt.
Pt.
is pregnant.
uses birth control.
has a single kidney.
is a carrier of an unexpressed genetic disease.
has mitral valve prolapse.
66
Multiple caries
Abscessed tooth
Gingivitis
Poor dental maintenance
Medical Strengths
A.
B.
C.
D.
E.
F.
G.
H.
Pt.
Pt.
Pt.
Pt.
Pt.
Pt.
Pt.
Pt.
Goals
I.
B.
II.
67
Reporting of Symptoms
A.
B.
C.
Pt. will participate in the physical therapy program once weekly for 1 month.
Pt. will attend speech therapy sessions twice weekly for 1 month.
Pt. will cooperate with dental work for the next three scheduled appointments.
V.
A.
B.
Treatment planning
1.
Pt. will consistently cooperate with at least one treatment team member in the treatment
planning process for 1 month.
2.
Pt. will cooperate with the treatment plan to restrict fluid intake for 1 week.
3.
Pt. will demonstrate cooperation with all aspects of the treatment plan for 1 month.
C.
Program activities
1.
Pt. will express the benefits of attending the physical therapy program.
Assessments
1.
Pt. will cooperate with the evaluation process for 2 weeks.
2.
Pt. will cooperate to complete the physical therapy assessment.
3.
Pt. will cooperate so that staff can determine the level of nursing care required for placement in
the community.
B.
C.
Laboratory tests
1.
Pt. will cooperate to complete the comprehensive laboratory screen.
2.
Pt. will cooperate to complete the EEG and CT scan.
3.
Pt. will cooperate to complete the ECG.
B.
Mini-Mental State
1.
Pt.s score on the Mini-Mental State will improve from a current score of 12 to 18.
C.
Laboratory tests
1.
Pt.s FBS will remain WNL for 3 months.
2.
Pt.s thyroid function will remain WNL for 6 months.
68
VII. Miscellaneous
A.
B.
Pt. will cooperate so that he or she can remain in an environment that protects the pt.
during the healing process.
Pt. will cooperate with the competency assessment to determine whether pt. is able to
make competent decisions about medical treatments.
Treatment Modalities
Because of the extremely broad range of the category Medical Impairment, only a brief outline of treatment
modalities is presented here. This outline focuses on the psychiatric aspects of the medical treatments. Additional
examples of treatment modalities for Medical Impairment are included on the sample Individual Problem Plans for
Medical Impairment.
I.
II.
Positive reinforcement
1.
Nsg. staff will give pt. positive feedback and encouragement for appropriate statements and
decisions concerning pt.s physical health.
2.
Staff will encourage pt.s independence by giving pt. as much decision-making power as possible.
3.
Psychologist will encourage pt. to be involved in the treatment planning process.
B.
C.
Other modalities
1.
Group therapy
a.
Group therapy will be used to facilitate discussion of pt.s medical problems.
2.
Psychodrama
a.
Role-playing will be used to help reduce pt.s anxiety about talking about his or her illness,
including the prognosis.
69
V.
A.
Stimulus reduction
1.
Staff will redirect pt. from triggering events or overstimulating areas to reduce stress that may
worsen pt.s physical symptoms.
2.
Sound-absorbing material will be added to pt.s dorm area to help reduce noise.
3.
Nsg. staff will redirect other pts. from yelling, talking loudly, or playing their radios too loudly
near patient, to help pt. relax while healing.
B.
C.
Medication
1.
Internist will prescribe meds as indicated for pt.s physical illness.
2.
Nsg. staff will give pt. prn meds to relieve acute exacerbations of illness.
3.
Psychiatrist will reduce antipsychotic meds to the lowest reasonable dose to minimize danger of
tardive dyskinesia.
B.
Medical illness
1.
Nsg. staff will educate pt. about ways to cope with medical illness.
2.
Nsg. staff will meet with the pt. and family once weekly for hour to teach them ways to
recognize signs of deterioration and other medical dangers.
3.
Internist will discuss with the pt. and family the nature of pt.s medical illness and the prognosis.
B.
Medication
1.
Nsg. staff will educate pt. about the risks and benefits of meds.
2.
Nsg. staff will show pt. concrete benefits of taking meds (e.g., The infection is clearing, You are
looking less pale, Your breathing is a lot less labored).
3.
Pt.s nurse or internist will discuss with pt.s family the reasons pt. needs to take meds.
610
C.
D.
B.
Psychiatric evaluations
1.
Staff will conduct a psychiatric diagnostic evaluation.
2.
Psychiatrist will perform a psychopharmacological assessment.
3.
Psychiatrist will perform an AIMS or AIMS Plus EPS exam every 6 months.
4.
Staff will measure EPS weekly using the AIMS Plus EPS to observe for reductions in pt.s EPS as
Risperdal is decreased.
C.
D.
E.
Medical guardianship
1.
Psychiatrist will seek a medical guardianship to obtain permission for the needed surgery.
No examples given
611
612
Date: 01/15/03
Problem Description:
1.
Enter any significant medical history, unless it is addressed under a separate problem.
2.
List any active or significant medical problems and any meds or treatment the pt. is taking, such as
prophylactic meds, multivitamins, aspirin, and such.
3.
List minor problems (such as acne, constipation, indigestion, mild obesity, mild hyperlipidemia, mild
dysphagia, mild hyponatremia, mild dehydration, mild hypertension).
4.
5.
6.
7.
If the treatment of a particular medical problem is very complicated, use a separate problem plan to address
that problem, such as an active breast cancer, severe diabetes, severe obesity, severe dysphagia, severe chronic
obstructive pulmonary disease (COPD), or difficult-to-manage seizure disorder.
1.
2.
3.
Pt. will comply with meds, treatments, and diagnostic tests for
pt.s medical problems for ____ month(s).
4.
Pt. will perform good basic facial cleansing daily with one verbal
prompt for ____ month(s).
5.
6.
7.
8.
9.
10.
Target Date
Date/Status*
Ongoing
Ongoing
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
613
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Medical:
1.
2.
Virginia Coleman, MD
Nsg. staff will monitor pt. daily and follow up on any signs and symptoms of illness.
2.
Nsg. staff will administer all prescribed meds and treatments as ordered and will
document pt.s compliance.
3.
Nsg. staff will assess and document pt.s level of understanding of prescribed
treatment and provide necessary teaching at pt.s level of understanding.
4.
Nsg. staff will prompt pt. to comply with treatments, lab work, and any other
medical procedures. If needed, nsg. staff will support and accompany pt. to
procedures. Staff will offer praise for compliance and will document compliance.
5.
Nsg. staff will prompt pt. to attend to basic daily personal hygiene, including bathing,
facial cleansing, shaving, combing hair, brushing teeth, and putting on clean clothes.
Staff will offer praise for compliance.
6.
Nsg. staff will weigh pt. q____________, take BP and pulse q_______________, and
report any significant changes to physician.
7.
Nsg. staff will monitor pt.s fluid and food intake and urine output and will report
any significant changes to physician.
8.
Nsg. staff will encourage pt. to eat a [healthy-heart, low-fat, low-cholesterol, low-salt,
high-fiber, low- or high-calorie], [whole, chopped, ground] diet and increase or
decrease fluid intake to prevent [constipation, hyponatremia, dehydration], promote
a healthy heart, reduce or gain weight, or maintain good health.
9.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
615
616
Date: 01/15/03
Problem Description:
Pt. has had hypertension for the last several years. His hypertension has been well controlled with a combination
of diet, exercise, and meds. This has led to a resolution of pt.s mild obesity. There is no history of alcohol abuse or
cigarette use. Pt.s family history is strongly positive for hypertension and heart disease. Pt.s cholesterol and
triglycerides are WNL.
1.
1.
Target Date
Date/Status*
Ongoing
Target Date
Date/Status*
Ongoing
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
617
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
2.
Internist will order blood work, including potassium and cholesterol levels.
3.
4.
5.
Donald Mason, MD
Dietitian:
1.
Dietitian will meet with pt. once a week to help pt. continue with his healthy-heart,
low-sodium diet.
2.
Dietitian will help pt. monitor calories to help ensure that pt. maintains his weight
loss.
Rehab:
1.
Rehab counselor will arrange a regular exercise program for pt. that he can safely
tolerate.
2.
Nsg. staff will make ongoing observations of skin color, swelling, and temp. for
evidence of edema or peripheral vascular disease.
3.
Nsg. staff will continue to educate pt. to help him understand, recognize, and
continue to reduce some of the underlying risk factors, such as lack of exercise, poor
diet, and psychological stress.
4.
Nsg. staff will ensure that pt. has routine follow-ups with the internist.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
618
Problem Description:
Pt. has long-standing history of cigarette use (one to two packs a day). Six months ago, she was diagnosed as
having COPD secondary to cigarette smoking. To prevent further deterioration in her respiratory status, she
stopped smoking at that time; however, at times, pt. appears to have difficulty maintaining her abstinence from
cigarettes. At present, pt. walks freely about the ward with no significant evidence of shortness of breath; however,
pt. has great difficulty walking up a flight of stairs. Over the last few months, pt.s pulse ox has been around 94%.
Target Date
1.
01/15/04
2.
Ongoing
1.
Target Date
Date/Status*
Date/Status*
04/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
619
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will prescribe bronchodilators, such as albuterol, and other respiratory meds
as ordered.
Margaret Patel, MD
Rehab:
1.
Rehab staff will provide activities as tolerated and provide an opportunity for rest as
needed.
Nsg. staff will make ongoing observations for evidence of respiratory distress,
including changes in pt.s skin color.
2.
Nsg. staff will assess pt.s breath sounds weekly, as well as when she is showing any
respiratory distress.
3.
Nsg. staff will use the pulse oximeter to measure pt.s blood oxygenation (pulse ox)
once daily.
4.
Nsg. staff will notify pt.s internist of any significant change in pt.s pulmonary
function.
5.
Nsg. staff will schedule pt. for routine follow-up at Pulmonary Clinic.
6.
Nsg. staff will encourage pt. to breathe deeply and to have a reasonable fluid intake.
7.
Nsg. staff will educate pt. to help her understand, recognize, and attempt to reduce
some of the underlying risk factors, such as smoking, air pollution, allergies
(including high pollen count), lack of exercise, and dehydration.
8.
Nsg. staff will educate pt. to help her understand and deal with the long-term aspects
of her COPD.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
620
Date: 01/15/03
Problem Description:
Pt. is a 48-year-old man who has had diabetes for the last 10 years. There is no known etiology of his diabetes,
other than having a family history that is strongly positive for adult-onset diabetes. When first diagnosed, his
diabetes was controlled with diet and low doses of oral hypoglycemics. However, for the last few years, pt. has
required insulin to control his blood sugar. Currently, pt.s diabetes is well controlled with diet and insulin;
however, pt. does not appear to have a good understanding of his diabetes and its possible complications.
Target Date
1.
Pt. will maintain good control of his diabetes, AEB normal blood
sugars, including absence of hyperglycemic and hypoglycemic
episodes, for 6 months.
Ongoing
2.
01/15/04
1.
Target Date
Date/Status*
Date/Status*
07/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
621
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will order blood sugar levels, including finger-stick blood sugar levels.
2.
Based on pt.s blood sugar levels, internist will make needed adjustments in pt.s
regular insulin dosage and adjust pt.s Insulin Sliding Scale as needed.
3.
Internist will order periodic complete blood workup; urinalysis, including sugar and
acetone levels; ECG; and chest X ray.
4.
Margaret Patel, MD
Nsg. staff will monitor pt. for evidence that he is developing diabetic complications.
2.
Nsg. staff will monitor pt.s finger-stick blood sugars and make adjustments in his
insulin according to pt.s Insulin Sliding Scale.
3.
4.
5.
Nsg. staff will run diabetic group 45 minutes per week for pt. education with regard
to the diabetic condition, nutrition, insulin, and risk factors and complications
associated with diabetes and insulin.
6.
Nsg. staff will ensure that pt. is seen in Podiatry Clinic at least once q 3 months.
Dietitian:
1.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
622
Date: 01/15/03
Problem Description:
Pt. has a history of elevated cholesterol that was first detected in 07/02. Pt.s cholesterol level at that time was 276.
Pt.s diet was very high in cholesterol and saturated fats. Nursing attempts to get pt. to stick to a low-cholesterol
diet led to a reduction of pt.s cholesterol level to around 240. Currently it is felt that pt. could benefit from
cholesterol-lowering meds, in addition to continuing his diet. Pt. does not have a good understanding of the
relationship between cholesterol and heart disease. Pt.s family history is strongly positive for cardiovascular
disease. Pt.s mother also has elevated cholesterol.
1.
Pt. will achieve and maintain normal blood cholesterol level for
at least 3 months.
Target Date
Date/Status*
07/15/03
Target Date
1.
04/15/03
2.
04/15/03
3.
04/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
623
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will order periodic blood cholesterol levels and lipid profiles.
2.
Internist will order a dietary consult for follow-up of pt.s low-fat, low-cholesterol
diet.
3.
Internist will prescribe cholesterol-lowering meds, such as niacin (vitamin B3), Lipitor
(atorvastatin calcium), or Zocor (simvastatin).
Donald Mason, MD
Dietitian:
1.
Dietitian will educate pt. on how to identify and avoid foods that are high in
cholesterol and saturated fats, as well as how to identify foods that are a part of a
low-fat, low-cholesterol diet.
Nsg. staff will educate pt. as to the importance of dietary compliance and help him
limit his intake of foods that are high in cholesterol and saturated fats.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
624
Problem Description:
Pt. has been on lithium for many years with associated hypothyroidism. Endocrinology workup diagnosed the
problem as hypothyroidism secondary to lithium. Pt. is on thyroid replacement meds (Synthroid) and is currently
euthyroid. She does not have a goiter. Pt.s psychiatric symptoms are clearly improved by lithium, and alternatives
to lithium are less effective. At times, pt. is reluctant to take her Synthroid because she has experienced very few
symptoms of hypothyroidism; therefore, she often argues that she does not have any problems with her thyroid
function.
1.
Target Date
Date/Status*
Ongoing
Target Date
1.
Ongoing
2.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
625
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
2.
3.
Internist will prescribe thyroid replacement medication, such as Synthroid, and adjust
the dose based on pt.s thyroid function studies.
Margaret Patel, MD
Nsg. staff will educate pt. for hour once weekly to help pt. understand the need to
take her thyroid replacement meds.
2.
Nsg. staff will monitor pt. for evidence of hyperthyroidism and inform pt.s internist
of any significant findings.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
626
Date: 01/15/03
Problem Description:
Pt. has had seizures since age 12, including grand mal seizures that occurred 1 to 2 times a month. The seizure
activity was present at the same frequency for years despite various attempts to reduce the frequency. EEGs
revealed multiple epileptic foci. Over the last few years, using a combination of anticonvulsants, the frequency of
seizures has stabilized at the current level of less than once every 6 months. At times in the past, pt. was reluctant
to take his anticonvulsants; however, currently he appears to have a fairly good understanding of the need to
continue his anticonvulsants.
1.
Target Date
Date/Status*
Ongoing
Target Date
1.
Ongoing
2.
Ongoing
3.
Ongoing
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
627
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
2.
Internist will order periodic serum blood levels, such as Depakote (divalproex sodium)
levels.
3.
Internist will refer pt. for follow-up appointments as needed with a neurologist.
Margaret Patel, MD
Nsg. staff will lead seizure group once per week to help pt. maintain an
understanding of his seizure disorder and the need to take his meds.
2.
Nsg. staff will keep a flow sheet on the frequency of pt.s seizures and will inform the
internist of any increase in the frequency of pt.s seizures.
Linda Larkin, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
628
Problem Description:
Pt. has a long history of drinking water and other fluids to a dangerous excess, which results in electrolyte
imbalances. There appears to be no organic basis for the polydipsia. Two years ago, this resulted in seizures when
her blood Na+ dropped to 124 (pt. has a seizure disorder that is well controlled by anticonvulsants when pt.s Na+
is above 130). Through monitoring and encouraging pt. to limit her fluid intake, pt. has not had seizures for years.
With monitoring, including twice-weekly Na+ levels, her Na+ is generally 134 or greater. Because of drops in her
Na+ below 130, she requires one-to-one monitoring once or twice every 6 months. Pt. appears to have a reasonable
understanding of the risk factors associated with polydipsia and the treatment modalities; however, she constantly
complains of being thirsty.
Target Date
1.
Pt. will maintain a Na+ of 130 or greater so that she will not
require one-to-one monitoring for 6 months.
01/15/04
2.
01/15/04
Target Date
1.
07/15/03
2.
Pt. will not gain 8 pounds or more during a 24-hour period for
3 months.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
629
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will order electrolytes twice weeklydaily if Na+ falls below 130.
2.
Internist will restrict pt. to the ward and place pt. on one-to-one monitoring if Na+
falls below 130.
Margaret Patel, MD
Nsg. staff will encourage pt. to limit her fluid intake and to eat solid foods and foods
high in Na+.
2.
3.
Nsg. staff will restrict pt. to the ward if pt. gains 8 pounds during a 12-hour period
and will have a blood Na+ drawn immediately.
4.
Nsg. staff will restrict pt. to the ward, place pt. on one-to-one monitoring, and restrict
pt.s fluid intake to 2000 cc/24 hrs if Na+ falls below 130.
5.
When pt. is restricted to the ward, nsg. staff will maintain intake/output records and
pt.s Na+ level will be drawn q day.
6.
Nsg. staff will provide positive reenforcement when pt. is able to maintain her blood
Na+ level at 134 or greater.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
630
Problem Description:
During a period of dehydration in association with a weight reduction diet, pt. developed lithium toxicity. Pt. had
been toxic once before in the past, in association with skipping blood lithium levels. During the toxic episode, pt.
was immediately taken off the lithium. Following the toxic episode, it was noted that pt. had developed diabetes
insipidus secondary to lithium toxicity. Pt. is currently off lithium, and fortunately her diabetes insipidus is
expected to resolve. Pt.s manic, aggressive behavior is being reasonably well controlled with a mood stabilizer,
Depakote. There are no plans at present to restart lithium because of pt.s difficulty following up with her diet and
blood tests required for lithium.
Target Date
1.
01/15/04
2.
01/15/04
1.
Pt. will have a normal blood Na+, BUN, and creatinine for
3 months.
Target Date
Date/Status*
Date/Status*
07/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
631
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
2.
Internist will monitor progress of diabetes insipidus and check for evidence of renal
failure with monthly electrolytes, BUN, and creatinine.
3.
4.
Margaret Patel, MD
Nsg. staff will ensure that pt. has adequate fluid intake to keep up with fluid loss.
2.
Nsg. staff will use an intake and output chart to monitor pt.s fluid intake.
Dietitian:
1.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
632
Date: 01/15/03
Problem Description:
Pt. has been noted to have difficulty swallowing, which appears to have been worsened by the use of neuroleptic
meds. Pt. eats very rapidly, and his chewing is very inefficient. Yesterday he choked on a meatball. The nurse had
to perform the Heimlich maneuver to open his airway. AIMS Plus EPS exam reveals a significant amount of EPS.
Pt.s mental status has clearly benefited from the use of neuroleptic meds.
Target Date
1.
01/15/04
2.
01/15/04
Target Date
1.
07/15/03
2.
07/15/03
3.
07/15/03
4.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
633
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatrist:
1.
Psychiatrist will treat pt.s EPS with a reduction in pt.s neuroleptic meds; a change to
another neuroleptic, such as Zyprexa; or a prescription for an antidyskinetic, such as
Cogentin.
2.
Psychiatrist will do an AIMS Plus EPS evaluation in 2 weeks following the above med
changes.
3.
Psychiatrist will refer pt. to Dysphagia Clinic for possible modified barium swallow to
more fully assess pt.s dysphagia.
Virginia Coleman, MD
Nsg. staff will provide one-to-one monitoring during meals by staff trained in
Heimlich maneuver.
2.
Nsg. staff will educate pt. on avoiding hard or dry foods and alternating bites of food
with fluids.
Dietitian:
1.
2.
Dietitian will evaluate and educate pt. in weekly one-to-one meetings concerning his
eating habits and the relationship to choking.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
634
Date: 01/15/03
Problem Description:
Pt. complains of stiffness of extremities. Exam reveals bradykinesia, left greater than right, cogwheel rigidity of
wrists and elbows, left greater than right 4 to 6 Hz hand tremor, shuffling gait, diminished arm swing, and foreflexed posture consistent with neuroleptic-induced extrapyramidal side effects (pseudo-Parkinsonism). These
findings were not present before reinitiation of neuroleptic treatment 6 months ago. Parkinsonism may be
associated with increased falling risk in this pt. Pt. is currently on Risperdal (risperidone) 6 mg bid. Maintenance
dose in the community had been 4 mg bid. The pt.s psychotic symptoms have responded well to Risperdal, but
she is known to decompensate rapidly when off neuroleptics.
1.
Target Date
Date/Status*
07/15/03
Target Date
1.
Ongoing
2.
04/15/03
3.
Pt.s score on the AIMS Plus EPS (EPS Section) will decrease from
current 12 to 6 or less, without a worsening of her psychotic
symptoms (i.e., without a decrease in her Kennedy Axis V score
for Psychological Impairment).
04/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
635
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will reduce Risperdal from 6 mg bid to 4 mg bid and begin Cogentin 1 mg
po bid. Increase Cogentin by 1 mg/day every 3 days until rigidity and shuffling
improve or until 6 mg/day is reached. Further changes in meds as ordered.
2.
Virginia Coleman, MD
Psychology:
1.
Kennedy Axis V rating prior to Risperdal reduction and then monthly to capture any
deterioration in pt.s mental status in association with the medication adjustment.
Nsg. staff will make ongoing mental status evaluations to observe for any
deterioration with decrement in Risperdal dosage.
2.
Nsg. staff will make weekly measurements using the AIMS Plus EPS exam to observe
for reductions in pt.s EPS during the period of Risperdal reduction.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
636
Date: 01/15/03
Problem Description:
Pt. complains of restlessness with difficulty sitting through 30-minute groups, sitting through meals, watching TV,
or calming down to go to sleep. Examination reveals no evidence of Parkinsonism or dystonia, but there is ongoing
motor restlessness with leg rubbing and rocking when seated, shifting from foot to foot when asked to stand still,
and a tendency to pace rapidly in the hallways. Low-potency antipsychotics and atypical antipsychotics have not
been as effective as Haldol (haloperidol) in controlling pt.s psychotic symptoms. It is felt that reasonable control
may be maintained on a lower dose of Haldol. Also, pt.s akathisia is suspected to be contributing to the appearance
of greater severity of his psychosis.
1.
1.
Target Date
Date/Status*
04/15/03
Target Date
Date/Status*
03/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
637
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will rate the Kennedy Axis V before Haldol reduction and then weekly to
observe for any deterioration in pt.s mental status in association with the medication
adjustment.
2.
Psychiatrist will slowly reduce Haldol and give entire dose at HS.
3.
Psychiatrist will make ongoing observations for changes in pt.s akathisia during the
period of Haldol reduction.
4.
Psychiatrist will make weekly measurements of akathisia using the AIMS Plus EPS to
observe for reductions in pt.s akathisia during the period of Haldol reduction.
5.
Psychiatrist will make ongoing mental status evaluations to observe for any
deterioration with the medication adjustments.
6.
Once pt. is medically cleared and if akathisia continues, psychiatrist will consider
starting pt. on a trial of beta-blockers, such as Inderal.
Virginia Coleman, MD
Internist:
1.
Margaret Patel, MD
Nsg. staff will make ongoing assessments of pt.s akathisia and mental status,
especially when administering his meds.
2.
Nsg. staff will report to the psychiatrist any significant changes in pt.s akathisia or
mental status.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
638
Problem Description:
AIMS exam about 2 weeks ago revealed moderate choreoathetoid movement of tongue and distal extremities
consistent with TD. Previous AIMS exams did not meet the criteria for TD. Several weeks before the current AIMS
exam, pt.s Haldol was decreased; therefore, the current increase in the AIMS score may represent a withdrawal
emergent syndrome. In the past, pt. has decompensated when Haldol was decreased to levels significantly lower
than she is currently on. Pt. has a general understanding of the risks associated with tardive dyskinesia and
continued use of Haldol. She agrees to continue Haldol at a reduced dose, despite the risks. She is also willing to
supplement the Haldol with Zyprexa (olanzapine), which may be less likely to worsen her TD. It is hoped that the
Zyprexa can be used to replace the Haldol.
Target Date
1.
07/15/03
2.
07/15/03
1.
Target Date
Date/Status*
Date/Status*
04/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
639
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
2.
To R/O TD versus withdrawal emergent syndrome, psychiatrist will repeat AIMS exam
q month to determine whether pt.s dyskinetic movements resolve consistent with
withdrawal emergent syndrome or persist consistent with TD.
3.
If pt. continues to meet AIMS criteria for TD more than 3 months after the reduction
of Haldol dosage, psychiatrist will refer pt. to Movement Disorder Clinic for
consideration of alternative drug treatment strategies aimed at a reduction of
dyskinesia.
4.
If pt.s AIMS scores worsen after 3 months, psychiatrist will consider a trial of
clozapine.
5.
Virginia Coleman, MD
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
640
Problem Description:
Pt. is a 32-year-old, twice-divorced mother of three children. All her children are in foster care. She remains sexually
active with various partners of the opposite sex and is requesting birth control. She does not want any more
children at this time. She has never practiced birth control and is not sure which method is right for her lifestyle.
Target Date
1.
07/15/03
2.
07/15/03
Target Date
1.
02/15/03
2.
03/15/03
3.
03/15/03
4.
03/15/03
5.
Pt. will choose a contraceptive method that fits her lifestyle and
meets her needs.
03/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
641
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
2.
Family planning counselor will provide pt. with literature on family planning and
meet weekly with pt. for hour for at least 2 weeks to educate pt. about the
following:
a.
The available birth control methods, including risks and benefits
b.
STDs and symptoms and when to seek help from her physician
3.
At the end of the educational program, counselor will schedule an appointment for
an additional hour to assist pt. in choosing a suitable birth control method.
4.
Nsg. staff will schedule pt. for follow-up appointments at the family planning clinic
in the hospital. At discharge, a follow-up appointment will be scheduled at her local
family planning clinic.
Ronald Donahue, RN
Linda Larkin, RN (Family Planning Counselor)
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
642
Problem Description:
Pt. is a 26-year-old, twice-divorced mother of three children. One of her children has been adopted and two are in
foster care. She has had two abortions. She remains sexually active with various partners of the opposite sex. She is
refusing birth control and is anxious to have more children. Pt. appears to have a lot of fantasies and misunderstandings concerning sexual relationships and having children. Pt.s sexual behavior appears to be related to her
loneliness and dependency needs. Also, she does not understand the risks of STDs.
Target Date
1.
07/15/03
2.
07/15/03
Target Date
1.
02/15/03
2.
04/15/03
3.
04/15/03
4.
04/15/03
5.
04/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
643
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychology:
1.
Psychologist will schedule meetings with pt. initially for 15 minutes twice a week;
meetings will be increased to hour as psychologist develops a therapeutic
relationship with pt.
2.
Psychologist will gradually explore pt.s fantasies around pregnancy and child rearing
and assist pt. in understanding the realities of pregnancy and child rearing.
3.
Psychologist will assist pt. with identifying needs met by her sexual behavior and
help pt. explore alternative means of meeting her needs.
4.
5.
Psychologist will encourage pt. to become involved in a sex education program that
addresses her needs and encourage pt. to work with the Family Planning Counselor.
Rehab:
1.
Rehab counselor will lead the weekly womens group to help pt. explore positive and
negative aspects of her relationships with men.
Family planning counselor will make pt. aware that family planning counseling is
available and encourage pt.s participation.
2.
Family planning counselor will provide family planning counseling for hour once
weekly when pt. is agreeable.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
644
Date: 01/15/03
Problem Description:
Pt. is a 28-year-old single female who is here in the hospital in her last trimester of her first pregnancy. She carries a
diagnosis of schizophrenia and has a history of multiple psychiatric admissions. She has not been going for
prenatal care, is not taking her antipsychotic meds, and is floridly psychotic. She denies that she is pregnant. The
paternity of the child is unknown. Pt.s mother is her legal guardian, and her mother wishes to care for the baby
once it is born. Staff feels that pt.s mother can provide a healthy, nurturing environment for the baby, as well as
allow pt., when she is doing well, to have an ongoing relationship with her baby.
Target Date
1.
04/15/03
2.
Pt. will concur with the need to place her baby in the care of her
mother until she can safely care for her baby.
04/15/03
Target Date
1.
01/29/03
2.
Pt. will cooperate with and will receive adequate nutrition, rest,
and exercise.
02/15/03
3.
02/15/03
4.
02/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
645
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work/Nursing:
1.
Staff will discuss with pt. and her mother the placement of pt.s infant with pt.s
mother.
Brenda St. Martin, MSW, and Linda Larkin, OBS Primary Nurse
Nsg. staff will maintain pt. in an environment that is safe for her and her unborn
child.
2.
Nsg. staff will develop a trusting relationship with pt. to get pt. to cooperate with
prenatal care.
3.
Nsg. staff will monitor nutrition, elimination, rest, and activity; staff will report any
difficulties to the obstetrician.
Nsg. staff will meet with pt. for hour once weekly to provide education about
pregnancy and delivery, including signs and symptoms of labor.
Nsg. staff will be educated to the signs and symptoms of labor so they can monitor
these signs and symptoms on a daily basis, as well as review them with pt.
Staff will collaborate to determine when pt. will be transferred to the Maternity Ward.
Ronald Donahue, RN
Linda Larkin, OBS Primary Nurse
7.
As pt.s due date approaches, check pt. every 15 minutes for evidence of labor.
Other:
1.
Staff as indicated
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
ANCILLARY IMPAIRMENT
(Problem Area 7)
71
73
ANCILLARY IMPAIRMENT
(Problem Area 7)
CONTENTS
Kennedy Axis V for Ancillary Impairment ................................................................................................ 74
This rating scale can be used to measure the outcome of treatment. It also helps to define the problems
that fit into the category of Ancillary Impairment and can be helpful in composing a short description
of each problem.
Strengths .................................................................................................................................................. 75
Examples of strengths that may be related to treatment and discharge in the area of Ancillary Strengths
are listed here.
Goals ......................................................................................................................................................... 76
Examples of treatment goals that may relate to problems in the area of Ancillary Impairment are listed
here.
74
70 Mild ancillary problems, e.g., some difficulty with his/her living environment, financial resources, or the
law; mild difficulty paying bills/credit cards; mild difficulty with parking or traffic tickets; occasional mild verbal
violence in his/her environment; however, generally safe living situation.
60 Moderate difficulty with living situation, finances, or the law; high risk for being in a dangerous
homeless or jail situation; criminal charges place him/her at high risk of incarceration; no stable residence and/or
income, often having to move from one living situation to another; moderate difficulty paying bills/credit cards;
evaluation and/or disposition is being made for nonviolent criminal activity (e.g., trespassing, stealing,
defacing/destruction of property, or lewd behavior); evaluation and/or disposition is being made for
competency to make decisions concerning person, estate, and/or treatment.
50 Serious problems with living situation, finances, and/or the law; frequent risks or threats of
moderate violence in his/her environment; evaluation and/or disposition is being made for relatively minor
but violent or dangerous criminal activity (e.g., minor assault, threats to do physical harm, driving while under
the influence, sexually touching someone or exposing self); serious placement difficulties, even when ready for
placement.
40 Major problems with living situation, finances, and/or the law; some real danger of being
physically injured in his/her environment; evaluation and/or disposition is being made for very violent
criminal activity (e.g., vicious assault, attempted rape, attempting to molest a child, arson).
30 Lifestyle is considerably influenced by ancillary problems; he/she is in a very dangerous homeless
or jail situation most of the time; unable to obtain basic food, shelter and/or clothing; frequent, mild to moderate
physical injuries from violence in his/her environment.
20 Major ancillary problems (e.g., he/she is in a very dangerous homeless or jail situation all
of the time); at times, his/her life is at serious risk due to lack of resources for basic food, shelter, and/or clothing
or because of high level of violence in his/her environment; evaluation and/or disposition is being made for
extremely serious criminal charges (e.g., attempted murder, vicious rape, viciously molesting a child).
10 Living/financial situation is totally inadequate; his/her life is continually at serious risk due to lack
of basic food, shelter, and/or clothing or because of extremely high level of violence in his/her environment;
evaluation and/or disposition is being made for the most extreme charges of violence (e.g., murdering anyone,
very viciously harming or very viciously raping a child, arson with intent of hurting others).
NR Not rated
Ancillary Problems
A.
Placement difficulties
1.
Homelessness
2.
Alienation of halfway house staff members
3.
Ambivalence about leaving the hospital
4.
Appropriate placement not available
5.
Placement blocked by unresolved legal difficulties
B.
Financial problems
1.
No means of support
2.
Debts beyond ability to pay
3.
Overwhelming credit card debt
4.
Social Security Disability Income (SSDI) benefits needed
C.
Legal difficulties
1.
Court report
2.
Court assessment of competency
3.
Court permission for forcing medication
4.
Court review of use of antipsychotic meds
5.
Court review of use of an experimental drug
6.
Court review of psychosurgery
7.
Criminal charges
8.
Guardian is not properly handling pt.s money
9.
Divorce
D.
Data collection
1.
Insufficient database
2.
No information available on pt.s psychiatric history
3.
No information available on pt.s current housing or legal status
E.
Ancillary Strengths
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
75
76
Goals
I.
II.
Expected Improvements
A.
Placement
1. Pt. will be able to demonstrate basic community living skills, including the ability to use public
transportation, budget money, shop for food, and prepare a meal, for 3 months.
2. Pt. will be able to verbalize fears and ambivalence about moving into a community residence.
3. Pt. will go on a no-strings-attached tour of prospective halfway houses.
4. Pt. will be able to consistently express an understanding of the benefits of going into a halfway
house for 1 month.
5. Pt. will be able to begin the process of slow transition to a community setting without serious
regression.
6. Pt. will be able to successfully go to the community day program two times a week for 1 month.
7. Pt. will be placed in a structured residential setting without serious regression during the
transition.
8. Pt. will be able to transition from a locked ward to an unlocked, open ward.
9. Pt. will reduce dependency on his or her mother to the point that pt. will begin to discuss
community residential alternatives to being discharged to live with mother.
10. Pt. will express an understanding of the fact that pt. can benefit from discharge to a halfway house
rather than return to mothers home.
11. Pt. will be discharged to the appropriately supervised residential setting.
12. Pt. will improve so that court approval can be obtained for discharge to a halfway house.
B.
Financial
1.
Pt. will begin getting SSDI benefits as a step toward being able to move out of the homeless
shelter.
2.
Pt. will be able to get a job that will provide the income necessary to stabilize pt.s life to live
outside of the hospital.
3.
Pt. will cooperate with social worker on ways to get credit card debt under control.
C.
Legal
1.
Pt. will cooperate so that the information needed to complete the mandated court evaluation can
be gathered.
2.
Pt. will show up for the court hearing.
3.
Pt. will have a permanent legal guardian appointed by the court for financial, medical, and
psychiatric concerns.
4.
Pt. will consistently maintain communication with the guardian for 3 months.
5.
Pt. will consistently cooperate with the lawyer in gathering the necessary information for pt.s
upcoming divorce, for 1 month.
6.
Pt. will consistently cooperate with the lawyer in pt.s defense against the charge of attempted
murder for 3 months.
D.
Other
1.
No examples given.
Reporting of Symptoms
A.
77
V.
A.
B.
Treatment planning
1.
Pt. will cooperate with at least one treatment team member in the treatment planning process.
2.
Pt. will be willing to participate in the court evaluation process as laid out in pt.s treatment plan.
C.
Program activities
1.
Pt. will express the benefits of attending community transition group meetings.
2.
Pt. will consistently agree to go for follow-up at the community clinic.
D.
Pt. will cooperate with the evaluation of the nature of pt.s anxiety about discharge.
Pt. will cooperate with the competency exam.
Pt. will cooperate with the treatment team to gather the information necessary to
complete mandated court evaluation.
Kennedy Axis V subscale for Ancillary Impairment will improve from a current score of
40 to 60.
VII. Miscellaneous
A.
B.
C.
D.
Once level of care has been determined, pt. will give staff permission to determine the
availability of appropriate discharge placement.
Pt. will allow the community case manager to be involved in the discharge planning
process.
Pt. will cooperate with determining who would be best to act as pt.s guardian.
Pt. will demonstrate motivation for discharge by advocating for self with case
management about the fact that an appropriate placement is lacking, despite pt.s
readiness to function in a community residence.
Treatment Modalities
Because of the extremely diverse nature of the category of Ancillary Impairment, no listing of treatment modality
examples is included. However, some examples of treatment modalities for Ancillary Impairment are included in
the samples of Individual Problem Plans at the end of this section on Ancillary Impairment. Also, the categories of
treatment modalities presented in previous sections should generally apply to the treatment of Ancillary
Impairment.
78
Problem Description:
1.
2.
Make sure that the description relates to goals and treatment modalities.
3.
Address the description and treatment of associated problems that may have led to pt.s alleged crime in the
appropriate problem area, such as Problem Area 1 Psychological Impairment, Problem Area 3 Violence, or
Problem Area 5 Substance Abuse.
1.
Pt. will consistently cooperate with the assessment process for ___
week(s).
2.
3.
4.
5.
6.
7.
Pt. will regain competency to stand trial AEB working with the
attorney and demonstrate an understanding of the charges and
the role of court members for ____ week(s).
Target Date
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
79
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will discuss case with the forensic team, including diagnosis, medication,
laboratory findings, physical findings, and follow-up psychiatric treatment
recommendations.
Victor Dyson, MD
Social Work:
1.
Social worker will discuss with the forensic team issues related to environmental or
social precipitants of the alleged crime and aftercare treatment services.
Rehab:
1.
Rehab staff will discuss with the forensic team issues relating to how pt. is doing in
scheduled program groups.
Nsg. staff will discuss with the forensic team issues relating to pt.s behavior on the
ward and any medical issues.
Marilyn Davis, RN
Forensic Team:
1.
Forensic team will gather the necessary information from the pt. and treatment team
members to complete the court-ordered forensic report.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
711
712
Date: 01/15/03
Problem Description:
In the past, pt. has resided in single rooms and shelters. Historically, she abuses alcohol and behaves
inappropriately in the community. With the assistance of friends, she has been able to function fairly well in the
community; however, these friends are unable to provide pt. with regular support and care. When they are not
available, she places herself in dangerous situations. Her friends are encouraging her to consider living in a
community residential program. She has historically rejected community residential programs.
1.
Target Date
Date/Status*
07/15/03
Target Date
1.
03/15/03
2.
04/15/03
3.
05/15/03
4.
06/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
713
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work:
1.
Hold one-to-one session twice weekly to discuss and address placement issues with
the pt.
2.
3.
4.
5.
Rehab:
1.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
714
Date: 01/15/03
Problem Description:
Pt. has a long history of homelessness, which began sometime before his first psychiatric hospitalization in his late
teens. He has no family support and has used alcohol and drugs when living on the streets. When not living on the
streets, he is in a shelter, a psychiatric hospital, or jail for minor legal offenses. He has refused previous attempts to
refer him to a community residence. Last winter, pt. had to be treated for medical problems suffered after exposure
to the severe weather conditions. Pt.s judgment is increasingly impaired and he is increasingly making irrational
plans to continue living on the streets. If brought to the court, it is very unlikely that the court would honor pt.s
request to be discharged to the streets.
1.
Target Date
Date/Status*
05/15/03
Target Date
1.
Pt. will agree to work with his social worker and community case
manager concerning discharge plans.
02/15/03
2.
03/15/03
3.
03/15/03
4.
04/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
715
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work:
1.
Social worker will meet with pt. at least 1 hour weekly to discuss discharge plans,
including the advantages of moving from the streets into a community residence.
2.
Social worker will arrange visits with pt. to appropriate community residences.
Social worker will assist pt. in establishing relationships in the community (e.g., staff
and residents in the community day program and the community residential
program).
2.
Case manager will arrange for residential tours, interviews, and the like.
Other:
1.
Staff as indicated
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
716
Date: 01/15/03
Problem Description:
Pt. faces criminal charges, including assault and battery, attempt to commit murder, and assault and battery with a
dangerous weapon. Pt. was committed for evaluation of competency to stand trial and criminal responsibility at
the time of the alleged crime. Commitment expires on 02/15/03.
1.
Target Date
Date/Status*
02/15/03
Target Date
1.
Pt. will cooperate so that the treatment team can begin to gather
the information necessary to complete the court evaluation.
01/22/03
2.
Pt. will cooperate so that the forensic team can complete the first
draft of the court report.
02/07/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
717
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work:
1.
Staff will obtain community records, including police report and report from
community psychiatrist.
Staff will give pt. Lambe warning that information obtained in the course of this
evaluation will be used as part of the evaluation to be sent to court.
2.
Nsg. staff will discuss with the forensic team issues related to pt.s behavior on the
ward, including any medical issues.
Forensic Team:
1.
Staff will gather the necessary information from the pt. and treatment team members
to complete the court-ordered forensic report.
2.
Forensic team will present the report to the court and testify, if necessary.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
718
Date: 01/15/03
Problem Description:
Pt. appears to be incompetent. She needs to have the courts declare her incompetent and appoint a guardian. Pt.
has a long history of being unable to care for herself. Her insight and judgment are markedly impaired. She appears
unable to make competent decisions concerning her money and medical care. She is also unable to make rational
statements as to why she needs to be in the hospital. Pt.s mother appears to be a good candidate for pt.s legal
guardian.
1.
Target Date
Date/Status*
04/15/03
Target Date
1.
02/15/03
2.
03/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
719
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Staff will complete report on pt.s competency to care for herself, her ability to make
decisions concerning medical treatment, and her ability to make decisions concerning
committing herself to a mental institution.
2.
Victor Dyson, MD
Psychology:
1.
2.
Psychologist will meet one-to-one with pt. for 45 minutes once weekly in supportive,
problem-solving therapy to improve pt.s mood and help her function, even if
depressive symptoms persist.
Social Work:
1.
Staff will discuss with pt.s mother the issues surrounding her seeking legal
guardianship of pt. and the responsibilities associated with being assigned legal
guardianship of the pt.
2.
Staff will assist the legal office in obtaining necessary paperwork from pt.s mother and
from pt.s record.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
BLANK FORMS
BF1
Blank Forms
BF3
BLANK FORMS
CONTENTS
Master Treatment Plan........................................................................................................................... BF5
Problem List .................................................................................................................................................. BF5
Strengths/Discharge Plan/Diagnosis ............................................................................................................. BF6
Individual Problem Plan................................................................................................................................ BF7
Signature Page ............................................................................................................................................... BF9
Notes
Blank Forms
BF5
Name:
Problem List
ID #:
Area:
Name of Facility
Date:
Date of Admission:
Problem
Number
Problem Name
Discharge
Barrier*
Date Changed
& New Status***
*DISCHARGE BARRIER: YES = Significant barrier to discharge; NO = Not a significant barrier to discharge
**ESTAB. STATUS: Active, Inactive, Inactive With Tx, Deferred, Noted
***CHANGED STATUS: Resolved, Active, Inactive With Tx, Revised, Canceled, Noted
Check if list is continued [ ]
BF6
Name:
ID #:
Strengths/Discharge Plan/Diagnosis
Area:
Date:
Patients Strengths (related to treatment and discharge):
Discharge Criteria/Planning (Include anticipated placement environment, criteria for discharge, long-term goals
needed for discharge, and anticipated target date. If a problem exists with placement, complete an Individual Problem Plan on
Placement.):
Ancillary Impairment =
AXIS V:
PSY =
SOC =
GAF Equivalent =
VIO =
ADL =
SAb =
MED =
Dangerousness Level =
Significant changes have been made in the diagnosis and those changes have been documented on the
Treatment Plan Review dated:
/ /
/ /
/ /
/ /___
Blank Forms
BF7
Name:
ID #:
Area:
Nursing Diagnosis:
Date:
Problem Description:
Target Date
Date/Status*
Target Date
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
BF8
Date: ________
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Blank Forms
Signature Page
BF9
Name:
ID #:
Area:
Name of Facility
Date:
Patient Participation in Treatment Planning (check as appropriate):
Contributed to goals and plan
Aware of plan content
Present at team meeting
Refused to participate
Unable to participate
Refused to sign plan
Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Date:
Print Name:
Nurse:
Date:
Print Name:
Social worker:
Date:
Print Name:
Psychologist:
Date:
Print Name:
Rehabilitation:
Date:
Print Name:
Other:
Date:
Print Name:
Note: The above signatures document that the participants have reviewed the Master Treatment Plan on the date
signed and that they agree with the plan, unless indicated otherwise under Staff Members Comments.
ALL SUBSEQUENT CHANGES ON THIS PLAN SHOULD BE DATED, INITIALED, and supported by associated progress
note(s) and/or Treatment Plan Review(s).
Notes
Blank Forms
Name of Facility
BF11
Name:
ID #:
Area:
Date:
3. Evaluation of Progress and Plans Effectiveness in Achieving Goals for Active Problems:
BF12
7. Continuation/Comments:
Awaiting SNF [ ]
9. Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Date:
Print Name:
Nurse:
Date:
Print Name:
Social worker:
Date:
Print Name:
Psychologist:
Date:
Print Name:
Rehabilitation:
Date:
Print Name:
Other:
Date:
Print Name:
Date:
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
QUESTIONNAIRES
Q1
Questionnaires
Q3
QUESTIONNAIRES
CONTENTS
Overview and Use of Questionnaires ...................................................................................................... Q4
References and Acknowledgments ......................................................................................................... Q4
Kennedy Axis V ........................................................................................................................................ Q5
Kennedy Nurses Observation Scale for Inpatient Evaluation (K NOSIE)............................................. Q17
AIMS Plus EPS (Abnormal Involuntary Movement Scale Plus Extrapyramidal Side Effects)................ Q19
Q4
The Kennedy Axis V and the Kennedy NOSIE are not in the public domain. For details on how to
obtain a licensing agreement to use the Kennedy Axis V or the Kennedy NOSIE questionnaires, please
contact James A. Kennedy, MD, or go online to www.kennedymd.com.
Dr. Kennedy, in conjunction with the Massachusetts State Medical Record Committee, developed
the AIMS Plus EPS. It was introduced in
Kennedy JA: Fundamentals of Psychiatric Treatment Planning. Washington, DC, American Psychiatric
Press, 1992
The AIMS and the AIMS Plus EPS are both in the public domain. The AIMS was developed at the
National Institute of Mental Health:
National Institute of Mental Health, Alcohol Drug Abuse and Mental Health Administration: Abnormal
Involuntary Movement Scale. Washington, DC, U.S. Department of Health, Education and Welfare,
1974
Questionnaires
Q5
Questionnaires
Q7
Instruction Sheet
What Is the Kennedy Axis V (K Axis)?
The K Axis consists of seven subscales for Axis V: Psychological Impairment, Social Skills, Violence, ADL
Occupational Skills, Substance Abuse, Medical Impairment, and Ancillary Impairment. These subscales capture the
clinicians impression of the individuals overall level of functioning during the previous week (longer if significant,
e.g., suicidal attempts).
In addition to an individual score for each of the subscales, clinicians can generate a patient profile using the
K Axis, as well as a score equivalent to the GAF. The K Axis is useful for developing Problem Lists, planning
treatment, measuring its impact, and predicting outcome. Note: If needed, each subscale can stand alone and act as
an individual questionnaire.
GAF Equivalent (GAF Eq): Add the first four subscales and divide by four to give a score that is roughly
equivalent to a score from the GAF Scale. This score should ensure that the major areas of functioning are
not overlooked when rating the patient.
Dangerousness Level (DL): The DL is roughly equivalent to the GAFs measure of dangerousness. The
numbers used to derive the DL are on the scoring sheet directly below each subscale score. The lowest of
these numbers becomes the DL. If the DL is 50 or less, it is often associated with the need for very high
intensity outpatient care, residential care, or even hospitalization.
The current rating should be based on the level of functioning at the time of the evaluation and is most
reflective of the current need for treatment or care.
The discharge rating should be based on the level of functioning at the time of discharge and, when
compared with the admission rating, is most reflective of the impact of treatment.
The highest level of functioning should be based on the highest level of functioning that lasted for at least a
few months during the last year. This score may be very predictive of outcome.
Measuring the Effects of Treatment, Stress, Physical Limitations, and the Like
The presence or absence of support, medication, other treatments, or even severe stress generally should not affect
the rating, unless it is covering up skills. The rating should be based on the level of functioning, and no
adjustment should be made for the presence or absence of these factors. Do not factor out the effects of
treatment, even if the patient may drop out of treatment.
The effect of physical/environmental limitations generally should be factored out of the rating. For example, factor
out not abusing drugs or not assaulting others due to being incarcerated or physically restrained; factor out
not being socially active or employed due to physical constraints of being in a wheelchair or confined to
bed. Rate how functional or dysfunctional a client would be if given reasonable opportunitythat is, do
not let physical barriers cover up skills or violence.
Q8
(Problem Area 1)
70
Some mild symptoms (e.g., depressed mood with mild insomnia, occasional truancy, theft within the
household, difficulty trusting others, mild insensitivity to the feelings and needs of others), but generally
functioning fairly well; however, those who know him/her well might express some concerns about his/her mental
state.
60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks; frequently
preoccupied; moderate impairment in attention span); moderate insensitivity to the feelings and needs of others;
to those who know him/her well it is clear that he/she has mental problems.
50 Serious symptoms (e.g., moderately depressed mood, moderate lethargy, severe obsessional rituals, severe
phobia, severe sexual perversion, moderate problems with anorexia/bulimia, frequent shoplifting, frequent anxiety
attacks, moderately guarded, mild but definite manic syndrome).
40 Major psychological impairment; some impairment in reality testing or communication (e.g., speech is
at times illogical, obscure, or irrelevant; moderate paranoia; may have hallucinations or delusions; however,
probably realizes they are not a part of reality); major impairment in several areas, such as judgment, thinking, or
mood (e.g., depressed man avoids friends, neglects family, and is not motivated to work; or, moderate negative
symptoms of schizophrenia); even those who do not know him/her well would likely consider him/her to have
mental problems.
30 Behavior is considerably influenced by delusions or hallucinations; appears to be responding to
hallucinations; serious impairment in communication or judgment (e.g., sometimes incoherent, thinking is
occasionally grossly inappropriate); severely depressed mood; withdrawn, with few spontaneous communications;
inability to function in almost all areas (e.g., stays in bed all day and does not care for own living space; no job,
home, or friends due to paranoia, poor motivation, social withdrawal, extremely poor insight, or being almost
totally insensitive to the feelings and needs of others); at times attention span is markedly impaired; severe
sociopathic behaviors have led to multiple arrests; severe sexual perversion toward prepubescent children.
20 Thinking and communication are generally grossly impaired; manic excitement or catatonia;
largely incoherent or mute; generally markedly impaired attention span; occasionally fails to maintain minimal
personal hygiene due to severe lethargy or very disorganized, bizarre thinking (e.g., too lethargic to attempt to wipe
food off shirt; smears feces for bizarre, delusional reasons).
10 Thinking is totally disorganized; totally insensitive to the feelings and needs of others; completely
incoherent; completely mute, extremely catatonic; persistent inability to maintain minimal personal hygiene or
minimal safety due to totally disorganized thinking or very severe lethargy; unable to focus attention for even a
few seconds; chronic, self-induced vomiting has led to a very life-threatening situation.
NR
Not rated
Questionnaires
Q9
(Problem Area 2)
100 Superior social skills, sought out by others because of his/her outstanding social/communication skills,
has many friends and no difficulty making new friends. No symptoms.
90
Good social skills, no difficulty being pleasant and engaging, good communication skills, socially
effective.
80 No more than slight impairment in social skills, slightly inappropriate social behavior leads to
infrequent interpersonal conflicts, no more than slight difficulty maintaining several friendships.
70 Some difficulty with social skills (e.g., mild difficulty knowing how to share with others, show
sympathy for others, and/or understand feelings of others), social skills are not obviously impaired, generally
functioning fairly well, has some meaningful interpersonal relationships.
60 Moderate difficulty with social skills (e.g., conflicts with peers due to inappropriate teasing or other
inappropriate social behavior; attempts to be pleasant and engaging are usually moderately awkward; moderate
difficulty knowing what to say even when talking with friends; moderate difficulty knowing how to share with
others, show sympathy toward others, and/or understand feelings of others); hardly any friends because of
problems with social skills; communications are understandable but vague.
50 Serious impairment in social skills; has no friends because of clearly impaired social skills;
however, has some peer relationships, despite social skills being clearly impaired; frequent conflicts with peers
or co-workers because of inappropriate social behavior; conversations are often socially inappropriate; great
difficulty communicating thoughts and feelings; unable to introduce self and a second person without clear
difficulty; frequently intrusive; inappropriate, nonsexual touching.
40 Major impairment in social skills; attempts to approach others quickly lead to embarrassing
situations; no friends and virtually no peer relationships because of poor social skills; unable to appropriately
engage in almost any social activity; continually intrusive with little understanding of the inappropriateness of the
behavior; major acts of socially inappropriate behavior lead to being assaulted, fired from work, or expelled from
school; great difficulty recognizing or coping with inappropriate sexual or aggressive advances by others;
great difficulty recognizing that his/her sexual advances are not welcome.
30 Acts grossly inappropriately toward others; virtually no understanding of the feelings of others, how
to share with others, and/or how to show sympathy toward others; conversations with others are grossly
inappropriate; unaware of or ignores most social norms as manifested by open masturbation, inappropriate sexual
touching, and the like.
20 Very few social skills; generally unable to communicate in an organized, understandable way; uses short
phrases or gestures to get basic needs met; acts with shocking inappropriateness in front of others, such as smearing
of feces or making sexual advances toward young children; however, may have some understanding that such
behavior is inappropriate.
10 Few if any social skills; unable to communicate in an organized, understandable way; shows no apparent
awareness of social norms (e.g., doesnt realize that it is inappropriate to grab food or cigarettes from others);
extremely vulnerable to victimization (e.g., has no understanding of the inappropriateness and/or dangers of
approaching strangers or assaulting others, needs constant care and supervision to not get into dangerous social
situations).
NR
Not rated
Q10
(Problem Area 3)
100 No evidence of violence to self or others; very satisfied with life; lifes problems never seem to lead to
any inappropriate anger, frustration, or conflicts. No symptoms.
90 No significant evidence of violence to self or others; generally satisfied with life, no more than
everyday problems or conflicts (e.g., an occasional argument with family members).
80 No more than slight problems with anger and irritability; if symptoms are present, they are transient
and expectable reactions to psychosocial stressors (e.g., occasional blow up with family members or friends; mild
anger after family argument); no suicidal ideation.
70
Mild symptoms (e.g., mild problems with anger and irritability; occasional thoughts of violent behavior;
thoughts that life may not be worth living); symptoms are not interfering significantly with his/her functioning;
severely assaulted others or serious suicidal attempt over 5 years ago; however, for years, has had no significant
problems with violence or self-harm.
60 Moderate difficulty with anger and irritability (e.g., moderate conflicts with peers or co-workers due
to anger and hostility; occasional threats of violent behavior); some evidence that self-destructive thoughts may be
present. Murdered someone over 10 years ago; however, for many years, has had no significant problems with
violence.
50 Serious problems with anger and irritability; moderate threats of violence; becomes verbally
threatening when needs/demands are not immediately met or when pushed to do something; occasionally hits
someone; occasional, relatively minor, sexual assault; occasional suicidal ideation; nonsuicidal self-abuse, such
as burning self with cigarettes or cutting self superficially; not felt to be in real danger of seriously hurting self or
others; however, some precautions including close observation may be indicated.
40 Major problems with anger and irritability; some real danger of hurting self or others; violent
outbursts toward family and neighbors; frequent threats of violence; hitting or biting someone is not unusual;
occasionally difficult to redirect from aggressive behavior; induces much fear of physical assault in others; single
suicidal gesture within the last month; moderate suicidal ideation; actively making plans to hurt self or others;
set a relatively minor fire within the last 3 months or is having fire-setting impulses with history of setting one or
two minor fires.
30 Often hitting or biting others; becomes physically aggressive when needs are not immediately met;
suicidal attempt without clear expectation of death during the last month; frequent suicidal preoccupation; actively
following through with plans to hurt self or others (e.g., obtaining a gun, pills, rope); at times close observation or
restraints may be necessary to prevent serious harm to self or others.
20 Frequently violent; very real danger of hurting self or others; serious thoughts of killing someone;
attempted to very violently harm or violently rape someone within the last month; constant suicidal
preoccupation; however, he/she is felt to have some control of the suicidal impulses; two or more suicidal
attempts without clear expectation of death within the last month; close observation to prevent harm to self or
others may be required 1 or 2 days a week.
10 Persistent danger of severely hurting self or others; attempted to kill someone within the last
month; attempted to very violently harm or violently rape a child within the last month; set a fire within the last
month with intent of hurting others; serious suicidal attempt within the last month with clear expectation of
death; little or no control of impulses to hurt self or others; expressing loss of control of command
hallucinations to hurt self or others; one-to-one, at-arms-length observation and/or physical restraint for
prevention of serious harm to self or others may be required 3 or more days a week; murdered someone within
the last 2 years.
NR
Not rated
Questionnaires
Q11
(Problem Area 4)
100 Superior ADLoccupational skills in a wide range of activities (e.g., in school, on the job, as a
homemaker, pursuing a complicated hobby); superior workmanship; work challenges never seen to get out of
hand; is sought out by others because of his/her work skills. No symptoms. Skills are consistent with those
expected of a successful college graduate.
90 Good skills in all ADLoccupational activities; no more than average difficulties with any work
assignment. Absent or minimal symptoms. Skills are consistent with those expected of a successful high school
graduate.
80 No more than slight impairment in occupational skills or skills in school; has slight difficulty
performing at an average level; slight difficulties with routine chores, work assignments, or schoolwork
assignments; slight impairment in workmanship.
70 Mild difficulty with occupational skills or skills in school (e.g., minor difficulty following
instructions, workmanship is somewhat sloppy), but generally functioning fairly well.
60 Moderate difficulty with occupational skills or skills in school (e.g., probably employed;
however, has trouble carrying through assignments; some difficulty problem solving or following instructions;
some difficulty driving a car; some difficulty knowing how to budget money; some difficulty maintaining a home
or apartment).
50 Serious impairment in occupational skills or skills in school (e.g., unable to keep a job for more
than a few weeks due to poor occupational skills; almost failing in school; moderate difficulty following
instructions; moderately sloppy workmanship); needs supervision when shopping for food; some difficulty using
public transportation; some difficulty preparing self a reasonable, family-style meal; some difficulty ordering, eating
properly, tipping, etc., in a regular restaurant; some difficulty making a long-distance phone call.
40 Major impairment in occupational skills or skills in school (e.g., unable to work at a job for any
significant period or do routine housework due to poor work skills; failing in school due to poor academic skills);
needs supervision to use public transportation; mild to moderate difficulty ordering and eating in a fast-food
restaurant; poor understanding of how to budget money.
30 No job and unable to independently maintain a home due to serious impairment in skills needed
to perform ADLs and tasks at home; serious difficulty following instructions; needs some supervision to prepare
simple meals for self, such as a sandwich and beverage; needs supervision to dress self, make a local phone call,
follow a very simple self-medication procedure; needs constant supervision to complete more complicated ADLs
(e.g., operating a washer and dryer); very sloppy workmanship; some difficulty responding appropriately to a fire
alarm; difficulty finding way back from short errands.
20 Gross impairment in skills needed to perform ADLs and tasks at home (e.g., needs some
supervision to maintain minimal personal hygiene; is almost totally unable to follow simple instructions; needs
supervision to feed self; unable to function independently (e.g., needs constant supervision to complete most
simple tasks; does not know the value of money; unable to dial 911 in an emergency; unable to find way back from
short errands).
10 Demonstrates almost no ADL skills (e.g., is totally unable to follow instructions; unable to complete
most tasks even with constant supervision; may even have to be physically assisted to complete a task, including
eating or dressing); persistent inability to maintain minimal personal hygiene; considerable external support
(e.g., nursing care and supervision) is needed to prevent him/her from accidentally harming self (e.g., wandering
into traffic, danger of seriously burning self when attempting to cook or when smoking); unable to appropriately
respond to a fire alarm.
NR
Not rated
Q12
(Problem Area 5)
100 No significant problems with drugs or alcohol; no use or almost no use of alcohol; nonsmoker; no
use of street drugs; never abuses substances, even when lifes problems get out of hand; is an example of someone
who is totally free of problems with substance abuse. No symptoms.
90 No more than the average problems and concerns with alcohol; minimal use of alcohol; social
drinker; no use of illegal drugs; history of serious alcohol or drug abuse with over 10 years of sobriety and
minimal, if any, treatment needed to maintain sobriety.
80 No more than slight impairment; drinks to mild intoxication about once a month; smokes cigarettes
daily; experiments with marijuana less than once a year; some mild abuse of over-the-counter medications and/or
caffeine; no more than slight impairment in social, occupational, or school functioning due to substance abuse
(e.g., temporarily falling behind in schoolwork); serious alcohol or drug abuser with over 5 years of sobriety
with minimal treatment needed to maintain sobriety.
70 Mild impairment in social, occupational, or school functioning due to substance abuse, but
generally functioning fairly well; drinks to mild or moderate intoxication 1 or 2 days a week; excessive prescription
drug seeking; experiments with drugs such as marijuana, Valium, Ativan, or Librium once or twice a year; heavy
smoker; unable to quit cigarettes despite numerous attempts.
60 Moderate difficulty in social, occupational, or school functioning because of substance
abuse (e.g., substance abuse results in moderate impairment in job performance and/or conflicts with peers or
co-workers); drinks on a regular basis, often to excess; drinks to moderate intoxication more than 2 days a week;
occasionally experiments with drugs such as cocaine, Quaaludes, amphetamines (speed), LSD, PCP (angel dust),
Ecstasy, inhalants; moderate abuse of over-the-counter medications and/or caffeine; unable to quit cigarettes
despite chronic medical complications; serious alcohol or drug abuser with less than 2 years of sobriety.
40 Major impairment in several areas because of substance abuse (e.g., alcoholic man avoids
friends, neglects family, and is unable to get a job; student is failing in school and having serious conflicts with his
family or roommate due to substance abuse); occasionally injects heroin or cocaine into his/her veins; occasionally
has an accidental drug overdose; severe alcohol or drug abuser with less than 1 month of sobriety.
30 Drugs or alcohol pervade his/her thinking and behavior; his/her behavior is considerably
impaired by substance abuse; injects heroin or cocaine into his/her veins once or twice a day; abuses substances
without regard for personal safety (e.g., some accidental overdoses and/or auto accidents resulting in medical
hospitalizations); blackout spells; prostitutes self for drugs/alcohol; multiple alcohol- or drug-related arrests; serious
neglect of children due to substance abuse.
20 Functioning is extremely impaired by daily use of drugs such as LSD, PCP, cocaine, heroin,
or inhalants; unable to go for more than a few hours without significant physical and/or psychological craving
for drugs or alcohol; continued use of alcohol or drugs (other than cigarettes) is beginning to cause very
serious medical complications (e.g., liver failure, overt brain damage, AIDS or high risk for AIDS); injects drugs
into his/her veins more than twice a day.
Not rated
Questionnaires
Q13
(Problem Area 6)
100 Superior medical health; physical exam and laboratory tests are normal, including no significant
weight problem; illnesses never seem to affect him/her; few if any problems with even common medical problems
(e.g., colds, headaches, indigestion, constipation, diarrhea); virtually never has to miss work or school due to
medical problems; exercises regularly; on no medication, except may take a prophylactic medication, such as a
multivitamin; doesnt wear glasses/contacts. No significant medical problems or symptoms.
90 Good medical health; has few if any medical problems; physical exam and laboratory test reveal no more
than minor abnormalities; illnesses seldom seem to affect him/her; average difficulties with common medical
problems (e.g., colds, headaches, indigestion, constipation, diarrhea); wears glasses/contacts that correct minor
visual problems; wears dentures; only occasionally misses work or school due to medical problems; occasionally
needs over-the-counter medication.
80 If medical problems are present, they are transient and cause minimal impairment in
social, occupational, or school functioning; somewhat more than average missing of work or school due to
medical problems; impairment in mobility or use of hands or hearing that is totally corrected by the use of a
prosthesis, hearing aids, and the like; mild obesity or mild emaciation; occasional urinary incontinence due to
organic problems.
70 Mild medical problems which may cause some difficulty in social, occupational, or school
functioning; however, generally functioning fairly well; missing no more than about 1 to 2 weeks a year from
work or school due to medical problems; mild impairment in mobility, speech, use of hands, vision, or hearing
despite use of prosthesis, glasses, hearing aids, and the like; has chronic illness but has few if any overt signs or
symptoms of the illness (e.g., mild asthma, mild hypertension, mild diabetes, mild arthritis; mild dysphagia;
epilepsy easily controlled with medication; mild tardive dyskinesia); requires medical follow-up several times a
year; takes prescription medication on a daily basis.
40 Major impairment in several areas (such as work or school or family relations) because of medical
problems; missing about 2 months a year or more from work or school due to medical problems; medical problems
result in major impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses,
hearing aids, and the like; frequently confined to bed or wheelchair because of chronic medical problems.
30 Behavior and/or lifestyle is considerably impaired by medical problems; very serious medical
problems confine him/her to bed or wheelchair most of the time (e.g., very symptomatic cases of diseases such as
metastatic cancer, multiple sclerosis, cerebral palsy, or AIDS); chronic failure of a major body system (e.g., heart,
lung, kidney, liver); on dialysis for kidney failure.
20 Major medical problems confine him/her to bed all of the time and intensive, continuous
medical treatment is required without which he/she would rapidly progress to death (e.g., late stages of metastatic
cancer, multiple sclerosis, AIDS, and the like); chronic, near terminal failure of a major body system (e.g., heart,
lung, kidney, liver); quadriplegic.
10 Chronic medical incapacity requiring basic life support (e.g., ventilator); removal of life support
would rapidly lead to death; he/she is in chronic vegetative or near vegetative state; persistent delirium or coma.
NR
Not rated
Q14
(Problem Area 7)
100 Superior life situation; currently in or has ready access to ideal living environment (neighborhood,
home, school, work, etc.); superior financial resources for his/her needs; no legal problems; extremely safe
environment. No significant ancillary problems or symptoms.
90 Good life situation; has few if any ancillary problems; no more than minor problems with living
environment, financial resources, and/or legal problems, e.g., occasionally living environment doesnt fully meet
his/her needs, rare late payment on a bill, rare parking or traffic ticket.
80 If ancillary problems are present, they are transient and cause no more than minimal
difficulty with his/her living situation, financial resources, or the law; somewhat more than average
problems with his/her living environment, financial resources, or legal problems.
70 Mild ancillary problems, e.g., some difficulty with his/her living environment, financial resources, or the
law; mild difficulty paying bills/credit cards; mild difficulty with parking or traffic tickets; occasional mild verbal
violence in his/her environment; however, generally safe living situation.
60 Moderate difficulty with living situation, finances, or the law; high risk for being in a dangerous
homeless or jail situation; criminal charges place him/her at high risk of incarceration; no stable residence and/or
income, often having to move from one living situation to another; moderate difficulty paying bills/credit cards;
evaluation and/or disposition is being made for nonviolent criminal activity (e.g., trespassing, stealing,
defacing/destruction of property, or lewd behavior); evaluation and/or disposition is being made for
competency to make decisions concerning person, estate, and/or treatment.
50 Serious problems with living situation, finances, and/or the law; frequent risks or threats of
moderate violence in his/her environment; evaluation and/or disposition is being made for relatively minor
but violent or dangerous criminal activity (e.g., minor assault, threats to do physical harm, driving while under
the influence, sexually touching someone or exposing self); serious placement difficulties, even when ready for
placement.
40 Major problems with living situation, finances, and/or the law; some real danger of being
physically injured in his/her environment; evaluation and/or disposition is being made for very violent
criminal activity (e.g., vicious assault, attempted rape, attempting to molest a child, arson).
30 Lifestyle is considerably influenced by ancillary problems; he/she is in a very dangerous homeless
or jail situation most of the time; unable to obtain basic food, shelter and/or clothing; frequent, mild to moderate
physical injuries from violence in his/her environment.
20 Major ancillary problems (e.g., he/she is in a very dangerous homeless or jail situation all
of the time); at times, his/her life is at serious risk due to lack of resources for basic food, shelter, and/or clothing
or because of high level of violence in his/her environment; evaluation and/or disposition is being made for
extremely serious criminal charges (e.g., attempted murder, vicious rape, viciously molesting a child).
10 Living/financial situation is totally inadequate; his/her life is continually at serious risk due to lack
of basic food, shelter, and/or clothing or because of extremely high level of violence in his/her environment;
evaluation and/or disposition is being made for the most extreme charges of violence (e.g., murdering anyone,
very viciously harming or very viciously raping a child, arson with intent of hurting others).
NR
Not rated
Questionnaires
Q15
19862003
#:
Age:
Instructions: For each subscale, enter the rating followed by a brief description of the relevant symptoms and behaviors. Round off
intermediate codes, e.g., 43, 62, 78, to the nearest multiple of 5, e.g., 45, 60, 80. Enter NR if Not Rated. The numbers for deriving the
Dangerousness Level are located directly below the subscale scores and are automatically indicated as one checks each subscale score.
FUNCTIONAL
DYSFUNCTIONAL
1. Psychological Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
50
40
35
25
15
5
Primarily (check one):
Not Impaired___
Antisocially Impaired___
Other Impairment___
Both___
2. Social Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
70
65
65
60
55
45
40
30
25
20
15
5
50
3. Violence
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
Primarily (check one):
Nonviolent___
Violent to Self___
Violent to Others___
4. ADLOccupational Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
50
40
35
25
15
5
5. Substance Abuse
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
45
40
35
30
25
20
15
10
5
100
95
90
85
80
75
70
65
60
55
50
Primarily (check one):
Nonabuser___
Alcohol Abuser___
Drug Abuser___
Both___
6. Medical Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
50
40
35
25
15
5
GAF Equivalent:
#1
+ #2
+ #3
+ #4
Date:
Notes
Questionnaires
Q17
1.
Social Competence
Never
Sometimes
Often
Usually
Always
A.
B.
C.
D.
E.
Never
Sometimes
Often
Usually
Always
2.
Social Interest
A.
+0
+1
+2
+3
+4
B.
+0
+1
+2
+3
+4
C.
+0
+1
+2
+3
+4
D.
+0
+1
+2
+3
+4
E.
+0
+1
+2
+3
+4
Never
Sometimes
Often
Usually
Always
3.
Personal Neatness
A.
Is sloppy
B.
+0
+1
+2
+3
+4
C.
D.
+0
+1
+2
+3
+4
Based on NOSIE30 (Gilbert Honigfeld, Roderic D. Gillis, and C. James Klett: NOSIE-30: A Treatment-Sensitive
Ward Behavior Scale. Psychological Reports 19:180182, 1966).
Q18
Kennedy NOSIE
(Page 2 of 2)
4.
Irritability
Never
Sometimes
Often
Usually
Always
A.
Is impatient
B.
C.
D.
E.
Never
Sometimes
Often
Usually
Always
5.
Manifest Psychosis
A.
B.
C.
D.
Never
Sometimes
Often
Usually
Always
6.
Motor Retardation
A.
B.
C.
(Range 76 to +28)
(76 Dysfunctional Functional +28)
Rating for last 3 days ________ or typical 3-day period during the last 2 weeks ________
Questionnaires
Q19
Name:
Hosp #:
Ward:
Date:
Instructions: Rate highest severity observed. Rate movements that occur upon activation one less than those
observed spontaneously.
Code:
e.g., movements of forehead, eyebrows, periorbital area, cheeks; include frowning, blinking, smiling,
grimacing
2.
3.
Jaw _________________________________________________________________________________ 0
e.g., biting, clenching, chewing, mouth opening, lateral movement
4.
Tongue______________________________________________________________________________ 0
5.
include choreic movements (e.g., rapid, objectively purposeless, irregular, spontaneous), athetoid movements
(e.g., slow, irregular, complex, serpentine)
6.
7.
TD Total:
Extrapyramidal Side Effects
1.
Dystonia ____________________________________________________________________________ 0
e.g., persistent spasm usually of the eyes, face, neck, or back muscles (this results in persistent abnormal
positioning of one or more extremities or of the face, neck, or trunk)
2.
Parkinsonism _______________________________________________________________________ 0
e.g., bradykinesia (decreased movement), shuffling gait, masklike facies, resting tremor, drooling
3.
Akathisia ____________________________________________________________________________ 0
e.g., restlessness, pacing, rocking, inability to sit still
4.
Rigidity _____________________________________________________________________________ 0
e.g., increased muscle tone with continuous passive resistance to movement, cogwheel rigidity
5.
6.
Akinesia_____________________________________________________________________________ 0
decreased motor movements often associated with weakness, decreased spontaneous
movements, and paresthesias
EPS Total:
Comments:
Examiner: _________________________________________________________________
Date: ___________
Q20
Examination Procedure
Either before or after completing the examination procedure, observe the patient unobtrusively, at rest (e.g., in
waiting room). The chair to be used in this examination should be a hard, firm one without arms.
1.
Ask patient whether there is anything in his or her mouth (such as gum or candy) and if there is, to
remove it.
2.
Ask patient about the current condition of his or her teeth. Ask if patient wears dentures. Do teeth or
dentures bother patient now?
3.
Ask patient whether he or she notices any movements in mouth, face, hands, or feet. If yes, ask patient
to describe and to what extent they currently bother patient or interfere with activities.
4.
Have patient sit in chair with hands on knees, legs slightly apart, and feet flat on floor. (Look at entire
body for movements while in this position.)
5.
Ask patient to sit with hands hanging unsupported. If male, between legs, if female and wearing a dress,
hanging over knees. (Observe hands and other body areas.)
6.
7.
Ask patient to protrude tongue. (Observe abnormalities of tongue movement.) Do this twice.
8.
Ask patient to top thumb with each finger, as rapidly as possible for 10 to 15 seconds; separately with
right hand, then with left hand. (Observe facial and leg movements.)*
9.
Flex and extend patients left and right arms, one at a time.
10.
11.
Ask patient to stand up. (Observe in profile. Observe all body areas again, hips included.)
Ask patient to extend both arms outstretched in front with palms down. (Observe trunk, legs, and
mouth.)*
12.
Have patient walk a few paces, turn, and walk back to chair. (Observe hands and gait.) Do this twice.
*Activated movements.
APPENDIX
A1
Appendix
A3
APPENDIX
CONTENTS
Focused Master Treatment Plans .............................................................................................................A5
Rating Master Treatment Plans..............................................................................................................A20
Rating Master Treatment Plans (Spreadsheet) ......................................................................................A27
Nursing Diagnoses..................................................................................................................................A28
Notes
Appendix
A5
In such cases, Dr. Black recommends having one comprehensive rehabilitation goal for most, if
not all, of the active problems. For example, when a patient has been admitted from the courts for
restoration of competency to stand trial, the comprehensive rehabilitation goal might be as follows:
Patient will return to the 15th Judicial District Court of Parker County upon demonstrating a
rational and factual understanding of the proceedings against him and sufficient ability to
consult with a reasonable degree of rational understanding.
In these focused Master Treatment Plans, Dr. Black suggests that one should attempt to defer most,
if not all, active problems that are not directly related to the comprehensive rehabilitation goal. These
deferred problems would be addressed after the comprehensive rehabilitation goal has been attained
and the patient has been discharged, transferred, or returned to court.
In these focused Master Treatment Plans, the patient should be expected to respond to treatment
for the active problems in a relatively short period of time, usually less than 30 days. Generally, the
longer the treatment that is needed, the more difficult it becomes to defer other active problems and to
focus on the comprehensive rehabilitation goal. Clearly, treatment for some active problems, especially
a medical problem such as diabetes or seizures, cannot be deferred.
On the following pages, Dr. Black presents a Kennedy Axis V rating and a focused Master
Treatment Plan for a patient, John Lightfoot, who was committed for treatment to restore competency
to stand trial.
Joseph L. Black, MD: Inpatient Treatment Plan Based on Functional Outcomes Measurement (Session 6, #18),
American Psychiatric Association Institute on Psychiatric Services, Innovative Programs, Orlando, FL, October 12,
2001.
A6
19862003
#: F02845
Age:
24
Instructions: For each subscale, enter the rating followed by a brief description of the relevant symptoms and behaviors. Round off
intermediate codes, e.g., 43, 62, 78, to the nearest multiple of 5, e.g., 45, 60, 80. Enter NR if Not Rated. The numbers for deriving the
Dangerousness Level are located directly below the subscale scores and are automatically indicated as one checks each subscale score.
FUNCTIONAL
DYSFUNCTIONAL
1. Psychological Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Not Impaired___
Antisocially Impaired___
Other Impairment X
Both___
Primarily (check one):
Major psychological impairment AEB auditory and visual hallucinations, delusions of grandeur, and impaired judgment and
insight.
2. Social Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
70
65
65
60
55
45
40
30
25
20
15
5
50
Major impairment in social relationships as evidenced by insensitivity to the feelings and needs of others and aggressive,
intrusive behaviors.
3. Violence
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 X 15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
Nonviolent___
Violent to Self___
Violent to Others X
Primarily (check one):
Frequently violent. Pt. is in real danger of hurting others and destroying property.
4. ADLOccupational Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Moderate difficulty in occupational and school functioning.
5. Substance Abuse
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 X 25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
Nonabuser___
Alcohol Abuser___
Drug Abuser X
Both___
Primarily (check one):
Pt.s behavior is considerably influenced by substance abuse, namely his frequent use of Peyote.
6. Medical Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Mild medical problems that may cause some difficulty in social, occupational, or school functioning, including his need to
take prescription meds on a daily basis and his need for periodic medical follow-up.
GAF Equivalent:
#1
40
+ #2
40
+ #3
20
+ #4
60
= 160 /
40
20
Date:
01/05/03
Appendix
A7
Problem List
ID #: F02845
Name of Facility
Date: 01/15/03
Problem Name
Discharge
Barrier*
1.1
Psychotic Symptoms
Yes
01/15/03
Active
2.1
Yes
01/15/03
Active
3.1
Assaultive Behavior
Yes
01/15/03
Active
4.1
No
01/15/03
Deferred
5.1
Peyote Abuse
No
01/15/03
Deferred
6.0
Health Maintenance
No
01/15/03
Active
6.0a
No
01/15/03
Active
7.0
Court Evaluation
Yes
01/15/03
Active
Date Changed
& New Status***
*DISCHARGE BARRIER: YES = Significant barrier to discharge; NO = Not a significant barrier to discharge
**ESTAB. STATUS: Active, Inactive, Inactive With Tx, Deferred, Noted
***CHANGED STATUS: Resolved, Active, Inactive With Tx, Revised, Canceled, Noted
Check if list is continued [ ]
A8
ID #: F02845
Strengths/Discharge Plan/Diagnosis
Date: 01/15/03
Patients Strengths (related to treatment and discharge):
Discharge Criteria/Planning (Include anticipated placement environment, criteria for discharge, long-term goals
needed for discharge, and anticipated target date. If a problem exists with placement, complete an Individual Problem Plan on
Placement.):
John Lightfoot will return to the 15th Judicial District Court of Parker County upon demonstrating a rational and
factual understanding of the proceedings against him and sufficient ability to consult with a reasonable degree of
rational understanding.
Discharge Coordinated By: Juan Sanchez, MSW
AXIS II:
No diagnosis
AXIS III:
No diagnosis
AXIS IV:
Ancillary Impairment =
AXIS V:
PSY =
40
SOC =
GAF Equivalent =
40
40
40
VIO =
20
ADL =
60
SAb =
Dangerousness Level =
30
MED =
70
20
Significant changes have been made in the diagnosis and those changes have been documented on the
Treatment Plan Review dated:
/ /
/ /
/ /
/ /__
Appendix
A9
Date: 01/15/03
Problem Description:
Off and on since 2000, John has had major psychological impairment AEB auditory and visual hallucinations,
delusions of grandeur, and poor judgment and insight. Recently he has reported that he had a vision in which the
Great Spirit appointed him as the leader of his people. Pt. has also made statements to the effect that local laws do
not apply to him. He has been observed by staff to sit motionless for 12 or more hours as if he were in a trance.
Johns poor focal attention, poor judgment, and poor insight impair his taking medication as prescribed.
1.
Target Date
Date/Status*
02/05/03
Target Date
1.
01/29/03
2.
John will seek out his unit advisor to get his needs met and to
discuss issues regarding his treatment daily for 1 week.
01/22/03
3.
01/22/03
4.
John will accept prescribed medication and necessary lab work for
2 weeks.
01/29/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
A10
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
1.
Date/Status*
Psychoactive meds per Dr. Blacks order by licensed vocational nurse (LVN) supervised
by the RN under the direction of the Nurse Manager.
Joseph Black, MD
Marilyn Davis, RN
2.
Unit advisor will talk with John for 2 hours per week.
Medication education group with LVN will meet with pt. 2 hours per week.
Marilyn Davis, RN
4.
The case coordinator will correspond with mental health assistant and primary
correspondent, once John signs consent, in order to facilitate aftercare planning.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Appendix
A11
Date: 01/15/03
Problem Description:
John has major impairment in social relations AEB his insensitivity to the feelings and needs of others and his
aggressive, intrusive behaviors.
1.
Target Date
Date/Status*
02/05/03
Target Date
1.
01/29/03
2.
01/29/03
3.
01/29/03
4.
02/05/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
A12
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
1.
Date/Status*
Pt. will participate in on-unit psychosocial rehab group (Social Skills Group) 2 hours
per week.
Pt. will participate in on-unit psychosocial rehab group (Relating Alternatives Group)
2 hours per week.
Pt. will participate in on-unit psychosocial rehab group (Cultural Awareness Group)
1 hour twice per week.
Pt. will participate in Problem-Solving Group with his family 1 hour per week.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Appendix
A13
Date: 01/15/03
Problem Description:
John has a history of aggressive and assaultive behavior. He is a known gang member; he is reputed to be a gang
leader. Currently he is frequently violent. He is felt to be in real danger of hurting others and destroying property.
Target Date
1.
02/05/03
2.
Johns K Axis score for Violence will improve from his current
score of 20 to a score of 60.
02/05/03
Target Date
1.
01/29/03
2.
01/29/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
A14
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
1.
Date/Status*
Psychoactive meds will be administered per Dr. Blacks order by the LVN/RN
supervised by the RN under the direction of the nurse manager.
Joseph Black, MD
Marilyn Davis, RN
2.
Pt. will participate in on-unit psychosocial rehab group (Stress and Anger Management
Group) 2 hours per week.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Appendix
A15
Date: 01/15/03
Problem Description:
Pt. has mild medical problems, including his need to take prescription meds on a daily basis and his need for
periodic medical follow-up. Pt. may have impairment of conscious awareness due to a seizure disorder.
1.
1.
Target Date
Date/Status*
Ongoing
Target Date
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
A16
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Medical:
1.
Doctor will work up John for the possibility of a seizure disorder, including EEG and
referral to Neurology Clinic, and will make appropriate treatment recommendations.
Joseph Black, MD
Virginia Coleman, MD
Nsg. staff will monitor John daily and follow up on any signs and symptoms of illness.
2.
Nsg. staff will administer all prescribed medication and treatments as ordered and will
document Johns compliance.
3.
Nsg. staff will assess and document pt.s level of understanding of prescribed treatment
and provide necessary teaching at Johns level of understanding.
4.
Nsg. staff will prompt John to comply with treatments, lab work, and any other
medical procedures. If needed, nsg. staff will support and accompany John to
procedures. Staff will offer praise for compliance and will document compliance.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Appendix
A17
Date: 01/15/03
Problem Description:
John was referred to North Texas State HospitalVernon pursuant to Article 46.02 Section 5(a) of the Texas Code of
Criminal Procedure after he was found incompetent to stand trial on charges of aggravated assault with a deadly
weapon (to wit: lance, revolver, and scalping knife) and of theft greater than $20,000 (horses and cattle) out of the
15th District Court of Parker County, Texas.
When local examiners evaluated him, pt. sat motionless, stared straight ahead, and refused to speak. He was
subsequently found incompetent to stand trial.
1.
Target Date
Date/Status*
02/05/03
Target Date
1.
02/05/03
2.
02/05/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
A18
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
1.
Date/Status*
The treatment team will meet with John as a part of the competency training group for
2 hours per week.
Pt. will receive counseling with case coordinator 1 hour per week to reinforce realitybased statements that promote competency and discourage those that do not.
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Appendix
A19
ID #: F02845
Signature Page
Area: Spruce Unit
Name of Facility
Date: 01/15/03
Patient Participation in Treatment Planning (check as appropriate):
Contributed to goals and plan
Aware of plan content
Present at team meeting
Refused to participate
Unable to participate
Refused to sign plan
X
X
Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Joseph Black, MD
Date:
01/15/03
Print Name:
Joseph Black, MD
Nurse:
Marilyn Davis, RN
Date:
01/15/03
Print Name:
Marilyn Davis, RN
Social worker:
-XDQ6DQFKH]06:
Date:
01/15/03
Print Name:
Psychologist:
Date:
01/15/03
Print Name:
Rehabilitation:
Date:
01/15/03
Print Name:
Other:
Date:
Print Name:
Note: The above signatures document that the participants have reviewed the Master Treatment Plan on the date
signed and that they agree with the plan, unless indicated otherwise under Staff Members Comments.
ALL SUBSEQUENT CHANGES ON THIS PLAN SHOULD BE DATED, INITIALED, and supported by associated progress
note(s) and/or Treatment Plan Review(s).
A20
=
=
=
=
=
Not applicable
Absent
Unacceptable
Mild to moderate problems
Acceptable to excellent
Problem List
Strengths
Discharge plan
Psychiatric diagnosis
Problem description
Long-term goals
Short-term goals
Treatment modalities
Changes in goal status and treatment modalities
Signature page
Record the score for each section on the summary sheet. Determine the plan rating as follows:
1.
2.
3.
Appendix
A21
SUMMARY SHEET
Master Treatment Plan Rating Form
2003 James A. Kennedy, MD
Patients Name:
ID#:
Raters Name:
Date of Plan:
Section
Rating
Date of Rating:
Comments
1. Problem List
2. Strengths
3. Discharge plan
4. Psychiatric diagnosis
5. Problem description
6. Long-term goals
7. Short-term goals
8. Tx modalities
9. Signature page
10. Goals and Tx modalities
status changes
Total
Comments:
A22
ID#:
Raters Name:
Date of Plan:
NA
0
1
2
3
=
=
=
=
=
Date of Rating:
Not applicable
Absent
Unacceptable
Mild to moderate problems
Acceptable to excellent
PROBLEM LIST
1. Problem List
Rating
Comments
Problem number
Problem name
Discharge barrier
Total
Appendix
STRENGTHS/DISCHARGE CRITERIA/DIAGNOSIS
2. Strengths
Rating
Comments
Total
3. Discharge Plan
Rating
Comments
Discharge environment
Criteria for discharge
Target discharge date
Discharge coordinator
Total
4. Psychiatric Diagnosis
(DSM-IV-TR)
Rating
Comments
Axis I
Axis II
Axis III
Axis IV (ancillary impairment)
Axis V (GAF-Eq)
Total
A23
A24
Rating
Comments
Total
6. Long-Term Goals
Rating
Comments
Total
Appendix
Continued
Rating
Comments
Total
8. Treatment Modalities
Rating
Comments
Total
A25
A26
SIGNATURE PAGE
9. Signature Page
Rating
Comments
Total
Rating
Comments
Total
Appendix
A27
Inpt./
Outpt.
P. List
Stgths.
D/C Crit.
Dx.
Albert Smith
Inpt.
David Jones
Outpt.
George Jones
Outpt.
Inpt.
Michael Jones
Outpt.
Linda Jones
Outpt.
Robert Jones
Outpt.
Name
Mary Jones
Prob.
D.
Ltg. Stg.
Tx.
Mod.
Sig.
Total
Plan
Rating
27
3.0
25
2.7
25
2.7
22
2.4
22
2.4
21
2.3
21
2.3
Chgs.*
Janet Jones
Inpt.
17
1.8
Alice Jones
Inpt.
15
1.7
William Jones
Inpt.
14
1.6
Brenda Jones
Inpt.
AVERAGE =
12
1.3
2.1
2.5
1.4
2.5
1.9
2.5
2.1
2.6
2.5
20.1
2.2
*This spreadsheet represents ratings of just-completed Master Treatment Plans and, therefore, does not include ratings of subsequent
changes (Chgs.) in Goals and Modalities.
A28
Nursing Diagnoses
The following pages list nursing diagnoses from Nursing Diagnoses: Definitions and Classifications that
have been categorized according to the Kennedy Axis V subscale areas. This reference should help
nurses to locate the appropriate nursing diagnosis when incorporating the Nursing Care Plan into the
Master Treatment Plan.
This categorization system has been reviewed by Rose Mary Carroll-Johnson, MN, RN, editor,
Nursing Diagnosis: The International Journal of Nursing Language and Classification. Many of the nursing
diagnoses fit into more than one subscale area; therefore, notes in italics help to separate many of the
nursing diagnoses into two or more subscale areas. For example, Activity Intolerance is included under
the subscale areas of Psychological Impairment and Medical Impairment. Its inclusion under
Psychological Impairment is clarified as Activity Intolerance (related to Psy. Factors) and its inclusion
under Medical Impairment is clarified as Activity Intolerance (related to Medical Factors).
When using the nursing diagnosis, it is not necessary to include the additions to the nursing
diagnoses. Also, some nursing diagnoses may extend into subscale areas that have not been indicated.
This categorization includes only what is felt to be the most likely area or areas that pertain. This is a
guideline; you must use your own clinical judgment when choosing a particular nursing diagnosis, that
is, when pairing a nursing diagnosis to a particular problem name in the Individual Problem Plan
section of the Master Treatment Plan or Nursing Care Plan.
Health Maintenance is commonly used as a problem name in treatment planning to allow
clinicians to list treatments that are intended to maintain good or optimal physical health, even when
the patient does not have any significant medical problems. There was no equivalent nursing diagnosis
to pair with Health Maintenance; therefore, it was added to NANDAs list. As described earlier, it is set
in italics to indicate that it is not an official NANDA-approved nursing diagnosis.
Nursing Diagnoses: Definitions and Classifications 20012002. Philadelphia, PA, North American Nursing Diagnosis
Association, 2001.
Appendix
A29
A30
2. Social Skills
Communication, Verbal, Impaired
Injury, Risk for (related to Social Skills Deficits)
Social Interaction, Impaired (related to Social Skills Deficits)
3. Violence
Falls, Risk for (related to Violence to Self)
Injury, Risk for (related to Violence to Self)
Self-Mutilation
Self-Mutilation, Risk for
Suicide, Risk for
Violence: Other-Directed, Risk for
Violence: Self-Directed, Risk for
4. ADLOccupational Skills
Breastfeeding, Ineffective (related to ADL Skills Deficits)
Breastfeeding, Interrupted (related to ADL Skills Deficits)
Confusion, Chronic (related to Retardation/Dementia)
Environmental Interpretation Syndrome, Impaired
Falls, Risk for (related to ADL Skills Deficits)
Health Maintenance, Ineffective
Health-Seeking Behavior, Impaired (related to ADL Skills Deficits)
Home Maintenance, Impaired
Injury, Risk for (related to ADL Skills Deficits)
Knowledge, Deficient
Memory, Impaired (related to Retardation/Dementia)
Poisoning, Risk for (related to ADL Skills Deficits)
Self-Care Deficit, Bathing/Hygiene (related to ADL Skills Deficits)
Self-Care Deficit, Dressing/Grooming (related to ADL Skills Deficits)
Self-Care Deficit, Feeding (related to ADL Skills Deficits)
Self-Care Deficit, Toileting (related to ADL Skills Deficits)
Suffocation, Risk for (related to ADL Skills Deficits)
Therapeutic Regimen Management, Effective
Appendix
5. Substance Abuse
Confusion, Acute (related to Substance Abuse)
Confusion, Chronic (related to Substance Abuse)
Coping, Ineffective (related to Substance Abuse)
Development, Risk for Delayed (related to Substance Abuse)
Falls, Risk for (related to Substance Abuse)
Family Processes, Dysfunctional: Alcoholism
Health Maintenance, Ineffective (related to Substance Abuse)
Injury, Risk for (related to Substance Abuse)
Protection, Ineffective (related to Substance Abuse)
Sensory Perception, Disturbed (related to Substance Abuse)
Thought Processes, Disturbed (related to Substance Abuse)
6. Medical Impairment
Activity Intolerance (related to Medical Factors)
Activity Intolerance, Risk for (related to Medical Factors)
Airway Clearance, Ineffective
Aspiration, Risk for
Body Temperature, Risk for Imbalanced
Breathing Pattern, Ineffective
Breastfeeding, Effective
Breastfeeding, Ineffective (related to Medical Factors)
Breastfeeding, Interrupted (related to Medical Factors)
Cardiac Output, Decreased
Confusion, Acute (related to Medical Factors)
Confusion, Chronic (related to Medical Factors)
Constipation
Constipation, Risk of
Dentition, Impaired
Development, Risk for Delayed (related to Medical Factors)
Diarrhea
Disuse Syndrome, Risk for
Dysreflexia, Autonomic
Dysreflexia, Risk for Autonomic
Falls, Risk for (related to Medical Factors)
Fluid Volume, Deficient (related to Medical Factors)
Fluid Volume, Deficient, Risk for (related to Medical Factors)
Fluid Volume, Excess (related to Medical Factors)
Fluid Volume, Imbalanced, Risk for (related to Medical Factors)
Gas Exchange, Impaired
Growth and Development, Delayed (related to Medical Factors)
Health Maintenance
Health Maintenance, Enhanced
Health Seeking Behaviors (enhanced)
Hyperthermia
Hypothermia
Incontinence, Bowel
Incontinence, Urinary, Reflex
Incontinence, Urinary, Risk for Urge
Incontinence, Urinary, Stress
Incontinence, Urinary, Total
A31
A32
7. Ancillary Impairment
Breastfeeding, Interrupted (related to Environmental Factors)
Caregiver Role Strain
Caregiver Role Strain, Risk of
Conflict, Parental Role
Coping, Community, Ineffective
Coping, Community, Readiness for Enhanced
Coping, Compromised Family
Coping, Disabled Family
Coping, Readiness for Enhanced Family
Development, Risk for Delayed (related to Environmental Factors)
Energy Field, Disturbed
Falls, Risk for (related to Environmental Factors)
Family Process, Interrupted
Growth and Development, Delayed (related to Environmental Factors)
Growth, Disproportionate, Risk for Altered (related to Environmental Factors)
Infection, Risk for (related to Environmental Factors)
Injury, Risk for (related to Environmental Factors)
Injury, Risk for, Perioperative Positioning
Appendix
A33
Notes