UNM INPATIENT PSYCHIATRY RESIDENT GUIDE

This is an outline of expectations for residents working on the inpatient rotations at the University of New Mexico
Mental Health Center. The information covered in this manual is current as of June 2007. Some required items are
subject to change over time. Other items are suggestions on how to go about doing the daily work in an efficient
manner. You may read it all at once or refer to a section as the need arises. Either way, it is meant to be only one
source of information, not the absolute bottom line on the exact rules for operating on the inpatient services. If in
doubt, please speak with your chief resident or attending for clarification.

Initial Contributors in 2006

Chris Abbott, MD
Karen Arnold, MD
Victoria Barrow, MD
Revised and Updated for 2007
Aaron Brodsky, MD
Pat Rabjohn, MD, Ph.D

TABLE OF CONTENTS
1.
2.
3.
4.
5.
6.
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8.
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10.
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14.
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MHC Daily Resident Schedule

Admission Criteria
Admission Orders
History and Physicals
Mental Status Examinations
Emergency Medication Orders
Progress Notes
Discharging Patients
Discharge Summary
Legal Matters/Court Paperwork
Legal Matters/Court Hearings
Informed Consent/Decisional Capacity
Teaching Medical Students
Patient Assignments/The Hit List
Psychiatric Emergency Services
Children/Adolescents in PES
Back-up Call
Evening Check-Out at MHC
Medication Reconciliation and Crisis Stabilization Services
MHC Float Resident
Geriatric Survival Guide
Important MHC Phone Numbers
MHC Dictation Guide
Locked Seclusion/Restraints

3-4
5
6-7
8
9
10
11
12-13
14
15-16
17-18
19
20
21
22-23
24
25
26
27
28
29-30
31
32
33

MHC DAILY RESIDENT SCHEDULE

Resident Pre-Rounding
It is recommended that you arrive on the ward before Morning Report to record vital signs, check the chart for
changes over the night/weekend, to record PRN medications given and to see if patient was medication compliant.
Vitals are recorded in a three-ring binder at the nurses station. PRNs are in the medication book either at the nurses
station or in the medication room. Both are organized by team. Vitals and PRNs are required in every daily
progress note. To avoid unnecessary conflict, dont try to take the patient charts away from the HUC (Ward clerk)
when she is doing her morning chart check.
Morning Report
Morning report is held at 08:00 in the Roadrunner Room near the outpatient offices and is required for all in-patient
residents and medical students as well as anyone who admitted patients overnight or over the weekend. Residents
give and receive checkout on patients admitted after hours (overnight or weekends). Residents present in the
following order: moonlighter, weekend coverage (if applicable) and overnight MHC resident. All are expected to
give a concise, oral presentation lasting less than two minutes that justifies the precipitant and the rationale for the
admission decision, diagnostic impression, and proposed initial treatment. Medical students who admitted a patient
overnight will be expected to present as well. Following resident presentations, the overnight resident will have an
opportunity to discuss any emergency psychiatric issues (the difficult patient that was not admitted, team call, when
to give IM medications in PES, etc). These cases should also be presented in a clear, concise fashion. Finally,
housekeeping issues will be addressed including assignment of the resident float, if applicable.
Morning Rounds
Depending on the attending, rounds to interview the patients may begin at the end of morning report or at a different
scheduled time. Also depending on the attending, rounding on the patients can range from walking about the ward
talking with each patient individually to having a group meeting with all the patients together. Check with your
attending to she if s/he wants you to have interviewed your patients prior to morning rounds. Your daily interview
with the patient should include the pertinent patient problems, target symptoms, side effects to medications, and
mental status findings. If the patient complains of auditory hallucinations, for example, check to see if the
hallucinations have changed in content, frequency, intensity or duration. If the patient was admitted for depression
and suicidal ideation, check to see if the patient is still suicidal and evaluate the severity of the patients mood. The
first interview with the patient after admission will be more comprehensive and include the patients history of what
events lead up to hospitalization, information to rule out or confirm other possible diagnoses, prior medications,
medication compliance, past psychiatric history, substance abuse history, and current social situation. The extent of
this interview may vary depending on whether the patient is new to the UPC or has several prior admissions.
Kardex
During Kardex the treatment team (attending, resident, nurse, social worker, nutritionist, and utilization review
representative) meets to discuss the daily plan for each patient. This is when the nurse gives the report on the
patients behavior from the staff and social work discusses pertinent issues including the discharge plan. The UR
representative may ask about the patients acuity and the need for continued hospitalization. Orders are written for
each patient. Most attendings allow you to write the orders for each patient when that patient is discussed.
Generally, you should not answer pages during Kardex. Attendings may also request that you do a formal
presentation of the mental status exam for each patient.
Resident Daily Work
At the end of Kardex, the resident can start his/her daily work which includes writing daily notes, writing discharge
orders and scripts, making telephone calls to family members, treatment guardians, etc, consenting patients for
medications, holding family meetings, and learning activities such as case conference. We recommend that you
prioritize by doing discharge orders first, followed by court petitions. (These two activities have a time factor to
them. See instructions on discharge orders and court paperwork for more information on how to complete these.)
Some people make telephone calls first so they can include the information from the telephone calls in the daily
note. Sometimes it is helpful to make telephone calls early as talking with family members may affect the daily
plan. Other people like to get the notes out of the way and then have the rest of the day without this task hanging
over their heads. Social work usually arranges the family meetings; it is usually the resident and the social worker
that run family meetings. Some attendings will check back late in the afternoon to get updated on any changes that

have happened throughout the day. Attendings are always available by pager throughout the day for immediate
questions that arise. Please contact the attending regarding any new admissions. At times, the attending will do the
initial interview with you. You should discuss the plan for each new patient with the attending before writing orders.
Court Hearings
Court hearings for commitment and treatment guardian appointments are held between 8:30 and 12:00 every day
except Wednesday. Most often they are scheduled into 30-minute time slots; however, occasionally, there is a
trailing docket for the day. The court will call the ward letting the staff know when they are ready for the patients
hearing. The staff will notify the resident. A staff member will accompany the patient to the courtroom. Either the
staff member or the resident will bring the patients chart to the courtroom. Whether it is during morning report,
rounds or Kardex, the resident is required to stop his/her current activity and go to court to testify.
Medicine Consults
Judy Gillum is the MHC inpatient nurse practitioner who handles our requests for help with medical problems. She
is the designated go-to person between our services and the hospitalists. Please call her if you have a medical
question. She will handle it herself, call the medicine consult for guidance and directions, or provide medicine with
the request and all pertinent available data (in this case please make sure a consult form is completed.)
Requests for Discharge from the Hospital
The issue does come up that patients may ask to be discharged from the MHC. The resident physician needs to
make a determination of whether to release the patient or initiate a 5-day hold (in consultation with the attending, if
possible.) This must be addressed in a timely manner. The resident caring for the patient or the house officer on-call
needs to evaluate the patient, discuss the treatment options and discharge plan with the patient and then contact the
attending to make a decision. The discussion should then be documented in the patients chart. If the decision is to
put the patient on a 5-day hold, then you should do the appropriate paperwork, including trying to get the patient to
sign the involuntary admission form. You should also explain to the patient why you and the attending made the
decision to put him or her on a hold. When communicating your plans with a cross-cover resident about a patient
you think may ask for discharge, you may not write the order If patient asks to leave, put patient on a hold. This
is illegal! You may write the order If patient asks to leave, please call house officer to evaluate options, including
need for a hold. You can verbally sign out to the resident on-call Do not let this person go under any
circumstances. You may also document in your daily note why it would be best for the house officer on-call to
strongly consider placing the patient on a 5-day hold. (Example: If patient requests discharge would strongly
recommend placing patient on a 5-day hold as the treatment team feels the patient continues to represent an
imminent likelihood of danger to self secondary to suicidal ideation, paranoid delusions and disorganized thinking.)
Patient Placement
The geriatric psychiatry in-patient service serves an elderly population, including many that are frail. The general
guideline is that people aged 60 or older are admitted preferentially to the geriatric ward. If there is an acutely
agitated patient age 60 or older who might present a danger to frail peers, it is okay to admit the person to the East or
West Ward. To make maximum use of our beds, patients 51-59 may be admitted to any of our units at your
discretion. Your discretion should include consideration of whether the patient might resent a danger to the frail
elderly patients if admitted to the geriatric ward. People who are 18-50 years of age are admitted to East or West. In
compliance with the Americans with Disabilities Act, all three wards are able to handle medical co-morbidities.
There are a few exceptions, such as patients with a primary diagnosis of an eating disorder. Eating disorder patients
are admitted to the geriatric ward, Dr. Apfeldorfs team if possible, as he is an expert in treating eating disorders. See
the Gero Ward Survival for details. Please discuss possible transfers of patients to or from the geriatric ward with
Dr. Apfeldorf because of the limited number of beds available.

ADMISSION CRITERIA
The goal of acute inpatient care is to stabilize patients who display acute psychiatric conditions associated with a
relatively sudden onset and a short, severe course, or a marked exacerbation of symptoms associated with a more
persistent, recurring disorder. Typically, the patient poses a significant danger to self or others or displays severe
psychosocial dysfunction. The goal of the first three sentences of any admission history should be to document the
criteria and precipitants necessitating this level of care.
Admission Criteria

The patient demonstrates symptomology consistent with DSM-IV-TR Axis I and Axis II diagnoses that require,
and can reasonably be expected to respond to, therapeutic intervention.
There is evidence of danger to self (patient) or others that could result in serious harms. Examples are:
Homicidal thoughts with plan.
A suicide attempt that is serious by degree of lethality and intentionality or suicidal ideation with a plan and
means.
Impulsive behavior and/or intoxication increase the need for consideration of this level of care.
Assessment should include an evaluation of the following: the circumstances of the suicide attempt or
ideation, the method used or contemplated and statements made by the patient.
The presence of continued feelings of helplessness and/or hopelessness, severely depressed mood, recent
significant losses, and the lack of an available and responsible support system.
Current threats or behavior resulting from an Axis I disorder with a clear risk of escalation or future repetition
(i.e., has a plan and means).
A recent history of significant self-mutilation (non-chronic), significant risk-taking or loss of impulse control
resulting in danger to self or others.
A recent history of violence resulting from an Axis I or II disorder.
Command hallucinations directing harm to self or others.
Disordered/bizarre behavior or psychomotor agitation or retardation that interferes with the activities of daily
living to such a degree that the patient cannot function at a less intensive level of care.
Disorientation or memory impairment that is due to an Axis I disorder and endangers the welfare of the patient
or others.
The patient manifests a major disability in social, interpersonal, occupational and/or educational functioning
that is leading to dangerous or life-threatening functioning and that can only be addressed in an acute inpatient
setting.
Inability to maintain adequate nutrition or self-care due to a psychiatric disorder and family/community support
cannot be relied upon to provide essential care.
The patient has experienced severe or life-threatening side effects of atypical complexity from using therapeutic
psychotropic drugs.
There is a co-existing medical illness that complicates the psychiatric illness or treatment. Together, the
illnesses or treatment pose a high risk for the consumer and cannot be managed outside a 24-hour treatment
setting.

ADMISSION ORDERS
Vital Signs and Blood ETOH
Always review a patient's vital signs before ordering medications.
If you suspect a patient is intoxicated, determine their blood ETOH level before ordering medications.
If a patient is acutely intoxicated and appears to be in delirium tremens already, they may need a monitored bed
- something we dont have at the MHC.
Sample Alcohol Detox Orders
Vital signs: Q 4 hours while awake x 48 hours, then Q shift
CIWA Q 4 hours while patient is awake.
If CIWA-AR is >=10 repeat q 1 hour until score <10 and then go back to q4 hours
Every time CIWA-AR scale is administered (either q 1 hour or q 4hour) give medication according to the
following (ordering physician should pick ONE benzodiazepine)
Call MD if CIWA-AR >=25 or >6 after 3 doses
Call MD if pt appears over sedated, disoriented, complains of distressing visual, auditory or tactile
hallucinations, respiratory rate is <10 or >40, has a seizure or has a cardiac arrhythmia
Call MD if total dose in 24 hours > 500mg chlordiazepoxide, > 300 mg oxazepam, or > 10mg lorazepam
If CIWA-AR scale is < 10 do not give benzodiazepine
Discontinue CIWA-Ar and benzodiazepine is score is < 10 for 24 hours
Choose one of the options below
Chlordiazepoxide 25mg PO q1-4h PRN CIWA-AR >=10 <15
Chlordiazepoxide 50mg PO q1-4h PRN CIWA-AR >= 15 < 20
Chlordiazepoxide 75mg PO q1-4h PRN CIWA-AR >=20 <25
Chlordiazepoxide 100mg PO q1-4h PRN CIWA-AR >=25
Call MD if dose > 500mg in 24 hours
If CIWA-AR is < 10 for 24 hours, then discontinue Chlordiazepoxide.
-OR Oxazepam 15mg PO q1-4h PRN CIWA-AR >=10 <15
Oxazepam 30mg PO q1-4h PRN CIWA-AR >= 15 < 20
Oxazepam 45mg PO q1-4h PRN CIWA-AR >=20 <25
Oxazepam 60mg PO q1-4h PRN CIWA-AR >=25
If CIWA-AR is <10 for 24 hours, then discontinue Oxazepam
-OR Lorazepam 1mg PO q1-4h PRN CIWA-AR >=10 <15
Lorazepam 2mg PO q1-4h PRN CIWA-AR >=15
If CIWA-AR is <10 for 24 hours, then discontinue Lorazepam
Additional medications for the patient with alcohol dependence:
Thiamine 100mg PO Q day; Folate 1mg PO Q day; MVI 1 tab PO Q day
Opiate Detox Orders
While uncomfortable, opiate detox is not life threatening. Methadone for opiate dependence may only be ordered at
the MHC if the dose has been verified by the patients methadone clinic. After hours this is impossible, so you may
choose some or all of the following comfort medications. If the patient is appropriate, inquire about
Buprenorphine starts during the admission by contacting the Substance Abuse fellow.

Vitals q 6 hours while awake

Clonidine 0.1mg PO q6h PRN withdrawal symptoms DBP>50<65

Clonidine 0.2mg PO q6h PRN withdrawal symptoms DBP >=65<85
Clonidine 0.3mg PO q6h PRN DBP >=85
Hold Clonidine for orthostatic symptoms and DBP<=50, SBP <90
Ibuprofen 400 mg PO QID PRN muscle aches, pains
Levsinex 0.375mg PO q12h PRN GI spasm
Robaxin 750 mg PO QID PRN muscle spasms
Oxazepam 30mg PO Q6hr PRN anxiety
Trazodone 50mg PO Qbedtime PRN insomnia, may repeat x 1
Acetaminophen 325mg PO Q4hr PRN headache
Hydroxyzine 25mg PO TID PRN anxiety
Promethazine 25mg PO/IM/PR Q6hr PRN nausea, vomiting
MVI 1 tab PO Qday
Thiamine 100mg PO Qday

ECT Patients
Occasionally, you will admit a patient on the night prior to ECT. Use these orders to ensure they are prepared for
their procedure the following morning.

Patient scheduled for ECT on _______ (date).

NPO at midnight before scheduled ECT.
No Benzodiazepines after 1700 on the evening prior to ECT.
Specify which medications to give with a sip of water prior to ECT and which to hold until after ECT.
Before ECT have patient shower, empty bowel/bladder and remove dentures/jewelry.

Orders for Diabetic Patients

1500 calorie ADA diet

CBGs QAC and QHS

Sliding Scale Insulin Protocol: The VA has this SSI as a quick order tab. It will have to be written out by

hand at MHC. It should be modified as necessary for geriatric and medically frail patients.
CBG < 50, give 1 amp D50 and contact HO

CBG 51-150, do nothing

CBG 151-200, give 2 units regular insulin

CBG 201-250, give 4 units regular insulin

CBG 251-300, give 6 units regular insulin

CBG 301-350, give 8 units regular insulin

CBG 351-400, give 10 units regular insulin

CBG > 400, give 12 units regular insulin and call HO

Ordering Admissions Labs

All psychiatric patients should have the following labs ordered at the time of admission: CBC, Chem 10, B1, B12,
Folate, UDM, LFTs, TSH, RPR. When patients are taking Lithium, VPA, Tegretol, or Phenytoin or any other AntiEpileptic drugs, order a level before scheduling these medications.
Additional Lab suggestions for special populations as follows:

Alcohol Dependence: Hep C, HIV

Geriatric Patients: UA w/ C&S, Pre-albumin & Phos (if concerns about malnutrition), Free T4, EKG
Women: Urine Pregnancey Test
Patients on Antipsychotics: fasting glucose and lipids (if none available during the last 6 months), CPK,
waist circumference, HbA1C, and admission weight

Cardiac Patients: An EKG should be ordered for any patient with known CAD, significant risk factors for
CAD, history of prolonged QTc, recent cocaine or methamphetamine use, or when considering a TCA for anyone
over 40, Lithium for anyone over 50 or Geodon on anyone
Delirious Patients: NH4 (cirrhotic patients), UA w/ C&S, Free T4, HCV, HIV

Homeless Patients: Hep C, HIV, place PPD

THE HISTORY AND PHYSICAL

The admission history must be concise and well-organized. You may not write unknown or not obtained for any
element of the H&P. The following is a guideline of information that must be included in your admit note. There are
many acceptable variations.
1.
2.
3.

4.
5.
6.
7.
8.
9.

10.
11.
12.

13.

14.

ID - Age, ethnicity, marital and employment status.

Chief Complaint - usually in quotes.
History of Present Illness - arranged in the following order:
Precipitant to admission including how the patient was brought to the hospital, along with current
psychosocial stressors.
Current symptoms and chronology (psychosis? Illicit drugs? SI?).
Brief review of symptoms to narrow differential diagnosis (period of decreased need for sleep? substances?
head injury? - a psychiatric review of symptoms).
Previous Psychiatric History include inpatient admissions, outpatient providers/medication trials, and
any suicide attempts and episodes of violence.
Substance Abuse History - longest period of sobriety, treatment, drugs of choice, withdrawal symptoms
(delirium tremens, withdrawal seizures) - gather information for abuse or dependence criteria including
consequences of use (DUI).
Family Psychiatric History include mental illness and completed suicides, if applicable.
Social History - include abuse history, legal history, highest level of education and employment history.
Include current living situation.
Review of Systems include pertinent positives, otherwise you can write, Patient denies. At least three
categories need to be included.
Physical Exam - You should not document patient refused. If the VA ER documented a physical exam as
part of their medical clearance, you may refer to their note instead of repeating an exam with an uncooperative
patient. For non-cooperative patients, try and complete the physical exam before discussing the admission.
However, if you feel you cannot safely perform an exam (agitation or threatening behavior), document that
patient was not cooperative and the potential for violence was too great to perform the exam.
Mental Status Exam - always included. See Mental Status Exam section for specifics.
Impression/Formulation: - Summarize the pertinent positives and negatives and further explain the
rationale for admission.
Axes I-V:
The goal of stating the primary diagnosis is to give everyone a working diagnosis. The NOS diagnosis may
be legitimately used from the VA ER. Some patients may be too agitated in the emergency setting to
determine a more specific working diagnosis. Once admitted, the primary working diagnosis should be
updated, both in your notes and in the physicians order. Please do not use a NOS diagnosis if another
identifiable disorder is more accurate.
The Axis I diagnosis should be as specific as possible and include the fifth digit (0 = unspecified, 1 =
subchronic, 2 = chronic, 3 = subchronic with acute exacerbation, 4 = chronic with acute exacerbation,
5 = in remission).
For example, schizophrenia, disorganized type chronic with acute exacerbation is coded 295.14.
Axis IV should include the list of psychosocial problems (primary support, social environment,
occupational, etc).
If you are admitting someone, Axis V should be < 20 (10-20: some danger of hurting self or others).
Plan At minimum your plan should state: Pt admitted to the adult/geriatric unit on a
voluntary/involuntary basis for evaluation and stabilization. Medical work-up will continue to rule out organic
contributors to current presentation. Treatment plan to include ward milieu and behavioral therapy, supportive
psychotherapy and pharmacotherapy. You can be more specific as you become more astute at developing
treatment plans.
Estimated Length of Stay - Typically 5 to 7 days, but can be longer

MENTAL STATUS EXAMINATION

The Mental Status Examination (MSE) is an important part of the History and Physical and will be a key component
of your daily progress notes. In addition, several attending psychiatrists will expect a formal presentation of the
MSE on rounds each day.
The following is a summary from the Concise Textbook of Clinical Psychiatry (Kaplan and Sadock, 2004). The
MSE is how the psychiatrist summarizes his/her observations and impressions of the patient at the time of the
interview. It is not what the nursing staff observed, it is what you observed during your time on that particular day
with the patient. Some residents focus solely on the MSE in their note, while some residents write the shortest one
they can and focus on other parts of their examination/interview. It is our position that the MSE should be a concise,
focused examination and impression of the patient. The following provides general categories, followed by common
(but not all) terms used as descriptors.
This is not meant to be comprehensive; there are several textbooks that do that (The Psychiatric Mental Status
Examination, Trzepacz and Baker, 1993). Below is a summary of the minimum expected in your daily MSE.
General Description:
Appearance: describe the patients appearance and physical impression
Healthy, lethargic, disheveled, tense, diaphoretic, well-groomed, etc
Behavior and Psychomotor Activity: describe their mannerisms
Tics, restless, hyperactive, pacing, psychomotor retardation/slowing, etc
Attitude towards examiner:
Cooperative, friendly, guarded, inattentive, defensive, seductive
Sensorium and Cognition: assessment of the patients brain function and intelligence
Consciousness:
Alert, lethargic, stuporous, comatose
Orientation: disorders are separated according to time, place, and person
To place, time, but not situation (pt thought he was here for a research study)
Other parts may include concentration, attention, abstract thought, etc
Mood and Affect:
Mood: you ask the patient, how would you describe your mood today?
Put in quotes whatever the patient states; down, horny
Affect: this is your impression of the patients mood based on their behavior
Congruent, constricted, blunted, flat, expansive, labile
Speech and Language: it is important to comment on the quantity and quality of a patients speech
Rate: talkative, rapid, pressured, hesitant, etc
Volume: loud, normal, soft, etc
Tone: dramatic, emotional, etc
Thought Process and Thought Content:
Thought Process: how the patient puts together ideas and associations
Rational or irrational, relevant or irrelevant, goal-directed or not
Flight of ideas, loose associations, thought blocking, circumstantial, tangential
Thought Content: what the patient is actually thinking about or focused upon
Delusions, obsessions, suicidal plans, hallucinations
Insight and Judgment:
Insight: the patients awareness of his/her illness
Poor, fair, good

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Judgment: the patients awareness of the outcome of his/her behavior

Poor, fair, good
EMERGENCY MEDICATION ORDERS
Occasionally, patients need emergent psychotropic medications to prevent harm to themselves or others.
Remember to offer patients PO medications first.
Include actual dosage, not dosage range (Zyprexa 5mg, not Zyprexa 2.5 10mg)
Choose the shortest scheduled time permitted by the drug manufacturer, not a time range
Include a not to exceed ceiling for 24 hours
Include a very specific indication prn acute agitation
Five IM neuroleptic preparations are available and are discussed below
Thorazine (Chlorpromazine) IM
Thorazine is rarely used and only under exceedingly special circumstances.
Unless directed by an attending physician, Thorazine should not be ordered by a resident.
Haldol (Haloperidol) IM
Haldol 5 mg, Ativan 2 mg, Cogentin 1 mg IM Now
- OR Haldol 5 mg PO/IM Q6hr PRN severe agitation, psychosis, NTE 10mg/24 hours AND
Ativan 2 mg IM Q6hr PRN severe agitation, psychosis, NTE 4mg/24 hours AND
Cogentin 1mg PO/IM PRN stiffness, EPS - please give with Haldol, NTE 6mg/24 hours.
Zyprexa (Olanzapine) IM
Zyprexa 10 mg PO/IM Q2hr PRN severe agitation, psychosis, NTE 30mg/24 hours
Generally, Zyprexa is more sedating than Geodon and Abilify.
Benzodiazepines (IM or PO) should not be given within two hours of IM Zyprexa secondary to case
reports of hypotension and respiratory depression.
For geriatric or frail patients, a 2.5mg or 5mg dosage is available.
The maximum daily dose of IM Zyprexa is 40 mg.
A second injection can only be given two or more hours after the initial injection.
If a third injection is required within 24 hours, it must be given four hours after the second injection.
Geodon (Ziprasidone) IM
Geodon 20mg IM now or Geodon 20 mg PO/IM Q6hr PRN severe agitation, psychosis, NTE 40mg/24 hours.
IM Geodon comes in preparations of 10 mg and 20 mg.
Geodon tends to be less sedating than Zypexa, and may enable a patient to be more interviewable
The maximum daily dose of IM Geodon is 40 mg.
Doses of 10 mg can be given every two hours and doses of 20 mg can be given every four hours.
Geriatric patients should receive the lower dose, 10 mg, if needed.
Abilify (Aripiprazole) IM
Abilify 9.75mg IM now
Abilify 9.75mg IM q6hrs PRN severe psychotic agitation, NTE 19.5mg IM/24 hrs
This medication is fairly new to the market (less than 1 year)
EPS and Acute Dystonic Reactions
If a patient is given a neuroleptic IM or PO and has a dystonic reaction:
Cogentin 1 or 2 mg PO or IM NOW OR Benadryl 25 or 50mg PO or IM NOW
Dosing depends on the size of the patient.
If the patients dystonia persists or includes ocular or laryngeal muscles, they will most likely need transfer to an ER
or medical ward as the airway could be compromised.

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For persisting EPS, patients can be put on a regular schedule of medications:

Cogentin 1 mg PO BID OR
Benadryl 25 mg PO or IM Q6hrs
PROGRESS NOTES
Each patient must have a progress note written every day. Make sure you date and time your progress note and sign
each page of the progress note. At the Mental Health Center, these are currently being dictated (see dictation guide
for further details).
Daily progress notes need to include the following
Brief identification of the patient including admission date.
The patients report (how the patient is feeling, does the patient report any side effects to medications, what the
patient is preoccupied with, etc.). When documenting target symptoms, be as descriptive as possible.
Staff report that includes nursing report of behaviors over the past 24 hours, PRNs and/or IM injections, social work
up-date, results from consults, etc.
Vital signs
Mental Status Exam.
Diagnoses (include Axes I-III).
Assessment and plan by problem. The assessment should include a statement regarding why the patient meets
acuity for continued hospitalization (Example: Patient continues with depressed mood and suicidal ideation
therefore representing an imminent danger to self thus requiring continued in-patient hospitalization.).
This is a UR requirement at the MHC; if this is not included, you will have to make time to meet with UR
to discuss your rationale hospitalization (much, much easier to just document this fact).
For clarification, see the next section.
Estimated length of stay.
Continued Stay Criteria for Inpatient Behavioral Health
This must be documented in your progress note. All of the following criteria are necessary for continuing treatment
at this level of care.
The patients condition continues to meet admission criteria for inpatient care, acute treatment interventions
have not been exhausted and no other less intensive level of care would be adequate.
The multi-disciplinary discharge planning process starts from the assessment and preliminary plan upon
admission and includes the patient and family/significant other as appropriate and/or feasible. An
individualized discharge plan has been developed which includes specific, realistic, objective and measurable
discharge criteria and plans for appropriate follow-up care. A timeline for expected implementation and
completion is in place but discharge criteria have not yet been met.
Treatment planning is individualized and appropriate to the patients changing condition with realistic and
specific goals and objectives stated. Treatment planning should include active family or other support systems,
social, occupational and interpersonal assessment with involvement unless contraindicated. Family sessions as
appropriate need to occur in a timely manner.
Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective
terms but goals of treatment have not yet been achieved, or adjustments in the treatment plan to address lack of
progress and/or psychiatric/medical complications are evident.
The patient is actively participating in plan of care and treatment to the extent possible consistent with
his/her condition.

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DISCHARGING PATIENTS
Discharging patients from the MHC involves the following criteria:

Treatment plan goals and objectives have been substantially met and/or a safe, continuing care program can
be arranged and deployed at a lower level of care.

The patient no longer meets admission criteria or meets criteria for a less intensive level of care.

An individualized discharge plan with appropriate, realistic and timely follow-up care is in place designed
to transition the patient to the most appropriate next level of care.

The patient is not making progress toward treatment goals and there is no reasonable expectation of
progress at this level of care despite treatment planning changes.

An individualized discharge plan with appropriate, realistic and timely follow-up care is in place designed
to transition the patient to the most appropriate next level of care.

To discharge a patient from the MHC, a resident must complete the following:
1. Discharge Note
This is the equivalent of your progress note for the patient on the day of discharge. Many of the elements of this note
will be included in your discharge summary.
Condition of patient at discharge: This is the risk assessment portion of your discharge summary. With the
exception of a transfer to Las Vegas State Hospital, you are discharging the patient to a less restrictive level of
care. You need to document the patients chronic and modifiable risk factors and what you did during the
current admission to address the modifiable risk factors.
Axis I V: This is your discharge diagnosis and reflects all of the diagnostic clarification that you performed
during the admission. Be sure to include all of the diagnoses on Axis III and all of the relevant psychosocial
stressors on Axis IV.
Discharge Medications: List all of the patients medications.
Disposition: Include follow-up appointments, group home, nursing home, including level of care for nursing
home, etc.
2. Discharge Orders
Order to discharge the patient. (Discharge the patient to home today. Discharge patient to group home
tomorrow at 07:30. Discharge patient to local shelter at 16:00 today.
5-Axis Diagnosis - Include all diagnoses on Axis I and III (billing purposes), list everything applicable on Axis
IV.
Discharge Medications: This section should list the form of the prescription, (written or called into pharmacy),
amount dispensed and number or refills. It should also include non-psychiatric medications the patient was
taking at the time of discharge. If applicable, the order for long acting injectable antipsychotics should be
included here for shot clinic. (Example: Haldol D 50 mg IM Q 4 weeks, last dose given 5/1/06, next dose due
6/1/06).
Discharge Disposition (Follow up appointments). Follow-up appointments will be written on the patients
discharge paperwork. Social work and nursing are responsible for making the discharge appointments.
Medications should be written in EasyScript in PowerChart Office.
4. Billing Sheet
The billing sheet can be found in the chart behind the face sheet.
Do not use abbreviations or diagnostic codes when filing out this form.

13

The 5-Axis diagnoses as written on the billing sheet should be the same as they appear on the discharge orders.

5. Multidisciplinary Discharge Summary

Completed by nursing and social work, but the resident needs to sign it.
6. Abnormal Involuntary Movement Scale
This form must be completed at some time during patients admission.
7. Discharge Summaries
It is advisable to dictate discharge summaries on the day of discharge, but they must be completed within 48
hours of the patients discharge.
See Discharge Summary section for specifics.

14

DISCHARGE SUMMARY
Discharge summaries are a brief summation of the patients hospitalization.
They are to be done within 48 hours of the patients discharge from the MHC.
Stat transfer summaries must be dictated for patients going to other units prior to transfer.
At the end of dictating at the MHC, the system should give you a job number. You should record this number
on your discharge orders for future reference in case the dictation gets lost.
Below is a template and a few words about everything that must be included in the dictation.
Dates of admission and discharge, name of attending at discharge.
Discharge Diagnoses exactly as written on discharge order and billing sheet (NOS and R/O diagnoses are
discouraged.).
Brief Admission History. Summarize the HPI, but dont simply copy/read the HPI from the H&P.
Laboratory Data should include admission labs, other significant labs done during hospitalization (ex. A
geriatric patient with malnutrition who had an initial and follow up pre-albumin.).
Dates and results of any significant imaging studies such as head MRIs, EEGs, etc.
Hospital Course can be listed by issues. (Ex. Psychiatric issues, medical issues, legal issues and social
issues.) If the patient has had a long or complicated course, you can break down the hospital course by
each major problem (ex. Major depressive disorder, PTSD, seizure disorder, coronary artery disease, and
housing.) This section should be a summary, not simply a list of every day you made a change in
medications. (For example, instead of writing On July 12 th the patient was given Geodon 20 mg BID, on
July 14th the patient was increased to Geodon 40 mg BID. On July 15 th the patient had some drowsiness so
the dose was kept at 40 mg BID but increased to 60 mg BID in July 16 th when the drowsiness had resolved
It would be better to write The patient was started on Geodon and titrated up to a dose of 60 mg BID.) If
a medication was tried during the hospitalization but discontinued for whatever reason, such as intolerable
side effects, it is important to include that in the dictation.
Discharge Disposition should include:
Discharge medications
Follow-up appointments after discharge
Condition of Patient upon Discharge should be in the form of a risk assessment as you are usually
discharging the patient to less restrictive environment. This should be the same as the risk assessment
completed on your discharge note.
Pertinent items from the mental status exam (denying SI, for example).
Modifiable risk factors that were addressed during hospitalization or discharge planning (psychosis
ameliorated with antipsychotic, alcohol dependence addressed with motivational interviewing during
inpatient stay followed by referral to ASAP).
Legal Status. Include whether patient has a Treatment Guardian, Fiduciary, Guardian of Person as well as
the relevant persons name, telephone number.

15

LEGAL MATTERS, COURT PAPERWORK

Certificate for Evaluation (aka "Pickup order" or "C for E")
This is a legal document that can be completed by any licensed physician or certified psychologist. If a physician
believes that a patient is potentially dangerous, this order allows the police to detain an individual for psychiatric
evaluation (not necessarily admission) at PES. Per New Mexico state law, the order should only be written by a
psychiatrist/psychologist who has treated/followed the patient and can speak to either the patient's past predictive
behavior or present decompensation necessitating evaluation. After the physician signs it, the order is valid for 72
hrs. The patient's address or location needs to be completed.
At the MHC, fax it to the appropriate APD sub-station and call to confirm that they have received it. The numbers
are available in PES. Leave the original with the nursing staff in PES to ensure that they know that the patient will
be brought in for evaluation and record the name of the patient on the PES board where "C/E" is written.
When placing a C for E during overnight call be sure to notify the on-call attending.
Involuntary Commitment
You must place every patient who is admitted involuntarily on an emergency seven-day hold. A patient admitted
voluntarily who later requests discharge may be placed on a five-day emergency hold if s/he is potentially dangerous
to self or others. The Physicians Certificate for Emergency Detention, Petition for Commitment for a Mental
Disorder, and Notification of Rights to Involuntary Patients must be completed and filed ASAP.
Physicians Certificate for Emergency Detention
To complete this form, list the actions that make the patient an imminent danger to self or others. Make sure

your check the box indicating whether this is a seven-day or five-day hold.
Petition for Commitment for a Mental Disorder
Fill in both the DOB (date of birth) and SSN (social security number). Both of these can be found on the

patients face sheet and on the cover sheet of the patients computerized chart at the VAMC.
On the line that starts, COMES NOW, the Petitioner the blank is asking what facility the patient is to be

committed to. Most times the answer is UNM Mental Health Center or Albuquerque VAMC. Sometimes you
may be requesting that the patient be sent to Las Vegas State Hospital. The longest time a patient can be
committed on an initial commitment to the VAMC or UNM is 30 days, so fill in 30 days. You can amend this
length of time in court if necessary.
On item 3, please be sure to check the appropriate space. Most often the space to check is Emergency 7
day hold placed on ___________ (the date of admission.)
On item 4, list the working diagnosis at the time you are filling out the document. (Psychosis NOS, Mood

disorder NOS, etc. are okay if that is the admitting diagnosis. It can later be modified in court if the diagnosis
changes.).
On item 6, give examples of what currently makes the patient dangerous. For example:

Patient expresses suicidal ideation.

Patient unable to take care of daily needs which places patient at risk for grave passive neglect
Patient responding to internal stimuli and unable to discern hallucinations from reality placing patient at
risk for self harm and victimization.
Patient has been violent towards family, friends etc.
Circle either item 7 or items 8, 9, and 10.

On item 12, circle whether or not the patient is capable of informed consent. For the next sentence,

appointment of _______ (list name of family member of NAMI volunteer) as a treatment guardian for a period
of time not to exceed 12 months. (This the maximum allowable time.)
On item 13, for expert witnesses, please list the resident who will by taking care of the patient and

his/her ward mate. (One of them may be on a vacation day and not be present to testify.) If it is near switch time
on the ward, you should list the residents coming to the ward to take over the patients care. The chief resident
and primary residents attending should be listed as well. If you list a lay witness, you MUST include an

16

answer on the summary line. Lay witnesses can include the police officer that brought the patient into the facility
or family members. Include lay witnesses only if you feel it is vital to presenting a strong case for commitment.
The petitioner/title is the resident filling out the document.

Notification of Rights to Involuntary Patients

If the patient does not sign the form, please list the reason why not. For example:

patient too psychotic or

patient refuses
In the body of the paragraph listing the rights, there are two boxes for the type of hold, seven-day or five
day. Please remember to check off one of those boxes
Treatment includes (make sure to list them all)

ward milieu and behavior therapy

supportive psychotherapy
pharmacotherapy
Seclusion and restraints as necessary
Decisional Capacity for Psychotropic Medications
If the patient does not have decisional capacity for psychotropics (see Informed Consent section in this manual),
then the admitting resident must file an Emergency Medication Petition (EMP) and a Petition for the
Appointment of a Treatment Guardian. Scheduled psychotropics may not be started until the court approves and
returns the EMP (typically within 24 hours), but PRN psychotropics may be used. If such a patient was taking
scheduled psychotropics prior to the admission, they must be discontinued immediately or tapered to avoid
withdrawal syndromes.
This is a separate evaluation from the hold/commitment decision. A person can be admitted voluntarily who needs
an EMP and treatment guardian, while a patient admitted on a hold/commitment may not need a treatment guardian.
Application for Permission to Administer Psychotropic Medication (Interim Medication Petition or IMP)
The Petitioner is the resident completing the form.
For Item # 3 list all of the appropriate classes of medications you think you might use (antipsychotics,
mood stabilizers, antidepressants, cognitive enhancers, anxiolytics and sedatives), including PRNs. To answer
the question of dose, use general statements such as
At therapeutic doses
Titrated to desired effect
For Item # 4 Do not answer Actively seeking. List what you are doing to find a treatment guardian, for

example Will seek family member or NAMI volunteer

For the additional length of time necessary to find a treatment guardian, put 7 additional days.

Please make sure to fill out the patients name, DOB and SSN on both pages of the application.

Petition for Appointment of a Treatment Guardian

If you are filing for commitment, this form is not necessary. You can complete the treatment guardian portion on the
commitment paperwork.
List the maximum length of time possible for appointment of a treatment guardian, 12 months. The

commissioner may modify this length of time if he grants the petition.

For Item # 3, list all of the appropriate classes of medications you think you might use (antipsychotics,

mood stabilizers, antidepressants, cognitive enhancers, anxiolytics and sedatives), including PRNs. Include ECT
as possible treatment.
For Item # 5, if the proposed treatment guardian is a family member, you must write down his/her address

and phone number. The court liaison MUST be able to contact them to notify them when the court hearing is
scheduled. If the proposed treatment guardian is a NAMI volunteer, DO NOT list the address or phone number.
The court liaison has a list of numbers to contact them. Remember that the patient is given a copy of all court
paperwork.

17

For Item # 6, list all possible residents that may be testifying for the hearing. (See Item # 13 for
commitment paperwork.)
For Petitioner/Title, this is the signature of the resident completing the form.

18

LEGAL MATTERS, COURT HEARINGS

Commitment Hearings
Hearings are held in the courtroom, which is just past the atrium at the MHC.
A staff member will escort the patient to the courtroom.
Either you or the staff member will bring the patients chart.
The patients attorney may object if you are looking at notes or the chart, so be prepared to answer from
memory.
The best advice for testifying well in court is to be prepared.
Review the patients H&P, commitment paper work, APD statements, etc. The court participants (the DA,
the attorney for the patient and the commissioner) will have received copies of all this documentation and
may ask you questions about it.
Review prior hospitalizations and prior treatments of the patient.
The patient will be seated next to his/her attorney on one side of the table; you will sit next to the DA on the
other side of the table. The commissioner will be seated at the head of the table.
Wait for directions and answer the questions that are directed to you. You will be the first witness to testify.
It is a good idea to give the DA a brief synopsis of the case before court if possible; he may tailor his
questions to elicit certain important information about the case.
Include enough pertinent information in response to each question to support your petition. For example,
in response to the question How has the patients diagnosis affected the patient, a good response would
be to include items regarding what behavior led to the patients admission and any dangerous or bizarre
behaviors by the patient prior to or since admission.
If there is an objection by either attorney, wait for directions from the judge before answering. Below are
the standard questions the DA will usually ask you.
Remember to turn your pager or cell phone on silent when in court.
The patients attorney may ask additional questions prior to accepting you as an expert witness during crossexamination. The questions to establish your qualifications as an expert witness are mainly to enter your
qualifications for the record in each individual case. The defense attorney may attempt to shake your confidence
with these questions. Just remember that in the eyes of the court, you are an expert in the field of psychiatry, even if
this is your first day of your psychiatric residency.
Questions asked by the District Attorney

How are you employed?

How long have you worked in the area of mental health?
Do you know the patient?
Do you have a diagnosis for the patient?
How has the patients diagnosis affected the patient?
What is your proposed treatment?
Do you feel the patient presents a likelihood of harm to himself or others? In what way?
What type of commitment are you seeking?
Do you feel the patient will benefit from the proposed commitment?
Is the commitment consistent with the treatment needs of the patient?
Is the commitment consistent with the least restrictive means of treating the patient?
Is it your understanding that the cost of treating the patient is for the patient and the facility to bear and not
the court?

Questions asked by the Patients Attorney

Have you spoken with the patient about his/her medications?

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You do know the patient would like to be discharged?

S/he may ask for specifics on what makes the patient a potential danger at this point, as opposed to how the
patient was a potential danger at the time of admission.
S/he may ask if the patient has improved since admission. This is your opportunity to introduce additional

information into evidence that proves why the patient requires continued inpatient hospitalization.

Questions asked by the District Attorney Regarding Appointment of a Treatment Guardian

Have you spoken with the patient about his/her medications?

Do you feel the patient can make an informed decision?
Do you feel the patient would benefit from the appointment of a treatment guardian?

Orders Following Court Hearings

When you return from court, make sure to write an order reflecting the outcome of the hearing. (Example: Patient
committed for up to 14 days. NAMI volunteer Kortni Jones appointed treatment guardian for up to 6 months.)

20

INFORMED CONSENT AND DECISIONAL CAPACITY

One of the most frequent requests made to on-call psychiatrists is to determine the mental "competence" of a patient
on a medical or surgical service. The following guidelines are intended to assist you in responding to this common
consultation. First, it is important to recognize the difference between mental competence and mental capacity.
Competence is a legal term and only a judge can declare a person competent or incompetent. Capacity is a medical
term that can be assessed by any physician. However, non-psychiatric physicians frequently call upon the expertise
of psychiatrists to evaluate the mental and neurological status of patients. Mental capacity must be assessed in
context. Capacity is not an all or nothing concept. A person may have the mental capacity to make certain decisions
and not others. Therefore it is critical to speak to the physician actually making the request and clarify what the
patient is being asked to do. It is also helpful to speak to family members or friends who can provide background
information regarding the patient's mental functioning. To determine if a person is capable of informed consent, you
need to assess the following three elements.
Decisional Capacity and Informed Consent requires the following abilities:
1. The ability to understand the relevant information concerning the proposed treatment including the risks
and benefits of the treatment and alternatives.
2. The ability to appreciate one's medical situation and its possible consequences for one's health and life.
3. The ability to freely make and communicate a choice about whether to accept treatment or not without
undue internal or external coercion.
4. The ability to engage in rational deliberation about one's own values in relation to the physician's
recommendations about treatment options.
Patients who clearly do not possess these abilities such as those who are comatose, severely demented, delirious or
psychotically delusional may not meet the criteria for mental competence and will require a surrogate decisionmaker. However, no class of patients, except for the comatose, can prima facie be considered incapable and each
case must be evaluated independently.
In an emergency situation, the family is customarily accepted as the surrogate decision-maker and you should
inform the primary physician of your finding and recommendation that he contact the family. If the situation is nonemergent, the patient has no family or the family may be not acting in the patient's best interest, then the courts can
appoint a treatment guardian to make decisions on the patient's behalf.

21

TEACHING MEDICAL STUDENTS

Residents are the primary teachers of medical students. Medical students are looking for structure and leadership in
their clerkships. They also want to feel like they are doing something with their time and that they are a
valuable member of the treatment team. You are in the fortunate position of being able to provide much of the
leadership and most of the structure they need. Your job is complicated by the constraints of time - we only
have 4 weeks for our clerkships. At UNM, medical students pre-clinical education is limited to only 4 weeks
of psychiatry in their first year. Therefore, we need to provide most of what they will lean about psychiatry in
their clinical clerkship.
At the VA, one medical student is typically assigned to each team. That means that both residents on a particular
team will be sharing one medical student. At the University, one or two medical students are usually assigned
to the Geriatric Ward and typically one student is assigned to East Ward and one to West Ward. The residents
on East and West will be sharing a student as described above.
It is important on their first day to orient them to the ward and to review safety protocols/precautions with them.
Please spend a few minutes the first week making sure that they are prepared for rounds (i.e., they know the
diagnosis, the HPI, the medications, and the treatment plan). In addition, please give them appropriate
feedback each week on their interviewing skills, their progress notes, and their professionalism.
It is difficult to teach psychiatry in four weeks. Therefore, it is important for each medical student (if possible) to be
responsible for a patient with schizophrenia, a patient with depression, a patient with mania, and possibly a patient
with substance dependence. During the first week, 1-2 patients is ideal, during the second week, 2-3 patients. At no
time should a medical student be responsible for more than four patients unless this has been discussed with the
Chief Resident and your Attending.
Please have them practice the Mental Status Examination. This is a large component of their Psychiatry Clerkship
final exam.
If you are having problems with your medical student (professionalism, quality/quantity or work) or if you have
general concerns, please do not hesitate to notify the Chief Resident, your Attending, or the Clerkship Director,
Deborah Dellmore, MD.

22

PATIENT PLACEMENT REPORT

AKA THE HIT LIST
In general, admissions during the day are assigned to residents according to a rotating, batting order known as the
"Hit List" which is kept in PES at the MHC.
Exceptions to the Hit List (each explained below) include post-call status, vacations, admissions on call, clinic days,
the "four-o'clock rule," bounce backs, and patient caps.
Post-call Status
When a resident is post-call, s/he is protected from further admissions. At the MHC, protection is granted only if
you did not have a moonlighter. In these cases, the post-call resident needs to write "post-call, his/her name and
date on the Hit List.
Vacations
When going on annual leave, the resident should write "A/L through ________ (the last day of vacation) on the Hit
List with their name and date.
Admissions On Call
When on call, residents may admit patients to themselves or to the next resident on the Hit List. For patient
continuity, residents are encouraged to keep their own admissions (up to two per on-call shift) unless they are
capped. When a moonlighter is on call, they will admit according to the Hit List.
Patient Caps
At the MHC, the cap is typically eight patients. If a resident is capped, he/she should write, capped on the Hit List
along with their name and date. This will continue until the resident is no longer capped.
Bounce Backs
Any patient that a resident has seen in the last two weeks of the same ward rotation goes back to that resident
regardless of where s/he is on the Hit List, unless the resident is already capped.
The Hit List is meant as an aid in fairly distributing patients, not an absolute and inflexible rule. It uses the
assumption that short-term inequalities in patient load will equalize over the long-term by consistent application of
the same rules. Not every contingency will be handled by the Hit List, and in these cases residents and attendings
are expected to amicably and fairly decide amongst themselves how exceptions should be handled. Whenever a
resident takes an admission out of the usual batting order, that patient's name is still written into the next slot next to
the resident's name, so the resident will still get credit for taking an admission. Lastly, unit clerks and nursing staff
should not have to decide which resident gets the next admission and resent being placed into a position where they
feel that they have to. Any exceptions to the Hit List that the residents work out amongst themselves must be clearly
and explicitly explained to the unit clerk and nursing staff.

23

PSYCHIATRY EMERGENCY SERVICE (PES)

Hours: During the week, residents provide primary coverage in PES from 5PM to 8AM the next morning. At 8AM
you are required to go to morning report. Sunday thru Thursday, a moonlighter will often relieve you at midnight.
An attending is with you until 9 PM during the week. After this time, the attending will be available by pager. On
weekends and holidays, you are required to arrive at 8AM and stay until 8AM the next morning. An attending is
always available by pager.
When to Call the Attending: If you have a question, always call the attending. You are not required to call the
attending for admissions, but you are required to call the attending on all discharges from PES that arrived from the
ED or police (referred to as level 1s). This includes anyone that arrives by Certificate of Evaluation.
Certificate of Evaluation: Familys will occasionally call about a patient that is dangerous and unwilling to come in
for an evaluation voluntarily. You may fill out a C of E at this time to have the police bring the patient in for an
evaluation. Always ask family if the patient has access to any firearms and notify the police accordingly. See Legal
Matters I/Court Paperwork section of this manual for more information about how to complete a C of E.
The Emergency Department: The emergency department is our best referral source. When listening to a
presentation about a possible referral from the ED, inquire about the precipitant to the patients arrival (brought in by
police? family?), medical diagnosis, labs and related work-up. If time is available, review the patients information
in PowerChart Office. Prior to accepting a patient for transfer to PES, you may ask for additional labs that may be
pertinent. UDMs can be very helpful. In addition, find-out if there is a blood alcohol level (BAL) or if the patient
has been medicated.
The Intoxicated Patient: Intoxicated patients often arrive at PES via police. The UNMH ER may send intoxicated
patients who show no signs of complicated withdrawal with psychiatric co-morbidities (recent suicide attempt,
suicidal ideation, etc). Intoxicated patients should be closely monitored while in PES for evidence of withdrawal. If
clinically indicated, start benzodiazepine withdrawal prophylaxis while checking vitals hourly. If oral
benzodiazepines do not attenuate vitals or the patient become delirious, etc, do not hesitate to transfer patient to the
UNMH ED as needed. If the patients vitals remain stable and the patient does not show any other signs or
symptoms of withdrawal, then the patient may stay in PES until interviewable. As a general rule, when the
patients breathalyzer < 0.08, then you can interview the patient. However, people with high tolerance may be
interviewed prior to this limit, but may not be discharged from PES until blowing below the legal limit.
Medical Emergencies: PES nurses are very good at identifying medical emergencies, but ultimately, you are
responsible for assessing and responding to them. If you need to transfer a patient to the UNMH ER and it is an
emergency, staff should arrange transport (911 or non-emergent transport). Call UNMH ER ASAP to give them the
pertinent presentation and get the accepting physicians name Complete the consult form documenting why you are
sending the patient to the ER. Ask the staff to copy pertinent information from the chart so that it can accompany the
patient to the ER. Stay with patient until EMS has left the building. Finally, call the consult liaison service at the
University hospital to leave them a message about the patients arrival the University ED (include name, MR#, ward
that the patient left, diagnosis and medical problem).
Referrals to the MHC: People seen in PES with a chronic, severe mental illness without a treatment provider may
be referred to the MHC. The patient will need financial counseling, and PES nursing will file the appropriate
paperwork in the phone triage basket.
Referrals to the Community Providers: If the patient seen does not have a chronic mental illness, or an illness of
insufficient severity to warrant referral back to the MHC, then the patient may be referred back to a community
provider (PCP, NP, etc). You should fill out a brief consult form documenting your diagnostic impression and
recommendation. You should either fax this form to the appropriate provider or give the patient of this
recommendation to hand-carry to their provider.

24

Communication with MHC Outpatient Clinics: You will see many patients in PES from different MHC clinics
(Dual, General Clinic and Continuing Care). It is important to let the primary provider know about the patients visit.
Preferably, the outpatient provider would be contacted the next weekday of the patients arrival. If this is not
possible, a brief email with the patients initials, medical record number and admitted or not admitted should be
sent to the primary provider. Just include enough information in the email to let the primary provider access the
chart and review your note. Do not include any more identifying or clinical information via email then absolutely
necessary.
When to Prescribe Opiates or Stimulants from PES: NEVER.
Consults in Main Hospital: Rarely, you will get a request form the University Hospital for an emergent consult
after hours. It is our policy that a physician (you as the resident on-call) must be in-house/present at the Mental
Health Center at all times. Our current way to handle this is to get information from the requesting provider and
discuss that request with your attending on-call to determine a solution. Possible solutions would be for either your
attending to do the consult (if emergent) or for the attending to cover PES while the resident on-call handles the
consult.
PES Medication Prescription Guidelines:
PES will not give 30 day prescriptions (refills) to patients who are in a UNMPC clinic. These patients will be
instructed to call their clinic in the morning. In other words, PES is for psychiatric emergencies and not for med
refills. PES may offer meds (from Pixis or by written prescription) for the evening or weekend to prevent
withdrawal or psychosis, until the patient can contact their respective clinic to obtain refills.
PES will avoid starting treatment on new patients unless considered an emergency. If the patient has a PCP, a consult
may be written and sent to the PCP, by fax, Powerchart or hand carried by the patient. Patients should be counseled
to obtain a PCP, including using HealthCare for the Homeless(HCH) or First Nations. Please consider the medicolegal risk of prescribing medications to someone who has not had a physical exam in some time and does not have a
medical provider. Also consider that the evaluation in PES may not be a complete psychiatric assessment.
Substance-abusing patients will be referred to AMCI (sobering services) or ASAP (they may present any weekday
morning to ASAP as a walk-in). AMCI is easier to access if the patient does not have UNM Cares or any form of
insurance. Based on clinical judgment, PES may offer detox meds, usually only for those going to sobering
services... again taking into consideration that we do not do physical assessments.
Higher acuity patients, such as those with psychosis or mania that do not quite meet criteria for inpatient admission,
may have treatment initiated. PES will remain responsible for these patients until they are engaged in a clinic, so
patients should be asked to follow up in PES during weekday business hours.
PES will never prescribe pain meds, stimulants or medications for non-psychiatric indications. Once again, PES
does not prescribe pain meds, stimulants or medications for non-psychiatric indications.
PES should not take over the care of a patient who already has a mental health provider in the community. Patients
with other providers will be counseled to call the phone triage service (272-1700) to coordinate an orderly transfer
of care (records,etc.) from the current provider.
Patients coming from jail or prison settings should be assessed like any patient coming to PES- meds should be
verified by calling the jail/prison, but no special provision is being made for these individuals. Consider referral to
HCH if homeless or without established Bernalillo County residency.
Do not refer patients to phone triage (the folks who get them in to our outpatient system) if you have recommended
another disposition. Do refer to phone triage if you have started treatment- please place a copy of the PES
interaction in the phone triage box in the PES reception office.
Finally, good clinical judgment trumps all "guidelines". When in doubt call your attending or Dr. Jenkusky (any
time!)

25

CHILDREN AND ADOLESCENTS IN PES

Children and adolescents are often evaluated in PES after hours. While a child fellow is on pager call at all times
from PES, the evaluation is the responsibility of the PES resident. If the child meets admission criteria, and if a bed
is available at UNM Childrens Psychiatric Hospital, and if you have no questions, then you do not need to call the
child fellow. Whenever discharging the patient from PES, you must always call the child fellow. Be prepared to
give a concise yet thorough presentation over the phone that includes information on guardianship and the social
context of the child. Be aware, children have different (lighter) admission criteria than adults (greater risk of
adolescents acting impulsively, protection from social chaos).
Voluntary v. Involuntary Admissions
If the child is 13 or younger and the parents agree to admission, then the child is admitted voluntarily.
If the parents disagrees with the admission decision and the resident, in collaboration with the child fellow,
decide that the patient needs admission, the child is placed on an involuntary hold (simply fill out Emergency
Detention Order, the child fellow will complete Involuntary Commitment paperwork the next day).
If the child is 14 or older and the parents or the teen disagrees with admission decision, the child must be
admitted on an involuntary hold (fill out Emergency Detention Order).
Consenting Children for Medications on Admission
If the child is 13 or younger, the parent must provide informed consent for all medications. It is good practice to
obtain assent (agreement) from the child while informing him or her of benefits and side effects of proposed
medications.
If the child is 14 or older and the child has decisional capacity to consent to psychotropics, the child can consent
to medications while the parent must be informed.
Sample Medications Orders
Unlike adults, children and adolescents need consents on file for scheduled and PRN medications. For example, you
cannot write the following orders without consent in the chart, but you can give an acute, one-time order for a PRN.
First Line Medication: Diphenhydramine 1mg/kg (25-50 mg) PO PRN severe agitation or out of control
behavior; MR x 1 in 1 hour if necessary, to max = 4mg/kg (100-200 mg) in 24 hours; may administer first dose
IM if PO refused.
Second Line Medication: Chlorpromazine 0.5 mg/kg PO (Usually 12.5 to 25mg) PRN severe agitation or outof-control behavior; MR x 1 in 1 hour if necessary, to max = 2 mg/kg (50-100 mg); may administer first dose
IM if PO refused
For larger children: chlorpromazine 1 mg/kg PO (Usually 25mg to 50mg PRN severe agitation or out-ofcontrol behavior; MR x 1 in 1 hour if necessary, to max = 4 mg/kg (100 to 200 mg); may administer first
dose IM if PO refused
When to ask the Child Fellow to go to PES for an evaluation
Either the child fellow or the PES resident judges that further evaluation by the child fellow is necessary
Either the general psychiatry or child psychiatry attending asks the child fellow to go see the patient
PES is flooded with acute adult patients and a child is waiting to be seen.
Flooded is currently defined as a minimum of four acute adult patients plus the child or adolescent or
if there are two or more adolescents waiting to be evaluated in PES.
This is a judgment call by the general resident and must be made in the spirit of collaboration with the
child fellow.
When a child/adolescent is in PES to be evaluated, that evaluation takes priority over all other pending
evaluations.
If a child/adolescent is in PES, then a guardian needs to be present. If no guardian is available, the PES nursing
staff will help you call to obtain a temporary guardian.

26

BACK-UP CALL
Having a person on back-up call is an essential part of any on-call system. The person on back-up needs to have
their pager with them at all times.
Appropriate reasons to call in the back-up psychiatrist are as follows:
A medical emergency prevents you from being able to take call
A family emergency occurs that prevents you from being able to take call
You are physically unable to get to the hospital
Inappropriate reasons to call in the back-up psychiatrist are unacceptable. Some (but not all) unacceptable reasons
are listed below:
You think you might have a fever and just dont feel too well
It is Mothers Day and you want to spend time with your children (this actually happens on other
services)
Your favorite football team is playing and you want to watch the game at Geckos.
You have a hangover.
In the past three years, the back-up resident has been put into action approximately 3-4 times each year. Residents
do become ill, they do require surgery at times, and family emergencies arise. Please be judicious about utilizing the
back-up system and please call the back-up resident as soon as you think you may not be able to take your call.
The back-up resident is not required nor expected to come in and help you if you are overwhelmed with
patients to see. That is not the purpose of this system.
When the back-up resident is utilized, both the back-up resident and the resident requesting the back-up need to
email their Chief Resident for notification. In addition, the original on-call resident will be required to take an
upcoming call shift scheduled for the back-up resident. For example; Brodsky is on-call and Rabjohn is the backup. Brodsky has to leave town for a family emergency, so he calls Rabjohn to inform him of the back-up
responsibility. Both Brodsky and Rabjohn email their Chief Resident, then Brodsky is required to take one of
Rabjohns upcoming call shifts.
Please be fair when arranging these trades. If you call in the back-up for a Monday shift, do not expect them to take
your 24 hour Saturday call at the MHC. In addition, if the back-up is called in for even as little as 2 hours of work,
then technically, they can ask for the original on-call resident to pay them back an entire call shift.
We cannot stress the importance of the back-up resident having their pager with them at all times when they
are the back-up. In addition, you cannot leave town when you are the back-up resident, nor can you have
anything alcoholic to drink.
Every year, a back-up resident forgets they are on back-up duty when someone is trying to call them in to work. If
the back-up is not available, then an attending gets called in to work. Last year, Dr. Lauriello had to take a few
hours of call by himself until the back-up was reached. Trust me, you do not want to be the resident that forgets he
is on back-up when the ED or an attending is trying to call you.
CALL SWITCHES/TRADES:
It is perfectly acceptable to trade calls with a fellow resident. However, please let Judith (2-5417) know so that she
can update the master schedule.

27

EVENING AND WEEKEND CHECKOUT AT MHC

Residents will often have issues (labs, levels, questionable vitals, concerning medical problems, etc) that will need
to be addressed after business hours. To convey this information to the residents who will be covering the evenings,
weekends or holidays, the primary resident must write the following information on the dry-erase board at PES
marked check-out. The following info must be included on the checkout board:
Date
Patients Name, MR#
Patients location
Specific instructions to the on-call residents (review labs, review O2 sat over weekend)
For example, 6-13, BL, MR# 876532, E green, please check lithium level on Sat morning
The covering resident should briefly document the action taken over the weekend in the patients chart.
Many of the attendings covering for the weekend would like to have sign out to get to know the patients they will be
covering for the weekend. Sign-out to attendings is somewhat different than sign out to fellow residents. For
attendings, some will want to speak to you directly on Friday afternoon; others will want the sign out in writing.
Sign-out to attendings should include a very brief description of the patient, current symptoms and any recent
medication changes.

28

MEDICATION RECONCILIATION

Medication Reconciliation is required whenever a new patient is seen in any setting, or when a follow-up patient has
their medications changed. It is a process whereby it is assured that the official medication list, in Easyscript, is
updated and current. It is the responsibility of each clinician to update that list and then add the medication
reconciliation statement. The patient is then given an updated list of new medications.
In your orientation you will be shown how to do this process. For pointers you can refer to the Medication
Reconciliation page in the HSC Intranet. Also feel free to ask Dr. Jenkusky for assistance at any time.
CRISIS STABLIZATION SERVICES
CSS is a place where patients can be sent from PES. The ideal patient is one in a current crisis who needs a
structured environment and/or social support for the next 48-72 hours. Patients can not be actively suicidal, can not
be actively withdrawing from substances, must have stable vital signs, and must not be taking any narcotics. THIS
IS NOT A HOMELESS SHELTER NOR IS IT A DETOX UNIT. The PES nursing staff is excellent about alerting
residents to patients who would benefit from CSS. In addition, CSS has already banned particular patients from
receiving further services; please check that list prior to making a referral. To refer a patient to CSS, please ensure
the following:

Clients must have stable VS and no active infectious disease

Clients must not be in the process of detoxing from any drugs.
Clients must not be taking narcotics (Vicodin, Methadone, Darvon, Percocet, etc.), or need to have written
proof from physician that they are not abusing these pain medications.
If clients have a chronic disease, they need to be able to manage their own medication
CSS cannot accept any clients that require active nursing care.
Please provide all medications, pain relievers, OTC comfort things as you think necessary for clients
comfort and ability to remain in this program for 72 hours. (i.e. Tylenol, Advil, MOM, etc.)
Please be sure to approve all meds that client or family is bringing to CSS (no meds will be able to be
brought to CSS without previously being approved by the doc.
All meds must be labeled and have instructions.
Please copy and include CAT, Med. Instructions, and/or First GC notes and most recent notes. Please
state what you would like CSS to address with the client while he/she is at CSS.
Please provide all phone numbers and contacts for each client to facilitate discharge planning.

Once these items are complete, please call and discuss the proposed admit with CSS staff at 925-4382.
If CSS accepts the patient, they typically will send a vehicle to transport the patient to CSS. If it is after 10:00 PM,
the patient will need to remain in PES until 8AM the next morning for transport.

29

MHC FLOAT RESIDENT

Purpose
At certain times, the UNM MHC will have seven inpatient residents. When this occurs, the seventh resident will
rotate as a float with his or her colleagues every two months. The purpose of this position is to satisfy the
requirements of the inpatient rotation while sharing the inpatient work load equally with the other inpatient
residents.
Responsibilities
The primary responsibility of the float resident will be to cover a team (east, west or geriatric) while another resident
is on medical, annual or educational leave. Prior to taking this team, the float resident will share responsibilities with
this resident for several days (admission, court, rounds and notes) to ensure adequate continuity of care. While the
primary resident is on leave, the float resident will assume all resident responsibilities for this team. The float
resident will continue to round and work with this team for several days after the primary residents return to again
ensure good continuity of care.
When all residents are present and no resident has leave is pending, during morning report the float resident will be
assigned to a team to share responsibilities in the following order:
1.
Co-coverage of team with primary resident during days with extensive court hearings, family meetings, etc.
2.
Co- coverage of team with primary resident during days with anticipated high-turnover anticipated
3.
Inpatient attendings and/or chief resident will assign a default team (no leave pending, equal distribution
of work on all teams). Every effort will be made to balance the workload among all inpatient residents. During
this time, the float resident will follow patients and perform admissions and discharge summaries along side the
primary resident.
4.
While co-covering a team (no leave, etc), the primary and float resident will be expected to assume a lead
role in medical student education (resident teaching, observe medical students conducting interviews, etc).
5.
The float resident will have the same expectations and responsibilities as the other inpatient residents.
Supervision
Dr. Apfeldorf will be the primary supervisor of the float resident, but all inpatient residents that work with the float
resident will contribute feedback and evaluation for the float resident.
At the time of the writing of this manual, another possible duty of the Floater is to help cover on Ward 7 during
times when interns are on annual leave.

30

GERIATRIC WARD SURVIVAL GUIDE

The Rules
PLEASE DONT KILL THE PATIENT. Bad things may happen but we dont have to cause them.
PRACTICE GOOD MEDICINE.
THINK MEDICAL. If youre not finding delirium in at least some patients, youre not looking hard enough.
TAKE AWAY MORE MEDICATIONS THAN YOU START. Simplify, simplify, simplify.
START LOW, GO SLOW.
FOLLOW THE BEERS CRITERIA WHENEVER POSSIBLE.
USE TARGETED PRNS JUDICIOUSLY.
BETTER TO PREVENT FALLS THAN TO EXPLAIN A BROKEN HIP.
ORDERING LAB TESTS WISELY. Ordering lab tests is like picking your nose in public its important to
know ahead of time what youre going to do if you find something.
FOOD AND WATER ARE IMPORTANT FOR LIFE. Make sure your patients are getting adequate nutrition
and hydration.
Kardex
Kardex should start promptly at 09:30 on M, T, Th, and F. Once assembled in the conference room area with the
cart of charts, the nursing staff will present first, followed by other ancillary services if present (i.e. food & nutrition
and activities,) social work and finally psychiatry for each patient. The psychiatric presentation will include the
main content of the discussion with the patient, the pertinent information from the MSE, and a problem based
assessment and plan. If asked, you should be able to clearly articulate your rationale for the proposed plan. Your
presentation should be from memory. Know your patients. Know the medications, dosages. Know the vocabulary of
the MSE and be able to give an example of how that patient demonstrates a particular concept. For example, know
the difference between irrational and confused, confabulation and delusional, perseverative and ruminating, etc.
The nursing report will include the vitals, hours of sleep, percentage of meals and weight if available. Nursing
report does not usually include the PRNs. You should know your patients PRNs and compliance prior to Kardex.
On Monday mornings, all of the patients are interviewed individually in Kardex. The morning will start with the
nursing report and then each patient will be brought in one at time to be interviewed by his or her resident, student,
or fellow. Depending on time constraints and the level of functioning of the patient, each member of the team will
introduce themselves to the patient. The objective of this brief, interview is to elicit and demonstrate the patients
target symptoms for the team. After all of the patients are interviewed, the team will then discuss only the plan for
the day (no statement of the MSE everyone saw that in the interview.)
Tuesdays are student and fellow article presentations. Thursdays are resident article presentations. 5 minutes on the
pertinent points of the article preferable with handout. Please make a copy of the article and hand-out for everyone,
including attending, residents, students, fellows, social workers and nurse practitioner.
Orders
All orders MUST be written at the end of Kardex. Try hard not to continue to write orders throughout the rest of the
day. Reminders on writing orders Include a NTE (not to exceed) amount on PRNs; PRNs must be written with a
definite time interval (ex. XYZ drug Q 4 hours PRN, not Q 4-6hr) D/C previous order exactly the way it was written
then write new order; watch carefully not to use unacceptable abbreviations.
Rating Scales
Rating scales such as the Geriatrics Depression Rating scale, the Barnes Akathisia scale, Simpson-Angus rating
scale, etc may be found in the file cabinet at the nurses station or in a stack next to the closet. Please remember not
to take the last copy! Additional books containing geriatric rating scales are found in the closet in the residents
office. Whenever diagnosing or describing a problem (OCD, akathisia) always use a rating scale.

31

Eating Disorders
A white three-ring binder either in the residents office or at the nurses station has many helpful articles and rating
scales addressing eating disorders. The standard eating disorder behavioral protocol includes weights for the patient
after first void, wearing hospital gown, facing away from the scale Q Monday, Wednesday and Friday. The patient
is not to be given the weight by the tech or nurse weighing the patient but by a member of the treatment team.
Additional orders or restrictions regarding a behavioral plan for eating disorders will vary according to the patient
such as LOS for 1 hour following meals, no double portions, patient to be out of the room for all meals, etc. Dr.
Yager wrote the treatment guidelines we follow. Please contact him regarding patients with eating disorders, he will
be happy to assist.
Vitamin B12 Deficiency
For purposes of the geriatrics rotation, deficiency is anything less than 400 (not 200 which is the labs lower limits
of normal.) Replacement is done by giving Vitamin B12 1000 mcg IM Q day x 7 days, 1,000 mcg IM Q week x 1
month then 1,000 mcg once monthly. Gradual replacement may be done by giving Vitamin B12 1000 mcg PO Q
day. Oral replacement is not the preferred route for geriatrics patients as there may be issues of GI absorption in this
patient population.
Starting Doses of Psychotropics in Geriatric Patients
Risperdal 0.5 mg PO QBetime
Zyprexa 2.5 mg PO QBedtime
Seroquel 25 mg to 50 mg PO QBedtime (antipsychotic of choice for Parkinsonism and Lewy Body)
Aricept 5 mg PO Qday and work up to 10 mg Q day
Namenda 5 mg PO Qday and work up to 20 mg divided BID
Additional Medication Tips
Avoid Benzos and anticholinergics if at all possible. Medications may often need to be crushed and mixed in
pudding (good idea to get okay from treatment guardian first). Lisinopril is not on the UNM formulary but
Fosinopril is. They can be used interchangeable with a 1:1 conversion. Do NOT start scheduled lithium until a
lithium level is back and on the chart!!
Medical Issues
When in doubt, go to Judith Gillum (Nurse Practitioner). Medical consults also request that you go to Judy first.
Dietary Issues
Patients are more likely to have the following needs: mechanical soft or puree diet, 1:1 staffing for meals and
hydration, and supplemental health shakes. If you order a diet and nutrition consult, you will actually get one. Prealbumins are helpful for assessing nutritional status.
Interim Summaries
Social work will often ask for interim summaries to aid in placement. Important things to note in these types of
interim summaries are: length of time without PRNs and behavioral disturbances, why the patient needs a nursing
home and why theyre stable enough to go.
Discharges
Orders must include Axis I-V diagnosis, the discharge medications and the discharge follow-up appointments.
Social work may ask for the orders the day before if it is certain the patient will be going to a nursing home, etc. the
next day. If the patient is being discharged to a nursing home, scripts do not usually need to be written. If at all
possible, try to have a discharge summary prepared at the time of discharge for any patient going to a nursing home
or assisted living facility.

32

IMPORTANT MHC TELEPHONE NUMBERS

CONSULT/LIAISON (MAIN HOSP)

24763

COURT LIAISON (HELEN PADILLA)

22811

EAST WARD
RESIDENTS OFFICE

22881, 28561
24942

EMERGENCY ROOM (MAIN HOSP)

22413

GERIATRICS WARD
RESIDENTS OFFICE

22994

LAB (MAIN HOSP)

22441

MEDICAL RECORDS (MHC)

BERTHA CORONADO
PES (MAIN NUMBER)
NURSES STATION

22170, 29131
21305
22920
24094, 22179

PHARMACY - IN-PATIENT (PAUL)

22831, 25906

PHARMACY - OUT-PATIENT

22819

PSYCHIATRY DEPARTMENT
JUDITH
KATHY
WEST WARD
RESIDENTS OFFICE

22223
28244
22880
25019, 25020

33

MHC/CPC Dictation Guide

Dictation Instructions
1. To access the dictation system: Dial Dictation Line 2-9007
2. You will hear a verbal prompt acknowledging access.
3. Enter you ID Code. (6-digits) Example: 123456
If you have a short ID press # after it. Example: 123#
4. Enter the Work Type. (2 digits)
5. Enter Medical Record Number (8 digit Subject Code)
6. Begin dictation at the beep.
7. When the report is finished:
To dictate another report, Press 5
The system will speak the Report Number. Then reset for the next report. You may then continue
with the next Subject Code (MR#) and Work Type, and then begin when you hear the beep. {Step 4}.
8. To end the call when last report is finished:
When you are done press 9
The System will speak the Report Number. Then hang up.
9. To switch to Review Mode:
Press *1 (Star Key then 1 on the keypad).
Follow the Voice Prompt Instructions to Review Report.
DIAL 2-9007
1= Listen/Play
2= Dictate/Record Over
3= Short Rewind
4= Pause/Stop
5= Next Report
6= Go To End of File
7= Fast Forward
8= Go To Beginning of File
9= Disconnect Phone
0= Replay Report #

Listen

Dictate

Pause

Next Report

4
Fast
Forward

Work Types Specific To MHC/CPC

37
38
39

47
Discharge Summary
48
Interim Summary
History & Physical / Psychiatric Evaluations

5
Go To
Begin

Replay
Report #

Rewin
d
Go To End

6
Disconnect

Daily Notes (Progress Note)

Detox Notes

34

For H&Ps, identify the attending from the team the pt will go to as a signer. If it is Friday night, Saturday,
or before a holiday, then identify the covering attending for the next day as signer so they will have the
new patient brought to their attention by power chart.
You do not have to dictate, but may type all notes (either directly or cut/paste word) if you so choose.
All notes at the MHC, including daily progress notes, are entered into powerchart office (aka PCO)
If you have any questions or need assistance, please call the Transcription Department at 2-0476, 2-0475
or 2-0057.

35

INPATIENT LOCKED SECLUSION/RESTRAINT

Each episode of seclusion or restraint must include five things, each of which is discussed below.
o a doctor's order
o an in-person exam and assessment
o a progress note
o a change in admission status to involuntary (if applicable)
o criteria for release from Restraints & Seclusion
Nursing staff can initiate seclusion/restraint for the safety of a patient or others at any time.
Initiation of seclusion/restraint must be followed by a doctor's order within one hour.
The order must include
o type of seclusion or restraint
o the reason for seclusion/restraint
o a time limit not to exceed 4 hours
o SAMPLE ORDER: "Place Mr. Jones into (locked seclustion/4-point restraints) for up to 4 hours for
(specific behaviors) that did not respond to (less restrictive means)."
Nursing is authorized to remove a patient from seclusion/restraint before the 4-hour limit if they feel the patient is
safe.
Initiation of seclusion/restraint must be followed by an in-person evaluation by the house officer within four hours.
If the patient is out of seclusion within four hours, an exam still needs to be done, but it can be done within 24 hours
of the initiation of seclusion/restraint. The exam must be documented with a progress note.
Seclusion and restraint orders must be renewed, if necessary, every 4 hours and also be accompanied by an inperson exam.
Each episode must be documented with a progress note.
The progress note must include a clinical assessment of the patient and justification for the continued use of
seclusion/restraint.
SAMPLE PROGRESS NOTE: "Mr. Jones was placed into (locked seclusion/4-point restraints) for (specific
behaviors) which did not respond to (less restrictive means). On exam, the patient was________ (pertinent
findings)."
If the patient was on voluntary admission status, s/he must be placed on a 5-day hold and the admission status
changed to involuntary for patients in locked seclusion or restraints.
If a patient is removed from seclusion or restraint before the original 4-hour time limit expires, this terminates the
order. If the patient escalates again & needs to be returned to Restraints or Seclusion, a new order must be written.
The resident will again have one hour to sign the order, and must document criteria for release as above.
The above applies to locked seclusion & restraints. Time-outs of up to 30 minutes in an unlocked seclusion room
may be instituted by nursing without MD involvement or chart orders. The unlocked seclusion room may be used
for more than 30 minutes if the MD writes an order for quiet room.
You will see the abbreviation "LSTR" used to refer to seclusion. It stands for Locked Seclusion Treatment Room.
In the past, ULSTR (Unlocked Seclusion Treatment Room) was used to order a patient into the quiet room. Do
not use this abbreviation any longer. Instead, use the order quiet room as above.

36

37