DAP DISCHARGE

[text name="SHIFT" default="0700-1930"]

[textarea name="variable_1" default="MALE TEXT AREA"]

[date name="variable_1" default="05/19/2019"]
[text name="variable_2" default="NAME"] is a [checkbox name="variable_1" value="year old|male|female"]
diagnosed with [text name="variable_3" default="sample text"].With [checkbox name="variable_5" value="no known food and drug allergy|no known food allergy| ALLERGIC TO|NO known drug allergy"]
He is on 
[checkbox name="variable_1" value="Q5|1:1|Q15|Q30|red risk|1:1 when using the bathroom|1:1 when eating||due to"] for level of safety, per MD orders. 
[checkbox name="variable_3" value="He/She is on court cont until|He/She is under petition court date| PATIENT L2K was certified on  DATE TIME"]
0730
[checkbox name="Received" value="in his room|in her room |in the courtyard|in the dayroom|getting Vitals signs taken|watching TV|laying down|respirations regular and unlabored|no apparent distress|pacing|interacting with peers|interacting with staff"]
0830
[checkbox name="variable_1" value="NO AM Meds|Compliant with AM meds|Refused |Non-compliant with AM meds|First dose ----given|Consent signed|verified consent signed|NO PRN's requested|No s/s of adverse reaction noted this shift"]


Denies[checkbox name="variable_9" value="Suicidal Ideation| Homicidal Ideation| Auditory Hallucinations| Tactile hallucination |Visual hallucinations|"]

Reports[checkbox name="variable_10" value="Suicidal Ideation| Homicidal Ideation| Auditory Hallucinations| Tactile hallucination |Visual hallucinations| Reports One bowel movement today|Reports last bowel movement on DATE "]


1400
[checkbox name="1400hrs" value="medication compliant|option B|option C|option B|option|option B|option|option B|option"]
1630
[checkbox name="1630hrs" value="Meal and medication compliant|option B|option C|option B|option|option B|option"]
1730
[checkbox name="1730hrs" value="option A|option B|option C|option B|option|option B|option"]

1800
[checkbox name="1800hrs" value="in his room|in her room |in the courtyard|in the dayroom|getting Vitals signs taken|watching TV|laying down|respirations regular and unlabored|no apparent distress|pacing|interacting with peers|interacting with staff|NO inappropriate nor aggressive behavior this shift|NO self harm this shift|"]


[checkbox name="discharge" value="ICOC reviewed with patient|Follow-up appointment was reviewed to follow up with |SNAMHS East Las Vegas Clinic 1785 E Sahara Ave #145 Las Vegas NV 89104 tel nos. 702-486-6400 at 4:00PM on 12/09/2021 for psychiatric follow up and continuity of care |6161 W. Charleston Blvd, Las Vegas, NV 89146, tel nos. 702-486-6045 on [date name="variable_1" default="12-06-2022"] at TIME with Dr Rouhani to follow up management of|HTN|DM|hypothyroidism|seizure |She verbalized understanding. |patient was discharged with following medication:|Patient was provided with education regarding alcohol/drug interaction and symptom management|Patinet verbalizes underatnding  of teachings. Per MD orders, all pending labs and PPD/ CXray discontinued. Personal belongings were checked by patient and MHT. Will give back to patient upon discharge.|||"]. 

[checkbox name="DC location" value="XXXX is discharged to XXX|discharged by taxi|discharged by bus| to Salvation Army, 35 W Owens Ave # 103, North Las Vegas, NV 89030 702-701-5347. Contacted shelter, Lawona, and verified that the shelter is open.|to The courtyard at 314 Foremaster Ln, Las Vegas, NV 89101 which is open  24 hours, & days a week, Phone: (702) 229-6117 |to Catholic charities at  1501 Las Vegas Blvd N, Las Vegas, NV 89101, phone number (702) 385-2662|"]





PATIENT IS
[checkbox name="behavior" value="calm|cooperative|AOX4|AOX3|visible|isolative in room|out for meals and snacks|option|option|option|cooperative with unit policies |interactive with peers and staff |interactive with select peers and staff| keep to self| interactive with peers and staff |poor boundaries| needs prompting| interactive with peers and staff |redirectable|attended groups|able to follow commands|pacing|interactive with peers and staff | has been compliant and cooperative with treatmen|cooperative with discharge assessment and education|option|option|"]
Patient appears
[checkbox name="appearance" value="fair grooming and hygiene|poor grooming and hygiene|malodorous|non-malodorous|disheveled|steady gait|unsteady gait|poor eye contact|maintains good eye contact|blunted|bright affect|flight of ideas|responding to internal stimuli|disorganized thoughts|delusional|angry affect|labile | blunted affect|intense look|irritable|agitated|unable to focus|preoccupied"]

[checkbox name="DISHCARGE 2" value="She denied SI, HI and hallucinations, denies pain or discomfort. Fall prevention education given and she verbalized understanding, environmental rounds done, no clutter noted.|Discharge assessments done, mental status assessments updated, AIM scale completed, treatment plan resolved. Patient was educated on when to call 911 and or go to ER in the event of acute distress or when symptoms worsen; provided suicide prevention hotline (1-800-273-8255), and advised patient on location of facility for medication clinic and outpatient services, she verbalized understanding. Personal belongings returned to patient. Discharge procedures completed and instructions were given and signed by patient with verbalization of understanding of the instructions. Gardenia offered no complaints at this time. A crisis hotline was provided to patient along with a community resource booklet outlining available resources. Patient is escorted by XXX to lobby for discharge at .
XXXXXGardenia is expected to comply with treatment plan of care and cooperate with follow up appointments as scheduled. Xennia Urbano RN-C"]






FIRST DOSE
[checkbox name="variable_1" value="Compliant with |option B|option C|option B|option|option B|option|option B|option|option B|option"]
PRNs
[checkbox name="variable_1" value="option A|option B|option C|option B|option|option B|option|option B|option"]

 [radio name="variable_1" value="Suicidal Ideation|Homicidal Ideation|Auditory Hallucinations"]

[checklist name="variable_1" value="POOR HYGIENE|option B|option C"]

Had [select name="variable_1" value=" No bowel movement|1 bowel movement|choice C"] this shift

[remark]CLEAR SPEECH[/remark]

[comment memo="COMMENT"]

[mark memo="STEADY GAIT" mark="mark"]

[var name="WHAT IS A VARIABLE"]