Generic plan/orders

Safety: 
[checkbox name="variable_safety" value="On assessment of risk of harm to self and others, patient's current acute and chronic risk factors outweigh his protective factors and he remains at imminent risk of harm to self or others due to his current severe psychiatric symptoms.|At present, the patient is at high risk of harm to self or others due to severe psychotic symptoms that significantly impair his judgment, behavior, capacity to recognize reality, and ability to cope with the ordinary demands of life.  He meets criteria for psychiatric hospitalization on involuntary status and will require transfer to inpatient psychiatric facility once medically stable.   6404 current on chart. While here, we will continue suicide precautions per hospital protocol and sitter in room for safety.|At present, protective factors outweigh the risk factors. The patient does not appear to be at imminent danger to self/ others at present, denies suicidal thoughts and will be referred to outpatient psychiatrist/ therapist.|Mental status continues to improve with treatment of underlying issues and supportive care.  Patient is not agitated, resistant to care, or hallucinating.  Sleep and appetite are adequate.  At this point, I see no treatment targets for medication trial during this hospital stay nor do I see symptoms that could not be safely addressed as outpatient.  It is recommended that patient follow-up  with psychiatry or neurology as outpatient within the next month for a more thorough evaluation of symptoms and behaviors, establishment of diagnosis, and formulation of treatment plan.|option C"]


PLAN

Management of Lethality Concerns:
In acute medical environment, we will continue to maintain patient safety through 1-1 sitter and implementation of psychiatric/suicide precautions protocol, while attempting to adjust his psychiatric medications as able and appropriate given his current medical circumstances.
6404 remains on chart.  Psych/suicide precautions and sitter orders are in place.

At the time of my evaluation,  patient requires treatment in an inpatient psychiatric setting  due to the severity and acuity of symptoms, the likelihood of response to treatment, and need  for an intensive 24-hour level of care for the following reasons:
[checkbox name="reasons" value="Threat to self or others requiring 24-hour professional observation| 
Suicidal ideation or gesture within 72 hours prior to admission|
 Self-mutilation (actual or threatened) within 72 hours prior to admission|
Chronic and continuing self-destructive behavior (e.g., bulimic behaviors, substance abuse) that poses a significant and immediate threat to life, limb, or bodily function.
Assaultive behavior threatening others within 72 hours prior to admission.|
Significant verbal threat to the safety of others within 72 hours prior to admission.|
Command hallucinations directing harm to self or others where there is risk of the patient taking action on them.|
Acute disordered/bizarre behavior or psychomotor agitation or retardation that interferes with the activities of daily living (ADLs) so that the patient cannot function at a less intensive level of care during evaluation and treatment|
Cognitive impairment (disorientation or memory loss) due to an acute Axis I disorder that endangers the welfare of the patient or others.|
For patients with a dementing disorder: for evaluation of treatment of a psychiatric comorbidity (e.g., risk of suicide, violence, severe depression) warranting inpatient admission.|
A mental disorder causing 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.|
A mental disorder that causes an inability to maintain, adequate nutrition or self-care, and family/community support cannot provide reliable, essential care, so that the patient cannot function at a less intensive level of care during evaluation and treatment.|
Failure of outpatient psychiatric treatment so that the beneficiary requires 24-hour professional observation and care. Reasons for failure of outpatient treatment include: Increasing severity of psychiatric symptoms;  Noncompliance with medication regiment due to the severity of psychiatric symptoms;  Inadequate clinical response to psychotropic medications; Due to the severity of psychiatric symptoms, the patient is unable to participate in an outpatient psychiatric treatment program"]
 

Medications:
-Trial of
 -Benefits/Risks/Possible adverse effects of medication and alternatives to medication were  discussed.
 -An opportunity was given to ask questions.
 -Patient and/or family appear to understand the information on the form.
 -Discussed the interaction of psychiatric medication with the following: Pregnancy, Lactation, Alcohol, Nutrition, and Non-Psychiatric Medications  

-PRN orders
[checkbox name="variable_1" value="-Trazodone 50 mg PO qbedtime as needed insomnia"]
[checkbox name="variable_2" value="-Olanzapine 10 mg PO/IM every 4 hours as needed severe agitation, psychosis, not to exceed 30 mg / 24 hours|can give second injection after 2 or more hours if needed|if third injection is required within 24 hours, must be given 4 hours after the second injection| for severe agitation, offer oral option first"]
[checkbox name="variable_3" value="-Zyprexa Zydis 2.5 mg p.o. every 6 hours as needed agitation, psychosis, not to exceed 20 mg / 24 hours|-Zyprexa Zydis 5 mg p.o. every 6 hours as needed agitation, psychosis, not to exceed 20 mg / 24 hours|-Zyprexa Zydis 7.5 mg p.o. every 6 hours as needed agitation, psychosis, not to exceed 20 mg / 24 hours|-Zyprexa Zydis 10 mg p.o. every 6 hours as needed agitation, psychosis, not to exceed 20 mg / 24 hours"]
[checkbox name="variable_8" value="-Risperidone oral solution 1 mg p.o. every 6 hours as needed agitation, psychosis, not to exceed 3 mg / 24 hours"]
[checkbox name="variable_4" value="-Haldol 5 mg p.o./IM every 6 hours as needed severe psychotic agitation, not to exceed 10 mg / 24 hours"]
[checkbox name="variable_5" value="-Lorazepam 2 mg IM every 6 hours as needed severe anxious agitation, not to exceed 8 mg / 24 hours"]
[checkbox name="variable_6" value="Benztropine 1 mg p.o./IM as needed EPS prophylaxis, not to exceed 4 mg / 24 hours"]

Other:
[checkbox name="variable_7" value="-Defer withdrawal management to primary team"]
[checkbox name="variable_8" value="-Continue work-up to rule out organic contributors to presentation, including treponema palladium antibody, vitamin B12, TSH"]

Patient/Family Education/Counseling:
Discussion with patient regarding possible diagnosis and prognosis, treatment options including pharmacological and nonpharmacological approaches, recommended medication and risks versus benefits, side effects/adverse effects.  Patient verbalizes understanding and is agreeable to the plan.
Patient counseled on substance use, need to abstain and pursue substance abuse treatment, poor prognosis with continued use, impact on comorbid psychiatric issues.
Safety planning is done with patient and family. The family was advised to secure all sharps and medication bottles out of patient's reach at home. The family denies having any firearms at home. They were advised to call 911 or take the patient to the nearest ED if patient's behavior worsened or if there are any safety concerns. The family verbalized understanding.
 

Recommendations for Follow-up:
Inpatient psychiatric facility then discharge to residential substance treatment program.  Long-term he will need to reestablish with outpatient mental health for psychiatric medication and treatment, engage in recovery community and positive social supports.
- Follow-up with prescriber of psychotropic medications within 2 weeks and at least monthly thereafter for evaluation of benefit of current psychiatric medications for managing target symptoms , assessment of current/potential SE and unintended consequences, and consideration of whether discontinuation/dose reduction trial can be undertaken. 

For SMI/SPMI
Medication Support: Medication monitoring to increase psychiatric stability—reduce auditory hallucinations and paranoid ideation.
Case Management: Linkage with vocational and social supports to improve daily functioning/manage psychotic symptoms.
Rehabilitation Group: Daily living skills and social skills training group to assist client with reduction of paranoia.

Discharge Planning:
Final disposition is dependent upon patients clinical progression and family decision making. Further input is anticipated on a daily basis, subject to patient/family discussion in light of evolving clinical situation.
Patient needs acute, intensive, inpatient psychiatric treatment in a safe and secure environment to avoid the risks, complications, morbidity, mortality associated with current  mental and physical condition and associated biopsychosocial stressors. 
Transfer to inpatient psychiatric facility on involuntary status once medically stable and bed available.
-Due to evidence of progressive declines in cognition and independent functioning, can no longer safely manage living independently and will require close involvement and monitoring from family members and additional support services if discharged home. Long-term placement may be necessary if this is not possible


[checkbox name="variable_7" value="-The patient and plan were discussed with supervising physician, Dr. Sharpe, who is in agreement with the assessment and plan."]


“Medication Support” means those services that include
prescribing, administering, dispensing and monitoring of
psychiatric medications or biologicals that are necessary to
alleviate the symptoms of mental illness. Service activities
may include but are not limited to evaluation of the need for
medication; evaluation of clinical effectiveness and side
effects; the obtaining of informed consent; instruction in
the use, risks and benefits of and alternatives for
medication; and collateral and plan development related to
the delivery of the service and/or assessment of the
beneficiary. 

https://dbhdd.georgia.gov/sites/dbhdd.georgia.gov/files/related_files/site_page/Training%20Manual%20-%20EMR-2.pdf