Inpatient Manual for MHC 2007-2008[1]

7/25/2019 Inpatient Manual for MHC 2007-2008[1]

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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 !!". #ome re$uired items are

su%&ect to change over time. 'ther items are suggestions on how to go a%out doing the daily work in an efficient

manner. (ou may read it all at once or refer to a section as the need arises. )ither way* it is meant to %e only onesource of information* not the a%solute %ottom line on the exact rules for operating on the inpatient services. +f in

dou%t* please speak with your chief resident or attending for clarification.

+nitial Contri%utors in !!,

Chris -%%ott* M/aren -rnold* M

0ictoria 1arrow* M

2evised and Updated for !!"-aron 1rodsky* M

3at 2a%&ohn* M* 3h.

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TABLE OF CONTENTS

4. MHC aily 2esident #chedule 567

. -dmission Criteria 85. -dmission 'rders ,6"

7. History and 3hysicals 9

8. Mental #tatus )xaminations :

,. )mergency Medication 'rders 4!". 3rogress Notes 44

9. ischarging 3atients 4645

:. ischarge #ummary 47

4!. ;egal Matters


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MHC DAILY RESIDENT SCHEDULE

Resident Pre-Rounding

+t is recommended that you arrive on the ward %efore Morning 2eport to record vital signs* check the chart for

changes over the nightollowing resident presentations* the overnight resident will have an

opportunity to discuss any emergency psychiatric issues Athe difficult patient that was not admitted* team call* when

to give +M medications in 3)#* etc. These cases should also %e presented in a clear* concise fashion. >inally*housekeeping issues will %e addressed including assignment of the resident float* if applica%le.

Morning Rounds

epending on the attending* rounds to interview the patients may %egin at the end of morning report or at a different

scheduled time. -lso depending on the attending* rounding on the patients can range from walking a%out the ward

talking with each patient individually to having a group meeting with all the patients together. Check with yourattending to she if s


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have happened throughout the day. -ttendings are always availa%le %y pager throughout the day for immediate

$uestions that arise. 3lease contact the attending regarding any new admissions. -t times* the attending will do the

initial interview with you. (ou should discuss the plan for each new patient with the attending %efore writing orders.

Court He"rings

Court hearings for commitment and treatment guardian appointments are held %etween 9D5! and 4D!! every dayexcept Bednesday. Most often they are scheduled into 5!6minute time slotsE 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 patient@shearing. The staff will notify the resident. - staff mem%er will accompany the patient to the courtroom. )ither the

staff mem%er or the resident will %ring the patient@s chart to the courtroom. Bhether it is during morning report*rounds or /ardex* the resident is re$uired to stop his


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ADMISSION CRITERIA

The goal of acute inpatient care is to sta%ili=e patients who display acute psychiatric conditions associated with a

relatively sudden onset and a short* severe course* or a marked exacer%ation of symptoms associated with a morepersistent* 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 %e to document the

criteria and precipitants necessitating this level of care.

Ad,ission Criteri"

The patient demonstrates symptomology consistent with #M6+06T2 -xis + and -xis ++ diagnoses that re$uire*

and can reasona%ly %e expected to respond to* therapeutic intervention.

There is evidence of danger to self Apatient or others that could result in serious harms. )xamples areD

Homicidal thoughts with plan.

- suicide attempt that is serious %y degree of lethality and intentionality or suicidal ideation with a plan and

means.

+mpulsive %ehavior and


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ADMISSION ORDERS

/it"$ Signs "nd B$ood ETOH

-lways review a patients vital signs %efore ordering medications.

+f you suspect a patient is intoxicated* determine their %lood )T'H level beforeordering medications.

+f a patient is acutely intoxicated and appears to %e in delirium tremens already* they may need a monitored %ed6 something we don@t have at the MHC.

S",$e A$(o+o$ Deto# Orders

0ital signsD I 7 hours while awake x 79 hours* then I shiftC+B- I 7 hours while patient is awake.

+f C+B-6-2 is K4! repeat $ 4 hour until score L4! and then go %ack to $7 hours

)very time C+B-6-2 scale is administered Aeither $ 4 hour or $ 7hour give medication according to the

following Aordering physician should pick 'N) %en=odia=epine

Call M if C+B-6-2 K8 or , after 5 doses

Call M if pt appears over sedated* disoriented* complains of distressing visual* auditory or tactile

hallucinations* respiratory rate is L4! or 7!* has a sei=ure or has a cardiac arrhythmia

Call M if total dose in 7 hours 8!!mg chlordia=epoxide* 5!! mg oxa=epam* or 4!mg lora=epam

+f C+B-6-2 scale is L 4! do not give %en=odia=epine iscontinue C+B-6-r and %en=odia=epine is score is L 4! for 7 hours

C+oose one o* t+e otions 0e$o1

Chlordia=epoxide 8mg 3' $467h 32N C+B-6-2 K4! L48

Chlordia=epoxide 8!mg 3' $467h 32N C+B-6-2 K 48 L !

Chlordia=epoxide "8mg 3' $467h 32N C+B-6-2 K! L8

Chlordia=epoxide 4!!mg 3' $467h 32N C+B-6-2 K8

Call M if dose 8!!mg in 7 hours

+f C+B-6-2 is L 4! for 7 hours* then discontinue Chlordia=epoxide.

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'xa=epam 48mg 3' $467h 32N C+B-6-2 K4! L48 'xa=epam 5!mg 3' $467h 32N C+B-6-2 K 48 L !

'xa=epam 78mg 3' $467h 32N C+B-6-2 K! L8

'xa=epam ,!mg 3' $467h 32N C+B-6-2 K8

+f C+B-6-2 is L4! for 7 hours* then discontinue 'xa=epam

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;ora=epam 4mg 3' $467h 32N C+B-6-2 K4! L48

;ora=epam mg 3' $467h 32N C+B-6-2 K48

+f C+B-6-2 is L4! for 7 hours* then discontinue ;ora=epam

-dditional medications for the patient with alcohol dependenceD

Thiamine 4!!mg 3' I dayE >olate 4mg 3' I dayE M0+ 4 ta% 3' I day

Oi"te Deto# Orders

Bhile uncomforta%le* opiate detox is not life threatening. Methadone for opiate dependence may only %e ordered at

the MHC if the dose has %een verified %y the patient@s methadone clinic. -fter hours this is impossi%le* so you may

choose some or all of the following FcomfortG medications. +f the patient is appropriate* in$uire a%out

1uprenorphine starts during the admission %y contacting the #u%stance -%use fellow.

0itals $ , hours while awake

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Clonidine !.4mg 3' $,h 32N withdrawal symptoms 138!L,8

Clonidine !.mg 3' $,h 32N withdrawal symptoms 13 K,8L98

Clonidine !.5mg 3' $,h 32N 13 K98

Hold Clonidine for orthostatic symptoms and 13LK8!* #13 L:!

+%uprofen 7!! mg 3' I+ 32N muscle aches* pains

;evsinex !.5"8mg 3' $4h 32N ?+ spasm

2o%axin "8! mg 3' I+ 32N muscle spasms 'xa=epam 5!mg 3' I,hr 32N anxiety

Tra=odone 8!mg 3' I%edtime 32N insomnia* may repeat x 4

-cetaminophen 58mg 3' I7hr 32N headache

Hydroxy=ine 8mg 3' T+ 32N anxiety

3rometha=ine 8mg 3'ree T7* )/?

&o,enD Urine 3regnancey Test

P"tients on Antis%(+oti(sD fasting glucose and lipids Aif none availa%le during the last , months* C3/*

waist circumference* H%-4C* and admission weight

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C"rdi"( P"tientsD -n )/? should %e ordered for any patient with known C-* significant risk factors for

C-* history of prolonged ITc* recent cocaine or methamphetamine use* or when considering a TC- for anyone

over 7!* ;ithium for anyone over 8! or ?eodon on anyone

De$irious P"tientsD NH7 Acirrhotic patients* U- w< C#* >ree T7* HC0* H+0

Ho,e$ess P"tientsD Hep C* H+0* place 33

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THE HISTORY AND PHYSICAL

The admission history must %e concise and well6organi=ed. (ou may not write FunknownG or Fnot o%tainedG for any

element of the H3. The following is a guideline of information that must %e included in your admit note. There aremany accepta%le variations.

4. ID6 -ge* ethnicity* marital and employment status.

. C+ie* Co,$"int6 usually in $uotes.5. Histor% o* Present I$$ness6 arranged in the following orderD

3recipitant to admission including how the patient was %rought to the hospital* along with current

psychosocial stressors.

Current symptoms and chronology ApsychosisO +llicit drugsO #+O.

1rief review of symptoms to narrow differential diagnosis Aperiod of decreased need for sleepO su%stancesO

head in&uryO 6 a psychiatric review of symptoms.

7. Pre.ious Ps%(+i"tri( Histor%P include inpatient admissions* outpatient providers


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MENTAL STATUS E4AMINATION

The Mental #tatus )xamination AM#) is an important part of the History and 3hysical and will %e a key componentof your daily progress notes. +n addition* several attending psychiatrists will expect a formal presentation of the

M#) on rounds each day.

The following is a summary from the Concise Textbook of Clinical Psychiatry A/aplan and #adock* !!7. TheM#) is how the psychiatrist summari=es his


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(ud#ment! the patient@s awareness of the outcome of his


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>or persisting )3#* patients can %e put on a regular schedule of medicationsD

Cogentin 4 mg 3' 1+ OR

1enadryl 8 mg 3' or +M I,hrs

PROGRESS NOTES

)ach 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. -t the Mental Health Center* these are currently %eing dictated Asee dictation guide

for further details.

D"i$% rogress notes need to in($ude t+e *o$$o1ing

1rief identification of the patient including admission date.

The patient@s report Ahow the patient is feeling* does the patient report any side effects to medications* what thepatient is preoccupied with* etc.. Bhen documenting target symptoms* %e as descriptive as possi%le.

#taff report that includes nursing report of %ehaviors over the past 7 hours* 32Ns andor clarification* see the next section.

)stimated length of stay.

Continued St"% Criteri" *or In"tient Be+".ior"$ He"$t+

This must %e documented in your progress note. -ll of the following criteria are necessary for continuing treatment

at this level of care. The patient@s condition continues to meet admission criteria for inpatient care* acute treatment interventions

have not %een exhausted and no other less intensive level of care would %e ade$uate.

The multi6disciplinary discharge planning process starts from the assessment and preliminary plan upon

admission and includes the patient and family


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DISCHARGING PATIENTS

Dis(+"rging "tients *ro, t+e MHC in.o$.es t+e *o$$o1ing (riteri"2

Treatment plan goals and o%&ectives have %een su%stantially met and

>7 Bi$$ing S+eet

The %illing sheet can %e found in the chart %ehind the face sheet.

o not use a%%reviations or diagnostic codes when filing out this form.

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The 86-xis diagnoses as written on the %illing sheet should %e the same as they appear on the discharge orders.

?7 Mu$tidis(i$in"r% Dis(+"rge Su,,"r%

Completed %y nursing and social work* %ut the resident needs to sign it.

@7 A0nor,"$ In.o$unt"r% Mo.e,ent S("$e

This form must %e completed at some time during patient@s admission.

7 Dis(+"rge Su,,"ries +t is advisa%le to dictate discharge summaries on the day of discharge* %ut they must %e completed within 79

hours of the patient@s discharge.

#ee Dis(+"rge Su,,"r%section for specifics.

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DISCHARGE SUMMARY

ischarge summaries are a %rief summation of the patient@s hospitali=ation.

They are to %e done within 79 hours of the patient@s discharge from the MHC.

#tat transfer summaries must %e dictated for patients going to other units prior to transfer.

-t the end of dictating at the MHC* the system should give you a &o% num%er. (ou should record this num%er

on your discharge orders for future reference in case the dictation gets lost. 1elow is a template and a few words a%out everything that must %e included in the dictation.

D"tes o* "d,ission "nd dis(+"rge6 n",e o* "ttending "t dis(+"rge.Dis(+"rge Di"gnosesexactly as written on discharge order and %illing sheet AN'# and 2


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LEGAL MATTERS6 COURT PAPER&OR!

Certi*i("te *or E."$u"tion 9"'" Pi('u order or C *or E:

This is a legal document that can %e completed %y any licensed physician or certified psychologist. +f a physician%elieves that a patient is potentially dangerous* this order allows the police to detain an individual for psychiatric

evaluation Anot necessarily admission at 3)#. 3er New Mexico state law* the order should only %e written %y a

psychiatristor the next sentence*

appointment of A$ist n",e o* *",i$% ,e,0er o* NAMI .o$unteer as a treatment guardian for a period

of time not to exceed


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answer on the summary line. ;ay witnesses can include the police officer that %rought the patient into the facility

or family mem%ers. +nclude lay witnesses only if you feel it is vital to presenting a strong case for commitment.

The petitioneror +tem 8* if the proposed treatment guardian is a family mem%er* you must write down his


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>or +tem ,* list all possi%le residents that may %e testifying for the hearing. A#ee +tem 45 for

commitment paperwork.

>or 3etitioner


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LEGAL MATTERS6 COURT HEARINGS

Co,,it,ent He"rings

Hearings are held in the courtroom* which is &ust past the atrium at the MHC.

- staff mem%er will escort the patient to the courtroom.

)ither you or the staff mem%er will %ring the patient@s chart.

The patient@s attorney may o%&ect if you are looking at notes or the chart* so %e prepared to answer from

memory.

The %est advice for testifying well in court is to %e prepared7

2eview the patient@s H3* commitment paper work* -3 statements* etc. The court participants Athe -*

the attorney for the patient and the commissioner will have received copies of all this documentation and

may ask you $uestions a%out it.

2eview prior hospitali=ations and prior treatments of the patient.

The patient will %e seated next to hisor example*

in response to the $uestion FHow has the patient@s diagnosis affected the patient*G a good response would

%e to include items regarding what %ehavior led to the patient@s admission and any dangerous or %i=arre

%ehaviors %y the patient prior to or since admission.

+f there is an o%&ection %y either attorney* wait for directions from the &udge %efore answering. 1elow are

the standard $uestions the - will usually ask you.

2emem%er to turn your pager or cell phone on silent when in court.

The patient@s attorney may ask additional $uestions prior to accepting you as an expert witness during cross6

examination. The $uestions to esta%lish your $ualifications as an expert witness are mainly to enter your

$ualifications for the record in each individual case. The defense attorney may attempt to shake your confidence

with these $uestions. Just remem%er 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.

uestions "s'ed 0% t+e Distri(t Attorne%

How are you employedO

How long have you worked in the area of mental healthO

o you know the patientO

o you have a diagnosis for the patientO

How has the patient@s diagnosis affected the patientO

Bhat is your proposed treatmentO

o you feel the patient presents a likelihood of harm to himself or othersO +n what wayO

Bhat type of commitment are you seekingO

o you feel the patient will %enefit from the proposed commitmentO +s the commitment consistent with the treatment needs of the patientO

+s the commitment consistent with the least restrictive means of treating the patientO

+s it your understanding that the cost of treating the patient is for the patient and the facility to %ear and not

the courtO

uestions "s'ed 0% t+e P"tients Attorne%

Have you spoken with the patient a%out his


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(ou doknow the patient would like to %e dischargedO

#


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INFORMED CONSENT AND DECISIONAL CAPACITY

'ne of the most fre$uent re$uests made to on6call 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 commonconsultation. >irst* it is important to recogni=e the difference %etween mental competence and mental capacity.

Competence is a legal term and only a &udge can declare a person competent or incompetent. Capacity is a medical

term that can %e assessed %y any physician. However* non6psychiatric physicians fre$uently call upon the expertise

of psychiatrists to evaluate the mental and neurological status of patients. Mental capacity must %e assessed incontext. Capacity is not an all or nothing concept. - 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 re$uest and clarify what the

patient is %eing asked to do. +t is also helpful to speak to family mem%ers or friends who can provide %ackground

information regarding the patients mental functioning. To determine if a person is capa%le of informed consent* youneed to assess the following three elements.

De(ision"$ C""(it% "nd In*or,ed Consentre$uires the following a%ilitiesD

4. The a%ility to understand the relevant information concerning the proposed treatment including the risksand %enefits of the treatment and alternatives.

. The a%ility to appreciate ones medical situation and its possi%le conse$uences for ones health and life.

5. The a%ility to freely make and communicate a choice a%out whether to accept treatment or not without

undue internal or external coercion.

7. The a%ility to engage in rational deli%eration a%out ones own values in relation to the physiciansrecommendations a%out treatment options.

3atients who clearly do not possess these a%ilities such as those who are comatose* severely demented* delirious orpsychotically delusional may not meet the criteria for mental competence and will re$uire a surrogate decision6

maker. However* no class of patients* except for the comatose* can prima facie %e considered incapa%le and each

case must %e evaluated independently.

+n an emergency situation* the family is customarily accepted as the surrogate decision6maker and you should

inform the primary physician of your finding and recommendation that he contact the family. +f the situation is non6

emergent* the patient has no family or the family may %e not acting in the patients %est interest* then the courts can

appoint a treatment guardian to make decisions on the patients %ehalf.

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TEACHING MEDICAL STUDENTS

2esidents 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 avalua%le mem%er of the treatment team. (ou are in the fortunate position of %eing a%le to provide much of the

leadership and most of the structure they need. (our &o% is complicated %y the constraints of time 6 we only

have 7 weeks for our clerkships. -t UNM* medical students@ pre6clinical education is limited to only 7 weeks

of psychiatry in their first year. Therefore* we need to provide most of what they will lean a%out psychiatry intheir clinical clerkship.

-t the 0-* one medical student is typically assigned to each team. That means that %oth residents on a particular

team will %e sharing one medical student. -t the University* one or two medical students are usually assignedto the ?eriatric Bard and typically one student is assigned to )ast Bard and one to Best Bard. The residents

on )ast and Best will %e sharing a student as descri%ed a%ove.

+t is important on their first day to orient them to the ward and to review safety protocols


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PATIENT PLACEMENT REPORT

A!A THE HIT LIST

+n general* admissions during the day are assigned to residents according to a rotating* %atting order known as the

Hit ;ist which is kept in 3)# at the MHC.

)xceptions to the Hit ;ist Aeach explained %elow include post6call status* vacations* admissions on call* clinic days*

the four6oclock rule* %ounce %acks* and patient caps.

Post-("$$ St"tus

Bhen a resident is post6call* s


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PSYCHIATRY EMERGENCY SER/ICE 9PES:

Hours2 uring the week* residents provide primary coverage in 3)# from 83M to 9-M the next morning. -t 9-M

you are re$uired to go to morning report. #unday thru Thursday* a moonlighter will often relieve you at midnight.

-n attending is with you until : 3M during the week. -fter this time* the attending will %e availa%le %y pager. 'nweekends and holidays* you are re$uired to arrive at 9-M and stay until 9-M the next morning. -n attending is

always availa%le %y pager.

&+en to C"$$ t+e AttendingD +f you have a $uestion* always call the attending. (ou are not re$uired to call the

attending for admissions* %ut you are re$uired to call the attending on all discharges from 3)# that arrived from the) or police Areferred to as Flevel 4@sG. This includes anyone that arrives %y Certificate of )valuation.

Certi*i("te o* E."$u"tionD >amily@s will occasionally call a%out a patient that is dangerous and unwilling to come infor an evaluation voluntarily. (ou may fill out a C of ) at this time to have the police %ring the patient in for an

evaluation. -lways ask family if the patient has access to any firearms and notify the police accordingly. #ee Leg"$

M"tters I3Court P"er1or' se(tionof this manual for more information a%out how to complete a C of ).

T+e E,ergen(% De"rt,entD The emergency department is our %est referral source. Bhen listening to a

presentation a%out a possi%le referral from the )* in$uire a%out the precipitant to the patient@s arrival A%rought in %y

policeO familyO* medical diagnosis* la%s and related work6up. +f time is availa%le* review the patient@s informationin 3owerChart 'ffice. 3rior to accepting a patient for transfer to 3)#* you may ask for additional la%s that may %e

pertinent. UM@s can %e very helpful. +n addition* find6out if there is a %lood alcohol level A1-; or if the patient

has %een medicated.

T+e Into#i("ted P"tientD +ntoxicated patients often arrive at 3)# via police. The UNMH )2 may send intoxicated

patients who show no signs of complicated withdrawal with psychiatric co6mor%idities Arecent suicide attempt*suicidal ideation* etc. +ntoxicated patients should %e closely monitored while in 3)# for evidence of withdrawal. +f

clinically indicated* start %en=odia=epine withdrawal prophylaxis while checking vitals hourly. +f oral

%en=odia=epines do not attenuate vitals or the patient %ecome delirious* etc* do not hesitate to transfer patient to the

UNMH ) as needed. +f the patient@s vitals remain sta%le and the patient does not show any other signs orsymptoms of withdrawal* then the patient may stay in 3)# until Finterviewa%leG. -s a general rule* when the

patient@s %reathaly=er L !.!9* then you can interview the patient. However* people with high tolerance may %einterviewed prior to this limit* %ut may not %e discharged from 3)# until %lowing %elow the legal limit.

Medi("$ E,ergen(iesD 3)# nurses are very good at identifying medical emergencies* %ut ultimately* you are

responsi%le for assessing and responding to them. +f you need to transfer a patient to the UNMH )2 and it is an

emergency* staff should arrange transport A:44 or non6emergent transport. Call UNMH )2 -#-3 to give them thepertinent presentation and get the accepting physician@s name Complete the consult form documenting why you are

sending the patient to the )2. -sk the staff to copy pertinent information from the chart so that it can accompany the

patient to the )2. #tay with patient until )M# has left the %uilding. >inally* call the consult liaison service at the

University hospital to leave them a message a%out the patient@s arrival the University ) Ainclude name* M2* wardthat the patient left* diagnosis and medical pro%lem.

Re*err"$s to t+e MHCD 3eople seen in 3)# with a chronic* severe mental illness without a treatment provider may

%e referred to the MHC. The patient will need financial counseling* and 3)# nursing will file the appropriatepaperwork in the Fphone triage %asketG.

Re*err"$s to t+e Co,,unit% Pro.idersD +f the patient seen does not have a chronic mental illness* or an illness of

insufficient severity to warrant referral %ack to the MHC* then the patient may %e referred %ack to a community

provider A3C3* N3* etc. (ou should fill out a %rief consult form documenting your diagnostic impression andrecommendation. (ou should either fax this form to the appropriate provider or give the patient of this

recommendation to hand6carry to their provider.

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Co,,uni("tion 1it+ MHC Out"tient C$ini(sD (ou will see many patients in 3)# from different MHC clinics

Aual* ?eneral Clinic and Continuing Care. +t is important to let the primary provider know a%out the patient@s visit.

3refera%ly* the outpatient provider would %e contacted the next weekday of the patient@s arrival. +f this is not

possi%le* a %rief email with the patient@s initials* medical record num%er and Fadmitted or not admittedG should %esent to the primary provider. Just include enough information in the email to let the primary provider access the

chart and review your note. o not include any more identifying or clinical information via email then a%solutely

necessary.

&+en to Pres(ri0e Oi"tes or Sti,u$"nts *ro, PES2 NEVER.

Consu$ts in M"in Hosit"$D 2arely* you will get a re$uest form the University Hospital for an emergent consult

after hours. +t is our policy that a physician Ayou as the resident on6call must %e in6house


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CHILDREN AND ADOLESCENTS IN PES

Children and adolescents are often evaluated in 3)# after hours. Bhile a child fellow is on pager call at all timesfrom 3)#* the evaluation is the responsi%ility of the 3)# resident. +f the child meets admission criteria* and if a %ed

is availa%le at UNM Children@s 3sychiatric Hospital* and if you have no $uestions* then you do not need to call the

child fellow. &+ene.er dis(+"rging t+e "tient *ro, PES6 %ou ,ust "$1"%s ("$$ t+e (+i$d *e$$o1. 1e prepared to

give a concise yet thorough presentation over the phone that includes information on guardianship and the socialcontext of the child. 1e aware* children have different Alighter admission criteria than adults Agreater risk of

adolescents acting impulsively* protection from social chaos.

/o$unt"r% .7 In.o$unt"r% Ad,issions

+f the child is 45 or younger and the parents agree to admission* then the child is admitted voluntarily.

+f the parents disagrees with the admission decision and the resident* in colla%oration with the child fellow*

decide that the patient needs admission* the child is placed on an involuntary hold Asimply fill out )mergency

etention 'rder* the child fellow will complete +nvoluntary Commitment paperwork the next day.

+f the child is 47 or older and the parents or the teen disagrees with admission decision* the child must %e

admitted on an involuntary hold Afill out )mergency etention 'rder.

Consenting C+i$dren *or Medi("tions on Ad,ission

+f the child is 45 or younger* the parent must provide informed consent for all medications. +t is good practice to

o%tain assent Aagreement from the child while informing him or her of %enefits and side effects of proposedmedications.

+f the child is 47 or older and the child has decisional capacity to consent to psychotropics* the child can consent

to medications while the parent must %e informed.

S",$e Medi("tions Orders

Unlike adults* children and adolescents need consents on file for scheduled and 32N medications. >or example* you

cannot write the following orders without consent in the chart* %ut you can give an acute* one6time order for a 32N.

>irst ;ine MedicationD iphenhydramine 4mgor larger childrenD chlorproma=ine 4 mgloodedG 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 %e evaluated in 3)#.

This is a &udgment call %y the general resident and must %e made in the spirit of colla%oration with the

child fellow.

When a child/adolescent is in PES to be evaluated, that evaluation takes priority over all other pendin

evaluations.

!f a child/adolescent is in PES, then a uardian needs to be present. !f no uardian is available, the PES nursin

staff "ill help you call to obtain a te#porary uardian.

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BAC!-UP CALL

Having a person on %ack6up call is an essential part of any on6call system. The person on %ack6up needs to have

their pager with them at all times.

-ppropriate reasons to call in the %ack6up psychiatrist are as followsD

- medical emergency prevents you from %eing a%le to take call - family emergency occurs that prevents you from %eing a%le to take call

(ou are physically una%le to get to the hospital

+nappropriate reasons to call in the %ack6up psychiatrist are unaccepta%le. #ome A%ut not all unaccepta%le reasonsare listed %elowD

(ou think you might have a fever and &ust don@t feel too well

+t is Mother@s ay and you want to spend time with your children Athis actually happens on other

services

(our favorite foot%all team is playing and you want to watch the game at ?ecko@s.

(ou have a hangover.

+n the past three years* the %ack6up resident has %een Qput into action@ approximately 567 times each year. 2esidents

do %ecome ill* they do re$uire surgery at times* and family emergencies arise. 3lease %e &udicious a%out utili=ing the%ack6up system and please call the %ack6up resident as soon as you think you may not %e a%le to take your call.

T+e 0"('-u resident is not re)uired nor e#e(ted to (o,e in "nd +e$ %ou i* %ou "re o.er1+e$,ed 1it+

"tients to see7 T+"t is not t+e urose o* t+is s%ste,7

Bhen the %ack6up resident is utili=ed* %oth the %ack6up resident and the resident re$uesting the %ack6up need to

email their Chief 2esident for notification. +n addition* the original on6call resident will %e re$uired to take an

upcoming call shift scheduled for the %ack6up resident. >or exampleE 1rodsky is on6call and 2a%&ohn is the %ack6

up. 1rodsky has to leave town for a family emergency* so he calls 2a%&ohn to inform him of the %ack6upresponsi%ility. 1oth 1rodsky and 2a%&ohn email their Chief 2esident* then 1rodsky is re$uired to take one of

2a%&ohn@s upcoming call shifts.

3lease %e fair when arranging these trades. +f you call in the %ack6up for a Monday shift* do not expect them to takeyour 7 hour #aturday call at the MHC. +n addition* if the %ack6up is called in for even as little as hours of work*

then technically* they can ask for the original on6call resident to pay them %ack an entire call shift.

&e ("nnot stress t+e i,ort"n(e o* t+e 0"('-u resident +".ing t+eir "ger 1it+ t+e, "t "$$ ti,es 1+en t+e%

"re t+e 0"('-u7 In "ddition6 %ou ("nnot $e".e to1n 1+en %ou "re t+e 0"('-u resident6 nor ("n %ou +".e

"n%t+ing "$(o+o$i( to drin'7

)very year* a %ack6up resident forgets they are on %ack6up duty when someone is trying to call them in to work. +fthe %ack6up is not availa%le* then an attending gets called in to work. ;ast year* r. ;auriello had to take a few

hours of call %y himself until the %ack6up was reached. Trust me* you do not want to %e the resident that forgets he

is on %ack6up when the ) or an attending is trying to call you.

CALL S&ITCHES3TRADES2

+t is perfectly accepta%le to trade calls with a fellow resident. However* please let Judith A6874" know so that shecan update the master schedule.

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E/ENING AND &EE!END CHEC!OUT AT MHC

2esidents will often have issues Ala%s* levels* $uestiona%le vitals* concerning medical pro%lems* etc that will need

to %e addressed after %usiness hours. To convey this information to the residents who will %e covering the evenings*

weekends or holidays* the primary resident must write the following information on the dry6erase %oard at 3)#

marked Fcheck6outG. The following info must %e included on the checkout %oardD

ate

3atient@s Name* M2

3atient@s location#pecific instructions to the on6call residents Areview la%s* review ' sat over weekend

>or example* F,645* 1;* M2 9",85* ) green* please check lithium level on #at morningG

The covering resident should %riefly document the action taken over the weekend in the patient@s chart.

Many of the attendings covering for the weekend would like to have sign out to get to know the patients they will %e

covering for the weekend. #ign6out to attendings is somewhat different than sign out to fellow residents. >orattendings* some will want to speak to you directly on >riday afternoonE others will want the sign out in writing.

#ign6out to attendings should include a very %rief description of the patient* current symptoms and any recentmedication changes.

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MEDICATION RECONCILIATION

Medication 2econciliation is re$uired whenever a new patient is seen in any setting* or when a follow6up patient has

their medications changed. +t is a process where%y it is assured that the official medication list* in )asyscript* is

updated and current. +t is the responsi%ility of each clinician to update that list and then add the medicationreconciliation statement. The patient is then given an updated list of new medications.

+n your orientation you will %e shown how to do this process. >or pointers you can refer to the Medication

2econciliation page in the H#C +ntranet. -lso feel free to ask r. Jenkusky for assistance at any time.

CRISIS STABLI;ATION SER/ICES

C## is a place where patients can %e sent from 3)#. The ideal patient is one in a current crisis who needs a

structured environment and


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MHC FLOAT RESIDENT

Purose

-t certain times* the UNM MHC will have seven inpatient residents. Bhen this occurs* the seventh resident willrotate as a FfloatG with his or her colleagues every two months. The purpose of this position is to satisfy the

re$uirements of the inpatient rotation while sharing the inpatient work load e$ually with the other inpatient

residents.

Resonsi0i$ities

The primary responsi%ility of the float resident will %e to cover a team Aeast* west or geriatric while another resident

is on medical* annual or educational leave. 3rior to taking this team* the float resident will share responsi%ilities withthis resident for several days Aadmission* court* rounds and notes to ensure ade$uate continuity of care. Bhile the

primary resident is on leave* the float resident will assume all resident responsi%ilities 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.

Bhen all residents are present and no resident has leave is pending* during morning report the float resident will %e

assigned to a team to share responsi%ilities in the following orderD

4. Co6coverage of team with primary resident during days with extensive court hearings* family meetings* etc.. Co6 coverage of team with primary resident during days with anticipated high6turnover anticipated

5. +npatient attendings and


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GERIATRIC &ARD SUR/I/AL GUIDE

T+e Ru$es

3;)-#) 'N@T /+;; TH) 3-T+)NT. 1ad things may happen %ut we don@t have to cause them.32-CT+C) ?'' M)+C+N).

TH+N/ M)+C-;. +f you@re not finding delirium in at least some patients* you@re not looking hard enough.

T-/) -B-( M'2) M)+C-T+'N# TH-N ('U #T-2T. #implify* simplify* simplify.#T-2T ;'B* ?' #;'B.>';;'B TH) 1))2@# C2+T)2+- BH)N)0)2 3'##+1;).

U#) T-2?)T) 32N@# JU+C+'U#;(.

1)TT)2 T' 32)0)NT >-;;# TH-N T' )W3;-+N - 12'/)N H+3.

'2)2+N? ;-1 T)#T# B+#);(. 'rdering la% tests is like picking your nose in pu%lic P it@s important toknow ahead of time what you@re going to do if you find something.

>'' -N B-T)2 -2) +M3'2T-NT >'2 ;+>). Make sure your patients are getting ade$uate nutrition

and hydration.

!"rde#

/ardex should start promptly at !:D5! on M* T* Th* and >. 'nce assem%led in the conference room area with the

cart of charts* the nursing staff will present first* followed %y other ancillary services if present Ai.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 M#)* and a pro%lem %asedassessment and plan. +f asked* you should %e a%le to clearly articulate your rationale for the proposed plan. (our

presentation should %e from memory. /now your patients. /now the medications* dosages. /now the voca%ulary of

the M#) and %e a%le to give an example of how that patient demonstrates a particular concept. >or example* know

the difference %etween irrational and confused* confa%ulation and delusional* perseverative and ruminating* etc.

The nursing report will include the vitals* hours of sleep* percentage of meals and weight if availa%le. Nursing

report does not usually include the 32N@s. (ou should know your patient@s 32Ns and compliance prior to /ardex.

'n Monday mornings* all of the patients are interviewed individually in /ardex. The morning will start with the

nursing report and then each patient will %e %rought in one at time to %e interviewed %y his or her resident* student*

or fellow. epending on time constraints and the level of functioning of the patient* each mem%er of the team will

introduce themselves to the patient. The o%&ective of this %rief* interview is to elicit and demonstrate the patient@s

target symptoms for the team. -fter all of the patient@s are interviewed* the team will then discuss only the plan forthe day Ano statement of the M#) P everyone saw that in the interview.

Tuesdays are student and fellow article presentations. Thursdays are resident article presentations. 8 minutes on thepertinent points of the article prefera%le with handout. 3lease make a copy of the article and hand6out for everyone*

including attending* residents* students* fellows* social workers and nurse practitioner.

Orders

-ll orders MU#T %e written at the end of /ardex. Try hard not to continue to write orders throughout the rest of the

day. 2eminders on writing orders P +nclude a NT) Anot to exceed amount on 32N@sE 32N@s must %e written with a

definite time interval Aex. W(S drug I 7 hours 32N* not I 76,hr


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E"ting Disorders

- white three6ring %inder either in the resident@s office or at the nurse@s station has many helpful articles and rating

scales addressing eating disorders. The standard eating disorder %ehavioral protocol includes weights for the patientafter first void* wearing hospital gown* facing away from the scale I Monday* Bednesday and >riday. The patient

is not to %e given the weight %y the tech or nurse weighing the patient %ut %y a mem%er of the treatment team.

-dditional orders or restrictions regarding a %ehavioral plan for eating disorders will vary according to the patient

such as ;'# for 4 hour following meals* no dou%le portions* patient to %e out of the room for all meals* etc. r.(ager wrote the treatment guidelines we follow. 3lease contact him regarding patients with eating disorders* he will

%e happy to assist.

/it",in Bor purposes of the geriatrics rotation* deficiency is anything less than 7!! Anot !! which is the la%@s lower limitsof normal. 2eplacement is done %y giving 0itamin 14 4!!! mcg +M I day x " days* 4*!!! mcg +M I week x 4

month then 4*!!! mcg once monthly. ?radual replacement may %e done %y giving 0itamin 14 4!!! mcg 3' I

day. 'ral replacement is not the preferred route for geriatrics patients as there may %e issues of ?+ a%sorption in this

patient population.

St"rting Doses o* Ps%(+otroi(s in Geri"tri( P"tients

2isperdal !.8 mg 3' I1etimeSyprexa .8 mg 3' I1edtime

#ero$uel 8 mg to 8! mg 3' I1edtime Aantipsychotic of choice for 3arkinsonism and ;ewy 1ody-ricept 8 mg 3' Iday and work up to 4! mg I day

Namenda 8 mg 3' Iday and work up to ! mg divided 1+

Addition"$ Medi("tion Tis

-void 1en=os and anticholinergics if at all possi%le. Medications may often need to %e crushed and mixed in

pudding Agood idea to get okay from treatment guardian first. /isinopril is not on the UNM formulary %ut

*osinopril is. They can %e used interchangea%le with a 4D4 conversion. o N'T start scheduled lithium until a

lithium level is %ack and on the chartVV

Medi("$ Issues

Bhen in dou%t* go to Judith ?illum ANurse 3ractitioner. Medical consults also re$uest that you go to Judy first.

Diet"r% Issues

3atients are more likely to have the following needsD mechanical soft or puree diet* 4D4 staffing for meals and

hydration* and supplemental health shakes. +f you order a diet and nutrition consult* you will actually get one. 3re6

al%umins are helpful for assessing nutritional status.

Interi, Su,,"ries

#ocial work will often ask for interim summaries to aid in placement. +mportant things to note in these types of

interim summaries areD length of time without 32N@s and %ehavioral distur%ances* why the patient needs a nursing

home and why they@re sta%le enough to go.Dis(+"rges

'rders must include -xis +60 diagnosis* the discharge medications and the discharge follow6up appointments.

#ocial work may ask for the orders the day %efore if it is certain the patient will %e going to a nursing home* etc. the

next day. +f the patient is %eing discharged to a nursing home* scripts do not usually need to %e written. +f at all

possi%le* try to have a discharge summary prepared at the time of discharge for any patient going to a nursing homeor assisted living facility.

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IMPORTANT MHC TELEPHONE NUMBERS

C'N#U;T


34/37

MHC/CPC Dictation Guide

Di(t"tion Instru(tions

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: 123456If 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 =-J

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 #

&or' T%es Se(i*i( To MHC3CPC

37 Discharge Summary 47 Daily Notes (Progress Note)

38 Interim Summary 48 Detox Notes

39 History & Physical / Psychiatric Evaluations

34

Listen Dictate Rewin

d

Pause

Next 2eport

5

Go To End

>ast

>orward

7

?o To

1egin

8

Disconnect

9

*

2eplay

2eport

0 #


35/37

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.

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INPATIENT LOC!ED SECLUSION3RESTRAINT

E"(+ eisode o* se($usion or restr"int ,ust in($ude *i.e t+ings6 e"(+ o* 1+i(+ is dis(ussed 0e$o17

o a doctors order

o an in6person exam and assessment

o a progress note

o a change in admission status to involuntary Aif applica%leo criteria for release from 2estraints #eclusion

Nursing staff can initiate seclusion


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Inpatient Manual for MHC 2007-2008[1]

Documents