CSS Correctional Service System
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1 Mental Health Services Staff Referral Form 09/20/2007 Medical Evaluation (To Be Completed By The Medical Staff) Reason for Referral- Check and Explain All That Apply Actively Suicidal or Homicidal Self-Reported Diagnosis and/or Medication Self-Reported Problem/concern ERMA Documentation of Diagnosis/Problem List: Schizophrenia Verified Medication(s)- Personal Property or by Form Other Yes No Medical Concerns Check All That Apply Intoxicated Substance Withdrawal DM HEP HIV Seizures Head Trauma None Medical Action Plan Check All That Apply None Withdrawal Protocol (COWS/CIWA) Med Verification ROI Medical and/or Mental Health Where? County General Hospital Referral to HCP for Medical Condition Yes No Mental Health Evaluation (To Be Completed By Mental Health Staff) Date Reviewed 9/20/2007 Date of Mental Health Services Contact 09/21/2007 Intake Screening Reviewed Yes No Mental Health Disposition To Provider E-signed by Ashley Thomas on 09/20/ :35 PM ET Page 1 of 1 E-Signed by Joshua Hamilton on 09/24/ :45 PM ET
2 Mental Health Initial Assessment 09/20/2007 Chief Complaint and History of Present illness- Subjective I/m was seen by mh due to a referral from medical reporting hx of tx for PTSD and Bipolar Disorder at County General Hospital. Presently I/m reports that he is worried about the listening devices that government put in his room and complains of the radio transmissions that he can hear that are keeping him up at night. He asked for all of the talking to stop. Psychiatric History ROI Verified: Yes No Outpatient Treatment: Current History None Where: N/A Inpatient Treatment: Current History None Where: County General Hospital Medication: Current History None List: Paroxetine, Lithobid, Zyprexa, Benadryl Family History: Violence History: Abuse History: Physical Sexual None Substance Abuse: Current History None ETOH THC Cocaine Other: Heroin Marital Status: Single Employed? Family/Significant Other supportive? Yes No Education (highest grade achieved): High school diploma Level of Cognitive Functioning: Average Page 1 of 4
3 Mental Health Initial Assessment 09/20/2007 Suicide Potential Screening Expresses thoughts of killing self Helplessness & Hopelessness (lack of future oriented thoughts) Suicide Plan or Instrument in possession Previous suicide attempt Family/Significant Other attempted or died by suicide Major problems other than legal Psychiatric History Currently under influence of Alcohol/Drugs Overly anxious, afraid, withdrawn Position of Respect in community- alleged crime is shocking in natureexpresses feelings of shame or embarrassment Yes No Yes No Yes No If there are any Yes answers to Red questions, or total # of Yes answers is 5 or more, a full mental health assessment should be performed. Medical History DM HTN HIV HEP Other History of Neurological disorders? Current Medications in jail See ERMA Legal History Current Charge: Criminal Trespassing Date of Arrest: 09/19/2007 # of Arrests/Incarcerations: 5 Bound Over? Court/Release date scheduled: 10/19/2007 Assessment Appearance: Appropriate Meticulous Unclean Disheveled Bizarre Other Speech: Appropriate Expressive Loud Slowed Pressured Slurred Other Page 2 of 4
4 Mental Health Initial Assessment 09/20/2007 Mood: Appropriate Depressed Euphoric Anxious Angry Irritable Other Affect: Appropriate Tearful Blunted Flat Labile Hostile Other Thought Form: Coherent Circumstantial Tangential Loose Associations Poverty of Thought Flight of Ideas Other Thought Content: Appropriate Compulsive/Obsessive Thought Insertion Broadcasting Delusional Other Orientation: Person Place Purpose Time Intelligence: Above Average Average Below Average Developmentally Disabled Memory: Intact Immediate Recent Remote Insight: Intact Good Fair Poor Judgment: Intact Good Fair Poor Behavior: Appropriate Belligerent Agitated Withdrawn Assessment Summary: I/m presented with an anxious mood, tangential thought form (I/m had to be re-directed throughout the assessment), pressured speech, flat affect, and delusional thought content. I/m reports that he is from Middleton, PA and was discharged from the Army in He has been homeless since his discharge and living under Barlow s Bridge in Rickett s Glen Park. I/m believes that the government is listening to everything and everyone. He reports that he can hear their radio transmissions that give him instructions and scare him. He is hyper vigilant about checking his surroundings and his eyes dart around when he isn t answering a direct question. I/m denies ah/vh but does report hearing things that others can not hear. I/m reports having been to County General Hospital and Page 3 of 4
5 Mental Health Initial Assessment 09/20/2007 has taken psychiatric medications. I/m is not currently taking medications and does not believe that he needs any. I/m has been referred to the mh provider. MHS to f/u as needed. Joshua Hamilton, LCSW Impression Axis I: R/O Schizophrenia, Paranoid Type Axis II: Defer Axis III: Defer Axis IV: Legal, Employment, Housing Axis V: 45 Plan Mental Health Treatment not indicated at this time- MH will follow up as needed. Mental Health Specialist follow-up. Initiate/discontinue suicide precaution protocol. Referral to medical staff Referral to provider Requested collateral information, chart review. Allow 4 weeks for sobriety. Other: E-Signed by Joshua Hamilton on 09/24/ :50 PM ET Page 4 of 4
6 Psychiatric Evaluation 010/03/2007 Chief Complaint and History of Present Illness I need to be in a room without any listening devices. Please do something about the constant government radios. I can hear them talking and they keep me from sleeping. This is a 29 yo AAM who was referred by MHS. He presents with paranoia and auditory hallucinations. Talks about the government s radio transmissions and listening and tracking devices that have been implanted in him and placed in his cell. Depression Mania Psychosis S I G E C A P S (Sleep disturb, Interest, Guilt/worthless, Energy loss, Conc dec, App chg, Psychomotor act chg, Sociality) G I D D I N E S S (Grandiosity, Irrit, Dec judgment, Distractibility, Inc GD act, Need of sl dec, Elev mood, Sp, Speedy thoughts) AH VH Disorg Del Paranoia Psychiatric History Previous Dx/Tx: He reports that he has been to County General Hospital. Records indicate previous dx of PTSD and Bipolar Disorder. He took medications there and took the medications that were supplied to him because they made him feel better. He never followed up for outpatient care. Substance Hx: ETOH THC Cocaine Other: Heroin Medication Hx: Paroxetine, Lithobid, Zyprexa, Benadryl Family Hx: None known Abuse Hx: Physical Sexual None Legal History Current Charge 09/19/2007 Current Probation Past Arrests/Incarcerations Abuse Hx: Physical Sexual Page 1 of 2
7 Psychiatric Evaluation 010/03/2007 Medical History DM HTN HIV HEP Other Medications None currently Allergies nkda Family Hx unknown Mental Status Exam Appearance/Behavior/Speech Dressed appropriately, speech wnl, cooperative Mood Mildly anxious Affect Flat Sensorium A&Ox4, coherent Thought Paranoid Impression Axis I: Schizophrenia, Paranoid Type Axis II: Defer Axis III: None reported Axis IV: Legal, Employment, Housing Axis V: 45 Plan Move to special needs. Start haloperidol 10 mg, amitriptyline 75 mg. Refer to XYC Community Mental Health Center upon release. E-Signed by Francesca Tompkins on 10/05/ :50 AM ET Page 2 of 2
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10 Follow-up Psychiatry Progress Note 010/17/2007 Subjective Seen for routine f/u apt. He reports consistency with medication. Describes feeling better. Does not appear to be as preoccupied with the voices from the radio. Only asked about the government tracking devices once. Will be released from jail in a few days. XYZ CMHC liaison notified. Objective Mental Status Exam Sensorium: Alert Oriented X 3 Distractible Poor concentration Other Appearance: Well-kept Self-neglect Other Behavior: Calm Agitate Slowed Other Speech: Clear/coherent Spontaneous Pressured Poverty Other Mood: Euthymic Depressed Anxious Elevated Irritable Other Affect: Appropriate Inappropriate Constricted Blunted Other Thought Process: Goal Directed Disorganized Loose Associations Tangential Other Thought Content: Homicidal Suicidal Paranoid Hallucinations Delusions Other Memory Recent Intact Remote Intact Impaired Other Lab Results: None Page 1 of 2
11 Follow-up Psychiatry Progress Note 010/17/2007 Medication Compliance? Yes No Medication Side Effects: Mild tdk AIMS Score (mark if baseline or follow-up): 0 Baseline 6 month follow-up N/A- based on current treatment regimen Response to Treatment: See above Diagnosis Axis I: Schizophrenia, Paranoid Type Axis II: Defer Axis III: None reported Axis V: 60 Plan 1. Medication (does, frequency, duration): Continue haloperidol 10 mg, amitriptyline 75 mg, daily Add Benadryl 25 mg prn 2 week supply upon release 2. Lab: None 3. Other (include F/U by MHP): Prn 4. Follow-Up Appointment: Yes f/u necessary No f/u necessary PRN 2 week appointment at XYC Community Mental Health Center E-Signed by Francesca Tompkins on 10/19/ :21 PM ET Page 2 of 2
12 Follow-up Psychiatry Progress Note /17/2012 Subjective Seen due to multiple disciplinary reports. I/m not reporting for count. He has been sitting in the cell talking rapidly to himself. Is preoccupied with the voices in the radio and struggles to focus on the questions of this writer. I/m seems very anxious and is constantly scanning the room. He has not been taking medications. I/m known to this writer. Objective Mental Status Exam Sensorium: Alert Oriented X 3 Distractible Poor concentration Other Appearance: Well-kept Self-neglect Other Behavior: Calm Agitate Slowed Other Speech: Clear/coherent Spontaneous Pressured Poverty Other Mood: Euthymic Depressed Anxious Elevated Irritable Other Affect: Appropriate Inappropriate Constricted Blunted Other Thought Process: Goal Directed Disorganized Loose Associations Tangential Other Thought Content: Homicidal Suicidal Paranoid Hallucinations Delusions Other Memory Recent Intact Remote Intact Impaired Other Lab Results: Page 1 of 2
13 Follow-up Psychiatry Progress Note /17/2012 None Medication Compliance? Yes No Medication Side Effects: Mild tdk AIMS Score (mark if baseline or follow-up): 0 Baseline 6 month follow-up N/A- based on current treatment regimen Response to Treatment: See above Diagnosis Axis I: Schizophrenia, Paranoid Type Axis II: Defer Axis III: None reported Axis V: 35 Plan 1. Medication (does, frequency, duration): Continue haloperidol 10 mg, amitriptyline 75 mg, daily, Benadryl 25 mg prn 2. Lab: None 3. Other (include F/U by MHP): F/U in 1 week to assess medication compliance 4. Follow-Up Appointment: Yes f/u necessary No f/u necessary PRN 1 week E-Signed by Francesca Tompkins on 02/19/ :33 PM ET Page 2 of 2
14 Psychiatric Evaluation /24/2012 Chief Complaint and History of Present Illness I/m believes that the COs are trying to harm him. He is very suspicious of the radios on their belts and gets very nervous and anxious when an officer is around. He reports only sleeping a couple hours at night because he has to keep watch. Staff report that he is not eating his food. He believes that the people preparing the food are poisoning it and has requested pre-packaged food. Depression Mania Psychosis S I G E C A P S (Sleep disturb, Interest, Guilt/worthless, Energy loss, Conc dec, App chg, Psychomotor act chg, Sociality) G I D D I N E S S (Grandiosity, Irrit, Dec judgment, Distractibility, Inc GD act, Need of sl dec, Elev mood, Sp, Speedy thoughts) AH VH Disorg Del Paranoia Psychiatric History Previous Dx/Tx: I/m has had many inpatient hospitalizations at County General Hospital. Records indicate previous dx of PTSD, Bipolar Disorder and most recently Schizophrenia. He has a history of non-compliance with medication. He does not attend outpatient treatment. Substance Hx: ETOH THC Cocaine Other: Heroin Medication Hx: Paroxetine, Lithobid, Zyprexa, Haloperidol, Benadryl Family Hx: None known Abuse Hx: Physical Sexual None Legal History Current Charge 02/12/2012 Current Probation Yes No Previously required to attend Local Charities Substance Abuse Treatment Program for 60 days in December Completed February 1, Page 1 of 3
15 Psychiatric Evaluation /24/2012 Past Arrests/Incarcerations 2011 November April 4-June February 2-March August 30-September May 3-May August April 1-June September 20- October 20 Abuse Hx: Physical Sexual Medical History DM HTN HIV HEP Other Medications None currently Allergies nkda Family Hx unknown Mental Status Exam Appearance/Behavior/Speech Dressed appropriately, speech wnl, uncooperative Mood Mildly anxious Affect Flat Sensorium A&Ox4, disorganized Thought Paranoid Impression Axis I: Schizophrenia, Paranoid Type Axis II: Defer Axis III: Hepatitis C Axis IV: Legal, Employment, Housing Page 2 of 3
16 Psychiatric Evaluation /24/2012 Axis V: 45 Plan Move to special needs. Start haloperidol 10 mg, amitriptyline 75 mg. Refer to XYC Community Mental Health Center upon release. E-Signed by Francesca Tompkins on 02/27/ :38 AM ET Page 3 of 3
CSS Correctional Service System
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