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***********************************************NYS Psych OthForms 01 reqfm.tif NEW YORK PSYCHIATRIC INSTITUTE Department of Biological Psychiatry Electroconvulsive Therapy Request Form STAMP WITH NAME PLATE.* To be completed prior to first ECT treatment: DSM Diagnosis: Axis I ______ Axis II________ Axis III____________ Axis IV Stressors: __________ Axis V GAF: ___________ 2. Prior ECT? [ ] Yes [ ] No Date(s) of treatment: Describe course: 3. Indications for ECT: (circle) 1. previous positive response to ECT 2. non-response to adequate pharma cotherapy 3. pharmacotherapy contraindicated due to medical /surgical contraindication 4. adverse response to pharmacotherapy 5. severe. acute symptomatology requiring prompt response 6. other (describe) 4. Current standing and PRN medications/dosage: 5. Significant Medical History: History of Glaucoma? [ ] Yes [ ] No Drug Allergies? (describe or write none) 6. Physical Exam (date): Abnormal findings (describe or write none) 7. Neurological Exam (date): Abnormal findings (describe or write none) Dental Consult (all patients over 50 years aid. others with Poor dentition) Done? [ ] Yes [ ] No Mouth Guard Necessary: [ ] Yes [ ] No Findings: 9. Laboratory findings (CBC. SMAC. Ms. UA required within last mouth) Date: Significant Abnormalities? (describe or write none) 10. Chest X-Ray (Date): Results: 11. EKG (Date): Results: 12. EEG (when seizure disorder is known or suspected) Results: Done? [ I Yes I ] No 13. CT/MRI (when neurological findings or significant cognitive impairment is present) Done? [ ]Yes [ ]No Results: Referring Physician Signature 92 ECT-TX Req ************************************************NYS Psych OthForms 02 PreIn.tif Psychiatric Institute PRE-ECT INFORMATION SHEET Patient's Name Date Doctor's order written for today's ECT and placed in patient's chart. [ ] Yes [ ] No Consent Form/Court Order for ECT signed and in patient's chart. [ ] Yes [ ] No NPO after midnight. Yes__ No___ Dentures removed. Yes__No___ Jewelry removed. Yes__ No__ Nail polish removed. Yes__No__ Pt. has voided. Yes__No__ Vital signs the morning before ECT. BP Medications given before ECT. 1. List of current medications. 4. Pulse 2. 3. Please bring Eyeglasses to ECT, if patient wears them. Patient should wear hospital gown, bathrobe and slippers to ECT. Biological Psychiatry Form #3 I Ward R.N. Rev. 12.'91 *************************************NYS Psych OthForms 03 RecTh.tif Department of Biological Psychiatry Record of Electroconvulsive Therapy Patient Name Date RX Unit Consent/Court Order Signed (in chart) Yes I Doctor's order for this Rx. is in chart Yes Psychiatrist Doctor: [ ] Devanand [ ] Nobler [ ] Lisanby Daly Anesthesiologist Doctor:[] Ornstein [ ] Finck [ ] Heyer [ ] Josh Berm' an Nurse: [ ] Fitzsimons RNC [ ] Doolity RN [ ] Adorno RN Medications: Atropine mg I Brevital mgI Anectine mg Other | mg Patient's behavior before anesthesia induction: CoooperativeI Other I Grand Mal Seizure was elicited Yes Pre Treatment Post Treatment Recovery: [ ] UNEVENTFUL PATIENT MONITORED FOR < I HOUR. [ ] UNEVENTFUL. PATIENT MONITORED FOR > 1 HOUR. (RESEARCH) [ ] PATIENT MONITORED FOR> I HOUR DUE TO COMPLICATIONS. Explain Patient is medically stable and is cleared for discharge from recovery area: Anesthesiologist Psychiatrist Nurse Returned to unit with staff. Alert Oriented X [ ] Ambulating [ ] Wheel chair [ ] Stretcher ECT Form #4 Revised 2/99 LF ********************************************** NYS Psych OthForms 04 Peri.tif State of No*; York Office of Mental Mc Patient's Nome (Last. First. M.I.) NEW YORK STATE PSYCHIATRIC INSTITUTE PERI-OPERATIVE NOTES ..c.. No. I Facility Name No. **********************************************NYS Psych OthForms 05 Anaes.tif NEW YORK STATE PSYCHIATRIC INSTITUTE ANESTHESIA RECORD Unit/Ward No. OR. AGE SEX M F PHYSICAL STATUS 1 2 3 4 5 E PRE-OP Y [ ] N [ ] CPT CODE LAST ORAL INTAKE BP P WT HEIGHT HABITUS TEETH ANESTHESIOLOGY TEAM OPERATING TEAM: I PRE-OP DIAGNOSIS. POST-OP DIAGNOSIS TIME I EFFECT NOTES ON MAINTENANCE ***********************************NYS Psych OthForms 06 Oper.tif OPERATION NOTES: (NOTE: Complete all relevant items.) Date: Pre-operatlve diagnosis: Post-operative diagnosis: Operation Pathology Operating Team: 1. 2. 3. 4. Was surgical attending scrubbed or present throughout? Yes [ ] No [ ] If yes give his/her name Anesthesia Estimated blood loss: Fluids at operation: Closure and degree of bleeding: Cultures: Drains, packs, catheters, etc.: Foreign bodies, grafts, implants, etc.: Medications (including antibiotics) in OR: Complications in OR: Condition at close of operation: Additional information: (Comments, bone flaps, plaster casts, etc.) Member of Operating Team: ***********************************NYS Psych OthForms 07 PstAn.tif ANESTHESIA CARE UNIT RECORD DATE TIME AM on PM [=I so 1060 240 105' 230 104° 220 103° 210 102° 200 101° 190 100° ISO 990 170 98° ISO 970 ISO 96° 140 95° 130 120 110 100 90 80 70 60 50 40 30 INTAKE Opt I 200 ISO 170 160 ISO 140 130 120 110 100 90 so 70 so so 40 DATE NURSES NOTES TIME IN PAM" I CVP HQ) IMP S2O DISCHARGE TIME: All DATE CONDITION: GOOD FAIR POOR DOCTOR'S SIGNATURE: CONDITIONS IN P.A.C.U. TOM TIME AMT URINE OUT TOTAL DRAINAGE ********************************************NYS Psych OthForms 08 TxSet.tif ECT TREATMENT SETTINGS Patient X.# Initial Medication Atropine Brevital Anectine Other- Setting # 1 Frequency: Pulse width: Duration: Setting # 3 Frequency: Pulse width: Duration: Administration No. Seizure Time (EEG): Static Impedance: Static Energy: Dynamic Impedance: Dynamic Energy: Voltage: Silence(1=No 2=Probable 3=Definite) Left: Right: Date Doctor- Rx. Mode Additional Medication Atropine Brevital Anectine Other Setting #2 Frequency: Pulse width: Duration: Setting # 4 Frequency: Pulse width: Duration: Administration No. Seizure Time (EEG): Static Impedance: Static Energy: Dynamic Impedance: Dynamic Energy: Voltage: Biological Psychiatry Form # 6 Revised 41 99 LF) |
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