Pilgrim Electroshock Policy Appendix IV Clinical Summary

APPENDIX V FORMS

621 A LIPC (1199) Side I

State of Now York, Office of Mental Health

CLINICAL SUMMARY FOR E.C.T.

Patlent's name:

"C" #.

Facility: Pilgrim Psychatric Center

Date of Birth:

Ward/Unit

PRESENT ILLNESS: (Description & narrative of current episode including current mental status.)

PSYCHIATRIC HISTORY: (Include age at the onset of illness, number of hospitalizations, number, severity & duration of episodes.)

TREATMENT AND MEDICATION HISTORY: (Describe treatment including E.C.T patient has received; dosages, duration and response.)

MEDICAL HISTORY: (Include any significant current or past medical problems.)

DIAGNOSIS:

AXIS 1:

AXIS 11:

AXIS III:

RATIONALE FOR RECOMMENDING E.C.T.:

621 A LIPC (1/99) Side 2

State of Now York, Office of Mental Health

CLINICAL SUMMARY FOR E.C.T. (Cont.) I Patient's name: "C" #

DESIRED OUTCOME:

REQUIREMENTS FOR E.C.T.:

A. Signed consent or court order [ ] YES [ ] NO B. Statement of patlent's capacity or lack of it documented in the patient's chart [ ] YES [ ] NO C. Medical clearance obtained [ ] YES [ ] NO (i) CBC (within I month) [ ] YES [ ] NO (ii) SMA-18 (within I month) [ ] YES [ ] NO (iii) EKG (within 1 month) [ ] YES [ ] NO (iv) Chest x-ray (within 1 month) [ ] YES [ ] NO (v) Dental assessment [ ] YES [ ] NO (vi) Pregnancy test, if indicated [ ] YES [ ] NO

TREATING PSYCHIATRIST:

Signature: Print Name: Date:

ASSOCIATE MEDICAL DIRECTOR:

I have evaluated the patient and reviewed this application for E.C.T. I recommend E.C.T. for this patient

Signature: Print Name: Date:

DIRECTOR FOR E.C.T.:

I have reviewed this application for E.C.T. I recommend E.C.T. for this patient.