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State of New York, Office of Mental Health PRE- E.C.T. PROGRESS NOTE (To be completed by the nurse in the morning of E C. T. administration) Patient's name: "C" #: Facility, Pilgrim Psychiatric Center Date of Birth: Ward/Unit: CURRENT MEDICATIONS AND DOSAGES: (if none, state 'NONE") DENTURES REMOVED? [ ] YES [ ] NO [ ] NA HAS PATIENT VOIDED? [ ] YES [ ] NO NPO AFTER MIDNIGHT? [ ] YES [ ] NO EYEGLASSES REMOVED? [ ] YES [ ] NO [ ] NA PULSE: BLOOD PRESSURE: TEMPERATURE: WEIGHT: SENSORIUM: ORIENTATION: AMBULATION: WARD NURSE: Comments: Signature: Print Name: Date: Time: TO BE COMPLETED BY THE E. C. T. TEAM NEXT E.C.T.: DATE: TIME: RECOMMENDATIONS, IF ANY: Signature: Print Name: Date: 621 C LIPC (2100) Side 2 State of Now York, Office of Mental Health 47 POST- E.C.T. PROGRESS NOTE Patient's name: "C" #: (To be completed on RETURN of the patient, by the nurse and the treating psychiatrist) E.C.T. #: PULSE: BLOOD PRESSURE: TEMPERATURE: SENSORIUM: ORIENTATION: AMBULATION: WARD NURSE: Signature: Print Name: Date: Time: TO BE COMPLETED BY THE TREATING PSYCHIATRIST PERTINENT MENTAL STATUS: (Including Cognitive and Memory Assessments) GENERAL PHYSICAL ASSESSMENT: Discussed with AMD in past week. Yes No (if No, Explain) (If yes, briefly describe content of discussion) PSYCHIATRIST: Signature: Print Name: Date: Time: LIPC 155 (Rev. 2/2000) State of New York Office of Mental Health 48 PILGRIM PSYCHIATRIC CENTER ELECTROCONVULSIVE THERAPY (ECT) PROCEDURE NOTE DATE: Patient's Name (Last, First, MI) "C" No: Sex: Date of Birth: Unit/ Ward No: Goal No. and Obj. Letter ECT Treatment: Patient was _____ cooperative. Mental Status: Physical Status: Changes from last treatment: Acute#: Continuation# Glycopyrrolate: mg. Atropine: mg. Brevital: mg. Succinylcholine: mg. Other: Time medications given: Per anaesthesiologist's record. Stimulus Placement: Bitemporal: Thymatron DG: % Seizure length: seconds By:EEG: Peripheral method: EKG was: Other medications given at ECT: Unilateral: Right: Bifrontal: Tonic: Left: Clonic: Postictal Suppression Index: Impedance: Time to leave recovery room: Per anaesthesiologist's record. Anaesthesiologist's Name: Comments: ECT Physician Signature Assisting Physician Signature ECT Physician Name (Print) Assisting Physician Name (Print) 49 LIPC 149-95 State of New York OFFICE OF MENTAL HEALTH "C"/Id No. Patient's Name (Last, First, M.I.) NURSING ECT PROGRESS NOTE Date of Birth: Pilgrim Psychiatric Center Age: Sex: Unit/Ward 1. NPO X HRS. 2. PT. VOIDED AT 3. PRE-ECT MEDICATION DRUG ROUTE DOSE TIME ADMINISTERED BY 4. BASE LINE VITAL SIGNS, PRIOR TO TREATMENT TIME TEMPERATURE PULSE RESPIRATIONS 5. VITAL SIGNS DURING TREATMENT - EVERY 2 MINUTES TIME B/P PULSE RESPIRATIONS B/P COMMENTS POST TREATMENT Patient's Name: 50 TIME B/P PULSE RESPIRATIONS COMMENTS 6. POST ECT TEMPERATURE TIME 7. TIME OF RECOVERY 8. TIME RETURNED TO WARD SIGNATURE, TITLE DATE 51 LI PC 31 (6/98) State Of New York OFFICE OF MENTAL HEALTH Patient's Name: C/ID No: PRE-ANESTHESIA EVALUATION Sex: Date of Birth: Facility: Unit/Ward No: 1. The patient has a medical history significant for increased anesthesia risks. (if yes, explain and address risks). Yes [ ] No [ ] 2. The patient's physical status places him/her at higher risk for anesthesia. (If yes, explain and address risks). Yes [ ] No [ ] 3. Lab results/diagnostic tests place the patient at a higher risk for anesthesia. (If yes, explain and address risks). Yes [ ] No [ ] 4. 1 have discussed and explained the risk/benefit of anesthesia for ECT to the patient. (If no, explain). Yes [ ] No [ ] 5. 1 have assessed the patient and believe that he/she is a candidate for ECTanesthesia. (if no, please explain). Yes [ ] No [ ] Signature of Medical Specialist Title Date PRE-ECT COMPLICATIONS No [ ] Yes [ ] DURING ECT COMPLICATIONS No [ ] yes [ ] POST-ECT TIME: RECOVERY ROOM ALERT VITAL SIGNS q 5 MINS. COOPERATIVE PULSIMETER & OXIMETER MONITOR VITAL SIGNS STABLE DISCHARGE TO WARD VIA WHEELCHAIR 52 PILGRIM PSYCHIATRIC CENTER ANESTHESIA RECORD FOR ECT Date Sex Consent PHY. STATUS PREMEDICATION (DRUG, DOSE, TIME, EFFECT) PATIENT'S NAME: AGE: BLDG. & WARD: CONC. #: Treatment # WT: SEE HARD COPY TEMPLATE for Graph SYMBOLS AGENTS DOSAGE A. 5% D & W TECHNIQUES Time I.V. B. GLYCOPYRROLATE C. BREVITAL I.V. IX. D. SUCCINYLOCHOLINE I.V. I.V. E. LOBETALOL F. TRIDILL (NITRO. DRIP) OTHER MEDS TREATMENT: RECOVERY: TECHNICAL DIFFICULTY ANESTHESIA TIME SEIZURE LENGTH SEC LARYNGOSPASM-EXCESS MUCUS RESP. DEPRESISON-02 WANT BUCKING-VOMITING REMARKS (induction, Maintenance, Emergence) Electro Encephalogram Electrocardiogram Pulsimeter Oximeter Blood Pressure Oxygen Mask Bite Block OTHER ECT Bi Temporal Bi Frontal TREATING PSYCHIATRIST HEMORRHAGE/ARRHYTHMIA BRADY/TACHYCARDIA-SHOCK ANESTHESIOLOGIST 621 D LIPC (2/200) ECT TARGET SYMPTOM SHEET Appendix 1: PATIENT Name Treating Psychiatrist AMD State of New York, Office of Mental Health C# Unit/ Ward Pre CT CGI - Clinical Global Impression (CGI) : Rate I - 7, (1 = absent, 7 = worst ever seen) Facility: Pilgrim Psychiatric Center DATE -4 WEEK PRE ECT# -4 Treating MD Initials CGI-C X Hallucinations Delusions Hostility/ violence Excitement/ Agitation Anxiety Self abuse Suicidality Depression Expansive mood Appetite Retardation Activities Mod Change? Page # 53 54 (ECT 0 1) 2/00 Patient Name C# ECT PROTOCOL Psychiatrist Ward TRACKING SHEET Med. Spec AMD Start Date Dx: Planned Number of ECT TX: o service needed DATE-# I WEEK# -> Pre 1 2 3 4 5 6 7 8 9 10 11 12 Treatment Number -> Consent/ Court Order 0 Capacity Statement 0 0 Periodic Rvw of Consent 0 0 Medical Clearance 0 CBC 0 0 SMA IS 0 SMA 6 0 EKG 0 0 Chest X-ray 0 U/A 0 0 HCG (pre-menopause 9) 0 0 Dental Evaluation 0 Cognitive Evaluation 0 0 0 0 0 0 0 0 0 0 0 0 0 Clinical Assessment 0 0 0 0 0 0 0 0 0 0 0 0 0 Target Symptom Sheet 0 0 0 0 0 0 0 .0 0 0 0 0 AMD Review 0 10 10 0 0 0 10 0 0 0 0 ECT Conference 0 55 PILGRIM PSYCHIATRIC CENTER |
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