SOP_NUMBER: 508.20-att-3
TITLE: Restrictive Housing Rounds - 30/90 Day Progress Note
REFERENCE_CODE: VG40-0001
DIVISION: Mental Health Services
TOPIC_AREA: 508 Policy-MH Administration/Staff/Certification
EFFECTIVE_DATE: 2022-08-02
WORD_COUNT: 180
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/1026384
URL: https://gps.press/sop-data/508.20-att-3/

SUMMARY:
This form is used by mental health staff to document progress notes for inmates in restrictive housing who have been confined for 30 days or longer. Staff must complete an initial progress note within the first 30 days of restrictive housing placement and then every 90 days thereafter. The form documents the offender's mental status examination findings, identifies any contraindications to restrictive housing, and outlines the plan for ongoing mental health monitoring.

KEY_TOPICS: restrictive housing, progress note, mental health rounds, mental status examination, MSE, suicidal intent, self-harm, depression, psychosis, aggression, solitary confinement, segregation, inmate mental health, psychiatric monitoring, contraindications

ATTACHMENTS:
  1. Restrictive Housing Rounds Log
     URL: https://gps.press/sop-data/508.20-att-1/
  2. Restrictive Housing Rounds - 48 Hour / Weekly Progress Note
     URL: https://gps.press/sop-data/508.20-att-2/
  3. Restrictive Housing Rounds - 30/90 Day Progress Note
     URL: https://gps.press/sop-data/508.20-att-3/

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FULL TEXT:
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SOP 508.20
Attachment 3

8/2/22


**GEORGIA DEPARTMENT OF CORRECTIONS** Institution: ____________________________________


**MENTAL HEALTH SERVICES** Name: _______________________________________


**"Restrictive Housing Rounds"** ID#: _________________________________________


**30 / 90 Day Progress Note** DOB: _______________________________________
(circle)
Date: ____________________ Race: __________________ Sex: _________________
**************************************************************************************************
**DATA:** Date offender was placed in Restrictive Housing: ___________________________________________

Reason for Restrictive Housing Placement: ________________________________________________

Chief Complaint(s): ____________________________________________________________________
_____________________________________________________________________________________

Offender MSE findings: (comment on pertinent findings)

[ ] Psychosis: __________________________________________________________________
__________________________________________________________________

[ ] Depression: _________________________________________________________________
__________________________________________________________________

[ ] Self-Injurious Thoughts: _______________________________________________________
__________________________________________________________________

[ ] Suicidal Intent: ______________________________________________________________
__________________________________________________________________

[ ] Aggression: ________________________________________________________________
___________________________________________________________________

[ ] Situational Upset: ____________________________________________________________
___________________________________________________________________

[ ] MSE within normal range (no problems)

**ASSESSMENT:** Are there any contra-indications to Restrictive Housing?        [  ] Yes [  ] No


Comments: __________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


**PLAN:** _As long as the offender remains in Restrictive Housing will monitor for contra-indications to housing assignment_
_and the need for mental health services. __________________________________________________________________
*************************************************************************************************
_________________________________________________________________________________________________
Staff Signature/Title

**This is to be done:**

 **On general population offenders in Restrictive Housing 30 days or longer. (Initial 1st 30 days of**

**confinement and every 90 days thereafter).**


Form no. M40-01-04 Page 1 of 1

Retention Schedule: Upon completion, this form shall be placed in the offender’s mental health file (section one). At the end of the offender’s need for mental health
services and/or sentence, the mental health file shall be placed within the offender’s health record and retained for 10 years.