SOP_NUMBER: 508.26-att-1
TITLE: Involuntary Medication Order Check Sheet
REFERENCE_CODE: VG66-0001
WORD_COUNT: 415
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/290543
URL: https://gps.press/sop-data/508.26-att-1/

ATTACHMENTS:
  1. Involuntary Medication Order Check Sheet
     URL: https://gps.press/sop-data/508.26-att-1/
  2. Physician Opinion for Involuntary Medication
     URL: https://gps.press/sop-data/508.26-att-2/
  3. Notification of Involuntary Medication Due Process Committee Hearing
     URL: https://gps.press/sop-data/508.26-att-3/
  4. Involuntary Medication Rights of Offender
     URL: https://gps.press/sop-data/508.26-att-4/
  5. Mental Health Due Process Committee Involuntary Medication Review
     URL: https://gps.press/sop-data/508.26-att-5/
  6. Involuntary Medication Hearing Log
     URL: https://gps.press/sop-data/508.26-att-6/
  7. Notification of Involuntary Medication Due Process Committee Decision
     URL: https://gps.press/sop-data/508.26-att-7/

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FULL TEXT:
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**Georgia Department of Corrections - Mental Health Services**

**Involuntary Medication Order Check Sheet**



SOP 508.26
Attachment 1

8/8/23



**Facility: ______________________________________** **Name: ______________________________**

**Prescribing Physician: __________________________  GDC ID#: ___________________________**


**DOB: _______________________________**

**Date of Order: ________________________________   Race: ___________  Sex: ______________**

|Once a decision has been made to involuntarily medicate an offender, the following documentation (dictation<br>is acceptable) and procedures must occur to comply with Georgia Department of Corrections Standard<br>Operating Procedures. This check sheet is provided to assure adherence to Standard Operating Procedures in<br>all cases of involuntary medication.|Col2|
|---|---|
|**DOCUMENTATION/PROCEDURE**|X|
|Document the presence and type of psychiatric emergency which precluded the initiation of the<br>involuntary medication order by answering as many of the following questions as are applicable:<br> <br>||
|A.  Has the offender demonstrated potential harm to self or others through recent acts or threats?||
|B.  Is the offender unable to care for themselves in such a way that presents as a life endangering<br>    situation?||
|C.  Does the offender's medical history support the diagnosis of a chronic psychiatric condition that<br>    presents a high probability of deterioration that could result in a life endangering situation to self<br>or others?||
|D.  Could the offender be reasonably expected to participate in treatment planning that would give<br>    them a realistic opportunity to improve their condition?||
|Document how the offender refused the medication (verbally, in writing, by gesture, by silence).||
|Document why the offender refused the medication, if responsive.||
|Document that you explained to the offender your assessment of their condition.||
|Document that you explained to the offender the reason for prescribing the medication.||
|Document that you explained to the offender the risks and benefits of taking the medication.||
|Document that you explained to the offender the advantages and disadvantages of taking the<br>medication voluntary vs involuntarily.||
|Document that efforts to counsel the offender without the use of force were attempted.||
|Document that the offender continued to refuse voluntary medication.||
|Document that you wrote a temporary order for involuntary medication, not to exceed the next five (5)<br>working days.||
|Document that you advised the offender that the issue of involuntary medication will be discussed by<br>the Mental Health Due Process Committee within the next five working days.||
|Request and then document that you requested a second opinion from another physician.||



Form no. M66-01-01

Retention Schedule: Completed forms shall be placed in the offender’s mental health file (section 5) and the medical file (section 5). 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.