SOP 508.31-att-1: CSU_ACU Daily Nursing Clinical Assessment

SOP 508.31
Attachment 1

12/9/19

|CSU/ACU Daily Nursing Clinical Assessment|Col2|
|---|---|
|
This assessment should be done on each CSU/ACU
patientdailyon Saturdays, Sundays, and holidays.
The information is to be relayed to the on-call
psychiatrist when he/she calls in and you should write
the psychiatrist plan of action for the offender in the
space provided. This will include any orders given.
(nursing staff will not be allowed to accept “standing
orders”; i.e., if ‘x’ happens, do ‘y’, etc.) *All orders
must be written on a physician order form.|
Facility: ________________________________

Offender: _______________________________
GDC ID#: ______________________________
DOB: __________________________________
Race: _____________ Sex: _______________

Date: __________________________________|
|Pertinent Information
Date of Admission:___________________ Reason for Admission:_______________________________________
_____________________________________________________________________________________________

Mental Health Diagnosis: _______________________ Status (i.e., SP, restraints): __________________________
_____________________________________________________________________________________________

Medication(s) and Dosage: _______________________________________________________________________
_____________________________________________________________________________________________

Allergies: _____________________________________________________________________________________

Medication Adherence while in CSU/ACU: __________________________________________________________

Mental Status: _________________________________________________________________________________
_____________________________________________________________________________________________

Offender Complaints: (to include physical health complaints): ___________________________________________
_____________________________________________________________________________________________

Referred to Medical for physical health: [ ] Yes [ ] No

Vital Signs: T___________________ P_________________ R________________ B/P____________________

Attitude: ______________________ Change in Behavior: _____________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Appetite: ______________________________ Orientation: ____________________________________________

Suicidal/homicidal thoughts or acts: ________________________________________________________________

Sleep Pattern while in CSU/ACU: _________________________________________________________________
|Pertinent Information
Date of Admission:___________________ Reason for Admission:_______________________________________
_____________________________________________________________________________________________

Mental Health Diagnosis: _______________________ Status (i.e., SP, restraints): __________________________
_____________________________________________________________________________________________

Medication(s) and Dosage: _______________________________________________________________________
_____________________________________________________________________________________________

Allergies: _____________________________________________________________________________________

Medication Adherence while in CSU/ACU: __________________________________________________________

Mental Status: _________________________________________________________________________________
_____________________________________________________________________________________________

Offender Complaints: (to include physical health complaints): ___________________________________________
_____________________________________________________________________________________________

Referred to Medical for physical health: [ ] Yes [ ] No

Vital Signs: T___________________ P_________________ R________________ B/P____________________

Attitude: ______________________ Change in Behavior: _____________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Appetite: ______________________________ Orientation: ____________________________________________

Suicidal/homicidal thoughts or acts: ________________________________________________________________

Sleep Pattern while in CSU/ACU: _________________________________________________________________
|
|
Psychiatrist Name: ________________________________________ Date: _____________ Time: ___________

Plan (to include new orders given): ________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Fax Number to fax orders for signature: _____________________________________________________________

_____________________________________________ ______________________________________
Signature Title
|
Psychiatrist Name: ________________________________________ Date: _____________ Time: ___________

Plan (to include new orders given): ________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Fax Number to fax orders for signature: _____________________________________________________________

_____________________________________________ ______________________________________
Signature Title
|

Form no. M70-02-01 Page 1 of 1

Retention Schedule: Upon completion, this form shall be placed in the offender’s medical file (Infirmary Section with CSU/ACU packets) and
retained for ten (10) years.