| Purpose: This page describes the development and the content of a computerized Integrated Summary report for psychiatric inpatients. |
| The following is a sample output from a Wordperfect/dos macro program to
help staff write Multidisciplinary Integrated Summaries on an adolescent psychiatric unit.
This format has been in use since 1994 at Mississippi State Hospital and received very
favorable comments from JCAHO reviewers. The macro was developed to resolve problems with redundancy across professions. One staff member runs the macro and answers demographic questions. The file is automatically saved. The files are stored on a network (though it can be configured for a stand-alone computer) and other members of the team can retrieve the document, re-start the macro, and complete their respective section of the document. Development of the macro involved extracting all the content areas from several representative Integrated Summaries, dividing that content into groups, associating those groups with specific staff (ie, psychology, social work, nursing, physician, education), then developing either "dialog boxes" or static prompts to help staff write their section of the report. Where a discrete number of choices are availble, the user simply chooses from a menu. Relatively open-ended matters are addressed by prompting the user to complete a sentence. The macro pauses for the users to complete the sentence. (In the example below the user input was left blank in order to illustrate the prompts used in the macro. To see a sample of a completed summary click here.) After each staff member works through the macro-driven prompts, he is in a standard WordPerfect document and is free to edit/insert additional comments. He then re-saves the document. "Prompt sheets" were developed to guide staff during their interviews. This assures they have all the right data at hand when they sit down to the computer to complete their section. (Most staff quickly master the organization and quit using the printed prompt sheets.) These prompt sheets are attached, below. Staff were initially hesitant about the automation, but quickly came around. The feedback typically received now is that this is the one place in the chart you can look to quickly get a good review/overview of the case. The macro is copyright. It is not currently for sale, but if anyone is interested... we can talk. Otherwise, I am open to collaboration concerning similar efforts by others. I am in the process of converting this to Microsoft Word format and extending it to include adult psychiatric populations. Greg Nail. |
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Mississippi State Hospital
| BLDG NUMBER: 45 Dr. Frito Bandito DATE OF ADMISSION: 2/1/95 DATE OF BIRTH: 2/2/82 IDENTIFICATION AND PRESENTING PROBLEM: This 14-2 year old black female
from Rankin County presents for her first Oak Circle Center Adolescent Unit admission.
The patient's primary physician is Dr. Frito Bandito. Jane was committed through
Chancery Court due to problems including recent suicidal ideation, welfare endangered by
severely impaired judgment, and severe maladaptive or disruptive behavior. The patient's
chief complaint at the time of admission is . Information available upon admission
reveals clinical problems/symptoms which include: . FAMILY AND SOCIAL FACTORS: Information concerning the patient's social history was obtained by interview with the patient, interview with the patient's mother, and review of commitment papers. Jane was born in Somewhere, OH, and raised there by her paternal grandparents. She is the third of six children in the family. Her father works as a butcher. Her mother is not employed outside the home. No history of emotional, sexual, or physical abuse is reported. The family lives in a suburban community and is perceived by the patient as above average in socio-economic status. Jane reports having poor relationships with teachers and other authority figures. The patient describes herself as being been socially withdrawn. She does not participate in extracurricular activities. Jane is currently described as normally affiliative. A preference is reported for solitary activities over social interests. The patient tends to interact primarily with younger peers and displays an age-appropriate range of recreational interests. A positive history of legal problems is reported for this patient, including .
Jane has reportedly been involved in "gang" activity, including . She has
a positive history of substance abuse, which includes . Further details of this
patient's social history will be available on the Social Service Plan in the medical
records. SCHOOL PERFORMANCE: Information concerning Jane's educational history was provided by interview with the patient and review of school records (including an Assessment Team Report, a Pupil Personal Data Sheet, and reports of absenteeism). The student was last enrolled in the Grenada County school district and attended Grenada Junior High School for the ninth grade. She was enrolled in school immediately prior to admission to Oak Circle Center. Jane is not eligible for Special Education services. Prior to admission Her special needs were being addressed through participation in an Alternative School. The patient has been a disciplinary problem at school, as evidenced by reports of
disruptive behaviors, fighting with peers, and not completing school work. Prior
disciplinary actions taken by the school have included detentions and expulsions.
Other factors which may have affected this child's education include social promotions and
grade failure/retention. A review of Jane's grade averages reveals . Test
data available in the education records at Lakeside School include results from
achievement tests and emotional tests. Results of these tests reveal . The
parent's educational and career goals for the patient include . Jane's personal
educational and career goals include . Further details concerning Jane's educational
program will be available in the medical chart and in school records. EMOTIONAL, BEHAVIORAL AND COGNITIVE FACTORS: I nformation concerning the patient's mental health history was obtained by interview with the patient, review of commitment papers, and review of available medical records. The family mental health history is significant for . The first reports of behavioral or emotional problems for Jane occurred at age . A t that time identified problems included . The primary etiology for these initial problems appears to have been . T herapeutic intervention at that time included . The identified problems remain unresolved, and continue to present intermittent difficulties for the patient. Additional therapeutic interventions have included treatment by a private therapist
(Joe Blow, Ph.D.). Details of these interventions will be available in the patient's
medical records. Results of prior psychological evaluation reveal . Based on
all available information, the primary reason for the decision to commit the patient at
this time appears to be . This preliminary review suggests that strengths/skills
which may influence the choice of treatment for this patient include . BIO-MEDICAL FACTORS: Review of medical history is significant for past treatment of . Review of current medical status reveals ongoing treatment for . J ane reports irregular menstrual cycles and she is currently using birth control medications. The patient's vital signs at the time of admission include: temperature 98.6, pulse 76, respiration 16, and blood pressure 120/80. Her height is 5'11" and her weight is 104 pounds. The patient is taking no medications at the time of admission. Jane has known allergies to cheese. Admission physical exam is within normal limits except for . Neurological exam
reveals CN II-XII within normal limits. Cerebellar function is grossly intact.
Muscle tone is good and without cogwheeling; motor exam is unremarkable.
Admission laboratory is pending at this time. See the patient's medical chart for
additional details. CURRENT MENTAL STATUS: Mental Status Examination reveals a well-developed, well nourished, 14 year old black female whose appearance is consistent with her stated age. The patient is alert upon interview. Orientation is intact for person, time and place. She is casually dressed and groomed. Eye contact is minimal. Her mood is mildly depressed. Affect is inconsistent with verbal content, but shows broad range. Speech is coherent. The patient reports auditory hallucinations but denies visual hallucinations or delusional thought. She voices suicidal ideation without current plan or intent. Memory functions are impaired for recent and remote recall of information. I ntelligence appears to be below average. Her level of personal insight appears to be fair, as evidenced by . Social judgment appears fair, as evidenced by . Proverb interpretation is concrete. The patient's attitude toward is significant for . PHYSICIAN'S PRELIMINARY DIAGNOSTIC IMPRESSION: AXIS I: AXIS II: AXIS III: AXIS IV: AXIS V: IDENTIFIED PROBLEMS AND PRELIMINARY TREATMENT PLANS: 1. TREATMENT TEAM SIGNATURES __________________________
______________________________ __________________________
______________________________
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SOCIAL WORK: Integrated Summary Worksheet
Name:
Sex:
Sources of Information:
Place of Birth:
Place Raised:
Raised by:
Birth Order:
Number of Siblings:
Father's Work:
Mother's Work:
Substance Abuse History:
Type Community where Raised:
Family SES:
Relationships with teachers and other adults:
Extroversion vs Introversion
Age when began dating:
Dating frequency:
Preference for social vs solitary activities:
Preferred age of peers:
Legal/arrest history:
Gang involvement:
Substance abuse history:
Social Service treatment plan:
EDUCATION: Integrated Summary Worksheet
Name:
Sex:
Sources of Information:
School District:
School:
Grade Level:
Enrolled prior to admission/ why not:
Eligibility for special services:
Involvement in special programs:
Discipline problems in school:
Other factors affecting child's education:
Average grades:
Results of prior education tests:
Education plans of parents:
Education plans of patient:
Education treatment plan:
MEDICAL: Integrated Summary Worksheet
Name:
Age
Sex:
Race:
Appearance:
Alertness:
Orientation:
Dress/Grooming:
Eye contact:
Mood:
Affect:
Speech:
Thought process/content:
Memory:
IQ:
Insight:
Judgment:
Proverbs:
Significant physical findings:
Neuro exam:
Cerebellar functions:
Muscle/Motor functions:
Significant lab findings:
Diagnosis:
Preliminary Plans:
PSYCHOLOGY: Integrated Summary Worksheet
In general, try to find out specifically what type of interventions have been attempted in the past, the name of the therapist/institution, and how successful the therapy was. The object is to avoid treatments that failed in the past and/or focus our efforts toward things that have helped in the past.
Name:
Sex:
Sources of Information:
Family history of mental illness/psychological problems:
Age of first behavior/emotional problems:
Description/etiology of initial problems:
Intervention at time of first problems:
Course of illness/problem over time:
List of therapeutic interventions:
Results of prior psychological testing:
Primary reason for decision to commit patient NOW:
DEMOGRAPHIC INFORMATION: Integrated Summary Worksheet
This section includes basic admitting information and can be completed by any member of the treatment team.
Name:
Case #:
Date of Birth:
Age:
Race:
Sex:
County:
Admission date:
Number of prior admissions:
Primary physician:
Reasons for commitment according to court papers:
Patient's statement of the problem:
Most prominent symptoms observed upon admission:
Sources of Information:
NURSING: Integrated Summary Worksheet
Name:
Sex:
Temp:
Pulse:
Resp:
BP:
Height:
Weight:
Meds:
Allergies:
Medical history:
Ongoing medical problems:
Menstrual pattern:
Birth control meds:
Nursing plan:
Since 10/4/98 you are visitor .
This page last updated January 31, 2002.