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CFOP 155-26 STATE OF FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES TALLAHASSEE, August 1, 2011 Mental Health/Substance Abuse SAFE

AND SUPPORTIVE OBSERVATIONS OF RESIDENTS Guidelines for Healthcare Staff in Mental Health Treatment Facilities 1. Purpose. This operating procedure describes guidelines for observing individuals who are at risk for harming themselves or others. 2. Scope. This operating procedure applies to individuals hospitalized in state mental health treatment facilities, whether operated by the Department of Children and Families or by contract with private entities. The operating procedure does not apply to the Florida Civil Commitment Center. 3. References. a. Chapter 394, Florida Statutes (F.S.), Florida Mental Health Act. b. Chapter 916, F.S., Forensic Client Services Act. c. Chapter 65E-20, Florida Administrative Code, Forensic Client Services Act Regulation. d. Jennings, A. (2004), The Damaging Consequences of Violence and Trauma: Facts, Discussion Points, and Recommendations for the Behavioral Health System, Alexandria, Virginia, National Association of State Mental Health Program Directors, National Technical Assistance Center for State Mental Health Planning. e. Section 65E-5.602, Florida Administrative Code, Rights of Residents of State Mental Health Treatment Facilities. 4. Definitions. For purposes of this operating procedure, the following definitions apply: a. Clinician. A Physician licensed pursuant to Chapter 458 or Chapter 459, F.S. or Advanced Registered nurse Practitioner (ARNP) licensed pursuant to Chapter 464 F.S b. Clinical Risk Assessment Guide (CRAG). The CRAG is located in Appendix A to this operating procedure. This guide provides some basic areas to consider and report on when assessing a residents risk of harm to self or others in the facility. The CRAG also includes some items related to medical risks. The guide is an adjunctive tool which, in some cases, may assist clinicians in developing a more broad-based review of a residents status. The tool may also assist with tracking issues related to risk which need to be in recovery plans. The CRAG is employed at the discretion of clinicians or as directed in facility based policy. c. Key Indicators. Signs or symptoms associated with, but not limited to, aggression, assault, suicidality, self-injury, homicidal ideation or behavior, arson, escape/elopement, seizures, falling, and difficulty swallowing. The indicators direct staff toward the need to implement special observation and precautions.

CF OPERATING PROCEDURE NO. 155-26

This operating procedure supersedes CFOP 155-26 dated February 1, 2011. OPR: PDMH DISTRIBUTION: X: OSES; OSLS; ASGO; PDMH; Region/Circuit Mental Health Treatment Facilities.

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CFOP 155-26

d. Recovery Team. An assigned group of individuals with specific responsibilities identified on the recovery plan including the resident, psychiatrist, guardian/guardian advocate (if resident has a guardian/guardian advocate), community case manager, family member and other treatment professionals as determined by the residents needs, goals, and preferences. Other treatment professionals may include but are not limited to psychologists, behavior analysts, and social workers. e. Resident. A person who receives services in a state mental health treatment facility. The term is synonymous with client, consumer, individual, patient, or person served. f. Special Observation and Precautions. (1) Observations consist of Routine Observation, Close Observation, Group Observation, One-to-One (1:1) Observation, and Two-to-One (2:1) Observation. (2) Precautions consist of any actions needed to maintain safety during observations. Examples of precautions are searching a bed area for harmful items, searching a resident for harmful items, restriction to a ward, determining the number of staff needed to observe the resident, establishing the proximity of staff to the resident, following a Personal Safety Plan (form CF-MH 3124, available in DCF Forms) to employ calming strategies. g. Trauma-Informed Care. Trauma-informed care is mental health treatment directed by a thorough understanding of the profound neurological, biological, psychological and social effects of trauma and violence on an individual, and an appreciation for the high prevalence of traumatic experiences in persons who receive mental health services. Trauma-informed care is based on an understanding of the vulnerabilities and triggers of trauma survivors that traditional service delivery approaches may not recognize and may exacerbate. 5. Levels of Observation. a. Routine Observation. This level of observation consists of visual observation which is not the result of a special written order in a residents medical record. It involves at least thirty (30)-minute face checks completed by direct care staff in settings which residents generally occupy such as bedrooms, wards, pods, restrooms, dining rooms, activity rooms, classrooms, and enclosed yards attached to buildings. Supervisors will ensure that staff members are vigilant and aware of each residents whereabouts and status. Exceptions for some residents occur at times as they accept greater responsibilities, gain unescorted freedom of movement, and have time away from routine observation. Each facility will maintain Residential Area Coverage Sheets (Appendix B to this operating procedure) on a daily basis. b. Close Observation (CO). This level of observation requires that staff monitor a persons condition, location, and/or behavior every 15 minutes. The person is not continually watched, and this procedure should be used for issues of a less than serious nature where Routine Observation would not be frequent enough, and 1:1 observation would be too intensive. Close observation will occur in settings residents generally occupy such as bedrooms, wards, pods, restrooms, dining rooms, activity rooms, classrooms, and enclosed yards attached to buildings. Close observation consists of visual observation which is the result of a special written order in a residents medical record. Supervisors will ensure that staff members are vigilant and aware of each residents whereabouts and status. Authorization for Close Observation is by clinician order as defined in this operating procedure. This level of observation must be reviewed and renewed at least every seven (7) days and include a faceto-face examination by a clinician. The clinician will document whether changes have occurred, note additional concerns, if any, write a new order and document justification for continuation or discontinuation of an order. c. Group Observation (GO). This level of observation requires a staff member to remain within visual contact and close proximity of up to three (3) designated residents, in order for the physical, 2

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CFOP 155-26

medical, emotional or security needs of the residents to be met. The assigned staff maintains visual contact with the assigned residents at all times. Should a resident need to separate from the group observation for medical care or the bathroom, additional staff assistance will be called to maintain the required observation. Documentation of behavior, activity, and location is required every 15 minutes. Authorization for GO is by clinician order as defined in this operating procedure. This level of observation must be reviewed and renewed at least every seven (7) days and include a face-to-face examination by a clinician. The clinician will document whether changes have occurred, note additional concerns, if any, write a new order and document justification for continuation or discontinuation of an order. d. One-to-One (1:1) Observation. This level of observation requires one staff member to maintain uninterrupted visual contact of a resident while remaining within arms length at all times. If it is determined by a clinician that within arms length creates a danger to staff members or is not therapeutic for the resident, the clinician may write an order indicating a variance from this requirement. The clinician will document justification for the variance. Staff assigned this coverage cannot be assigned to more than one resident at a time. One-to-one observation requires documentation at least every 15 minutes. Authorization for One-to-One Observation is by clinician order as defined in this operating procedure. This level of observation must be reviewed and renewed at least every 24 hours and include a face-to-face examination by a clinician. The clinician will document whether changes have occurred, note additional concerns, if any, write a new order and document justification for continuation or discontinuation of an order. e. Two-to-One (2:1) Observation. This level of observation requires two staff members to maintain uninterrupted visual contact of a resident while remaining within arms length at all times. If it is determined by a clinician that within arms length creates a danger to staff members or is not therapeutic for the resident, the clinician may write an order indicating a variance from this requirement. The clinician will document justification for the variance. Staff assigned this coverage cannot be assigned to more than one resident at a time. Two-to-one observation requires documentation at least every 15 minutes. Authorization for Two-to-one observation is from a clinician as defined in this operating procedure. This level of observation must be reviewed and renewed at least every 24 hours and include a face-to-face examination by a clinician. The clinician will document whether changes have occurred, note additional concerns, if any, write a new order and document justification for continuation or discontinuation of an order. 6. Trauma-Informed Care. All direct care staff and treatment professionals will be trained in TraumaInformed Care. Staff will review each residents Personal Safety Plan (form CF-MH 3124, available in DCF Forms) in his or her assigned area. Staff will continue to reduce trauma when employing alternative solutions for residents in crisis or in potentially harmful situations. Staff will use calming strategies and avoid triggers, as indicated on the Personal Safety Plan, when residents are in danger of harming themselves or others. 7. Key Indicators of the Need to Employ Special Observation and Precautions. Key indicators that special observation and precautions may be needed include but are not limited to: a. Suicidal/Self-Abuse. Residents who display or who have a significant potential for suicidal or self-injurious behavior. b. Homicidal/Assaultive. Residents who display or who have a significant potential for assaultive behavior toward others. c. Arson. Residents who threaten to or have deliberately attempted to set fires. d. Escape/Elopement. Residents who have significant potential for leaving hospital grounds without authorization. 3

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e. Medical. Residents who have significant medical problems which require special monitoring and documentation (e.g. seizures, choking, falling, special diets, grabbing food from others, excessive drinking of fluids, etc.) 8. Assessment of Risk and Orders for Special Observation and Precautions. a. Clinicians may authorize observation and precautions for individuals who are estimated to be at increased levels of risk to demonstrate harm against themselves or others. Orders for observation may also be related to the collection of information for diagnostic purposes. Observation and precautions may be authorized for medical, psychiatric, or behavioral concerns following face-toface examination. Authorizations for special observations and precautions are generally provided after a clinical assessment, and to the extent possible, assessment should involve members of the recovery team. b. If a situation exists where special observation and precautions must be initiated, renewed or discontinued after hours, during the weekend or on state approved holidays, a Registered Nurse may, after a face-to face assessment, seek verbal authorization from a clinician. All verbal authorizations (orders) must be signed by a clinician within 48 hours. c. All written orders for special observation and precautions, at a minimum, shall: (1) Identify and describe key indicators or other problems; (2) Delineate type of observation and precautions needed to maintain safety; (3) List evaluation or treatment goals aimed at lifting the observation and precautions; (4) Include the time limit of the order; and, (5) Include signature, credentials, date, and time. d. At the end of the specified duration, a new order must be written to continue the special observation and precautions (if continuation is warranted) . The clinician must write a progress note which includes justification for the previously mentioned decision. e. Observers will use either the Clinical Observation Progress Note sheet in Appendix C to this operating procedure or the Special Observation Flow Sheet in Appendix D to this operating procedure in accordance with facility policy. 9. Longer-Term Use of Special Observation or Precautions. In rare cases where an individual requires observation on a longer term or chronic basis (defined as two months or longer) to ensure safety of the individual or others, an order for longer-term observation may be written. Before implementation, the Clinical Director must approve this intervention. This intervention must be part of the recovery plan and must be reviewed by the recovery team on a weekly basis. Once implemented, the physicians order must be renewed on a weekly basis. 10. Discipline Responsibilities for Special Observation and Special Precautions. a. Clinician Responsibilities. (1) Assess and evaluate the status of residents risk to self or others. (2) Assess and evaluate the resident for need to implement, continue or discontinue special observation and precautions.

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(3) Sign orders to initiate, continue, or discontinue special observations and precautions. (4) Conduct face-to-face examinations within the frequency required by the particular observation or precaution. (5) Document justification for initiation, continuation or discontinuation of an order. (6) Notify the Recovery Team leader of the residents status. b. Direct Care Staff Responsibilities. (1) Observe resident for change in behavior and/or condition. (2) Immediately report any changes to the unit nurse or the most senior recovery team member available. (3) Document observations as ordered. (4) Make documented recommendations to Recovery Team for change in treatment. (5) Report changes, interventions, or preventative measures utilized during each change of shift report. c. Nurse Responsibilities. (1) If a situation exists where special observation and precautions must be initiated, renewed or discontinued after hours, during the weekend or on state approved holidays, a Registered Nurse may, after a face-to face assessment, seek verbal authorization from a clinician. All verbal authorizations (orders) must be signed by a clinician within 48 hours. (2) The registered nurse will evaluate and document the residents behavior and/or condition while on any special observations and precautions as authorized by a clinician as defined in this operating procedure. The frequency will be dictated by facility policy based on individual need. (3) The registered nurse will notify the clinician of any changes in behavior and/or health status of resident. d. Recovery Team Responsibilities. (1) Meet with residents who are on special observation or precautions, assess the need for continuation, and document the review in the clinical record. (2) During normal duty hours, the recovery team leader shall notify members of the Team of the residents status. The team will decide the extent to which a holistic approach to the residents problems is needed, and whether to meet with the resident to determine any additional needs for treatment planning. (3) The assigned staff person will ensure that the residents Personal Safety Plan is complete and up to date.

August 1, 2011 BY DIRECTION OF THE SECRETARY:

CFOP 155-26

(Signed original copy on file)


DAVID A. SOFFERIN Assistant Secretary for Substance Abuse and Mental Health

SUMMARY OF REVISED, ADDED, OR DELETED MATERIAL The definitions of various types of observation have been deleted from paragraph 4 and a new paragraph 5 has been added to describe levels of observation. A sentence has been added to paragraph 8b requiring that the verbal orders described in that paragraph be signed by a clinician within 48 hours. A new paragraph 9 has been added describing longer term use of special observation or precautions. In paragraph 10, a few changes have been made to the responsibilities described in that paragraph.

August 1, 2011 Clinical Risk Assessment Guide Date:____________


Reason for Assessment-- CIRCLE ONE: 1. 120-hr

CFOP 155-26 Most Recent/Previous CRAG Date:____________

2. Annual 3. Any Recovery Service Plan (RSP) review w/chg in coding 4. Transfer to new service team 5. Restraint 6. Seclusion 7. Placement in Forensic Security Area 8. Return from LOA 9. Other (e.g. FOM review, resident to resident injury): ___________ 10. Critical Event review Date of event: ___________ Time: _______ Type of Event defined in Attachment 1: ___ Elopement ___ Escape ___ Suicide Attempt ___ Alleged Sexual Battery ___ Resident Significant Injury ___ Staff Injury resulting in hospital admission: I. FACTORS ASSOCIATED WITH RISK OF HARM TO SELF OR OTHERS
Checklist for Psychiatrist, ARNP, or Psychologist coder Check ALL that apply ___Any by history ___Any w/in 12 mos. ___Any w/in 30 days ___None ___Any by history ___Any w/in 12 mos. ___Any w/in 30 days ___None ___Any by history ___Any w/in 12 mos. ___Any w/in 30 days ___None ___Any by history ___None
After 120-hr CRAG, code chg in risk

Instructions & Comments

RSP Issue No.(s) & Status*

1. SELF-INJURY BEHAVIOR Any intentional


act to harm oneself, regardless of stated intent or function of behavior (i.e., suicidal, expression of other needs)

___ risk ___ risk ___ no change ___ risk ___ risk ___ no change ___ risk ___ risk ___ no change ___ risk ___ risk ___ no change ___ risk ___ risk ___ no change ___ risk ___ risk ___ no change ___ risk ___ risk ___ no change

Any occurrence within 12 months must be addressed in Recovery Service Plan (RSP) Any occurrence within 12 months must be addressed in RSP

2. SELF-INJURY THREATS OR IDEATION

Any self reported or observed threats to harm self, including command hallucinations of self injurious nature

3. VIOLENT BEHAVIOR Any attempt,

regardless of outcome, to harm another person, as observed, documented in records, or self-reported

Any occurrence within 12 months must be addressed in RSP Specify: persistent or intermittent Any occurrence within 12 months must be addressed in RSP Any occurrence within 12 months must be addressed in RSP

4. VIOLENT IDEATION Any self reported or

observed, thoughts, daydreams, threats, or urges to ___Any w/in 12 mos. ___Any w/in 30 days harm others

5. ELOPEMENT/ESCAPE BEHAVIOR Any


act of leaving ward, unit, or grounds without permission, regardless of success of attempt

___Any by history ___Any w/in 12 mos. ___Any w/in 30 days ___None ___Any by history ___Any w/in 12 mos. ___Any w/in 30 days ___None ___Any by history ___Any w/in 12 mos. ___Any w/in 30 days ___None ___No ___Yes ___No ___Yes

6. ELOPEMENT/ESCAPE IDEATION Any self


report or observation of threats or plans to elope or escape substances and alcohol. Do not code based on presence or absence of a substance related diagnosis.

Any occurrence within 12 months must be addressed in RSP

7. SUBSTANCE ABUSE Significant use of illicit

Any occurrence within 12 months must be addressed in RSP ___Use of substances at time of

offense (persons w/ NGI commitment must be addressed in RSP) ___ risk ___ risk ___ no change ___ risk ___ risk ___ no change ___ risk ___ risk ___ no change

8. PHYSICALLY VULNERABLE Any identified


physical conditions that place person at risk (specify
conditions & whether temporary or enduring)

If yes, must be addressed in RSP If yes, must be addressed in RSP

9. COGNITIVELY/PSYCHOLOGICALLY VULNERABLE Significant cognitive deficits,

significant trauma history, or significant symptoms that impair cognitive ability

10. RULE VIOLATING BEHAVIOR Pattern of

noncompliance with written rules of living environment (Note: Limiting grounds access in civil units cannot be based solely on minor violations irrelevant to safety & security)

___Monthly ___Weekly ___Daily ___None ___Any personality d/o dx ___Substance abuse dx ___Antisocial P. D. dx ___Protective factor/Axis I ___None

___Major ___Minor ___Both Brief description or reference to chart document which details the behavior issues Specify Axis I, if protective factor:

11. DIAGNOSIS (As listed in current Service

Plan) This category includes diagnosis factors identified in risk assessment literature which heighten or lessen risk (see definitions in policy)

___ risk ___ risk ___ no change

INSTRUCTIONS:
*RSP status codes: A = Active, R = Regulated, I = Inactive File in the Recovery Plan section of the ward chart. For critical events, send copy to Risk Management. Maintain the five (5) most recent Clinical Risk Assessment Guides in the active chart.

ADDRESSOGRAPH:

Unit: _______

Ward: ______

Office of Primary Responsibility: PDMH

*** CONFIDENTIAL & PRIVILEGED INFORMATION *** FOR PROFESSIONAL USE ONLY ***
Appendix A to CFOP 155-26

CLINICAL RISK ASSESSMENT GUIDE

Page 1 of 2

August 1, 2011
___Command hallucinations ___Suspicious/paranoid ___Anger assessment literature associated with heightened risk of harm to self or others (check any that are present at a ___Depressed mood ___Hopelessness clinically significant level) ___None

CFOP 155-26
___ risk ___ risk ___ no change

RESIDENTS NAME AND NUMBER:__________________________________________________


12. SYMPTOMS ASSOCIATED WITH INCREASED RISK: Symptoms identified in risk
Any selected symptoms must be addressed in psychiatry documentation Supporting documents:
RSP Issue No.(s) & Status

II. FACTORS ASSOCIATED WITH MEDICAL RISK (Checklist for Nurse, Physician or ARNP Coder)

13. MEDICAL ISSUES: Circle all that apply:


a. b. c. d. e. f. None Potential for falls/fractures Diabetes/Seizures Potential for Choking/Aspiration Cardiac Serious longterm illness g. h. i. j. k. l. Blood/Body Fluid Precautions Above/below IBW Nutritional issues Skin integrity issues Bowel/bladder issues Other (specify): ____________________

Any circled items must be addressed in RSP

14. PSYCHOTROPIC MEDICATION ISSUES I: Circle all that apply:


a. New Abnormal Involuntary Movement Scale (AIMS) score >3 on single item b. New AIMS score> 5 total d. >3 medication refusals in 30 days c. >3 psychotropic emergency injections in 30 days e. None of the above 15. PSYCHOTROPIC MEDICATION ISSUES II: Circle all that apply: a. >1 anxiolytic d. >1 anti-Parkinson b. >2 antipsychotics medication c. >3 antipsychotic/mood stabilizers in combination e. None of the above

Any circled items must be addressed in RSP

Any circled items must be addressed with rationale in psychiatric progress note documentation

CLINICAL RISK ASSESSMENT SUMMARY AND RECOMMENDATIONS


OVERALL, considering frequency & severity of all risk factors, persons current risk in comparison to most recent CRAG is (circle one):
Increased Decreased Unchanged assistance Referral to UD/MSD made? Yes No Purpose of referral? Information only Request for

Referrals: For the 120-hour CRAGI, refer if any occurrence of self-injury, violent, or escape/elopement behavior in past 30 days (items 1,3,5); if any yes on items 8 or 9; if any significant issues in items 13, 14, 15; OR if any occurrence of significant behaviors prior to, or since, admission. For all other CRAGs, refer if the overall risk is increased. In summarizing, the team may find it useful to consider three aspects of risk: (1) Risk to Others, (2) Active Risk to Self. and (3) Passive Risk to Self through Personal Vulnerability. If overall risk is increased, summarize on this form using specific data & behavioral examples, and refer. If team makes a referral for purposes of information only, briefly describe how current risk factors are managed. If team makes a referral for purposes of requesting assistance, specify the nature of the request on the referral form. If the overall risk is rated as unchanged, and some boxes are checked risk, justify the overall rating of unchanged in the summary.

Signature/Title of Coders: Section I: _______________________________ Section II ______________________________ Other members of quorum at team meeting (Signature/Title): ________________________ _______________________

Team Leader Signature: ____________________________________________________ Date: ____________________

*** CONFIDENTIAL & PRIVILEGED INFORMATION *** FOR PROFESSIONAL USE ONLY *** Facility Name:

CLINICAL RISK ASSESSMENT GUIDE

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A-2

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RESIDENTIAL AREA COVERAGE SHEET


INSTRUCTIONS FOR COMPLETING RESIDENTIAL AREA COVERAGE SHEET: Enter day, date and circle shift hours. Each ward coverage staff must sign their name in the observer block, and enter the time when receiving the board, and enter the time when the board is relinquished to the next staff (lunch & breaks included). Midnight shift observer enters resident names for the next shift's ward coverage sheet. Observer #1 should record hour (e.g., 0900) in blank square with 30 blocks indicative of half-hour intervals (e.g., 0930). Enter appropriate codes for the residents Area/Status (all codes are on page 2). Supervisor signs ward coverage at end of shift after review of form for completeness and submits to UTRSSIII or equivalent for further review and filing.
Unit: _________________________________ Observer # 1 Time Begin _______Time End ________ Time Begin _______Time End ________ Ward/Pod: __________________________________ Observer # 2 Time Begin _______Time End ________ Time Begin _______Time End ________ 7--3:30 3--11:30 11:00--7:00 11:00--7:30 11:15--7:15 __________________________________ Ward/Pod Supervisor DAY: _____________________________ DATE: ____________________________

__________________________________ Observer # 3 Time Begin _______Time End ________ Time Begin _______Time End ________

Resident Name

Evacuation Symbols

30

30

30

30

30

30

30

30

30


Faci

lity Name Office of Primary Responsibility: PDMH

Appendix A to CFOP 155-26

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2

CFOP 155-26
Page 1 of

Appendix B to CFOP 155-26

RESIDENTIAL AREA COVERAGE SHEET


Unit: __________________________________ Observer # 1 Time Begin _______Time End ________ Time Begin _______Time End ________ Ward/Pod: __________________________________ Observer # 2 Time Begin _______Time End ________ Time Begin _______Time End ________ 7--3:30 3--11:30 11:00--7:00 11:00--7:30 11:15--7:15 __________________________________ Ward/Pod Supervisor DAY: _____________________________ DATE: ____________________________

__________________________________ Observer # 3 Time Begin _______Time End ________ Time Begin _______Time End ________

Resident Name

Evacuation Symbols

30

30

30

30

30

30

30

30

30

CODES FOR AREAS/BEHAVIORS:

Evacuation Symbols (H=Hearing Impaired, W=Wheelchair or Other Mobility Limitations, B=Blind or Impaired Sight, S=difficulty speaking English, ? = e.g., confusion, difficulty following instructions) Areas 1-Bedroom 2-Day Room 3-Quiet/Comfort Room 4-Bathroom 5-Shower 6-Dinning Room/Area 7-Therapeutic Area on Ward/Pod 8 Therapeutic Area Off Ward/Pod 9 -Yard 10- Community Medical Setting 11-Medical Setting Off Ward in the Facility

Areas (Continued) 12-Legal Setting on Campus 13Visitors Area 14 -Seclusion Designated Area 15- Restraint Designated Area 16-Hallway 17-Treatment Mall 18-Patio 19-Recreation/Gym 20-Religious Services 21-Administration 22-Security Office 23-Beauty/Barber Shop 24-On grounds (e.g., freedom of movement) 25-Off Campus (Authorized, e.g. Town Pass, Furlough) 26-Off Campus (Unauthorized, e,g., elopement/escape) 27-Out of Facility (LOA) 28-Other

Status A-Awake and no appearance of mental, emotional, behavioral, or physical distress (no need for urgent professional care) B- Awake and some appearance of mental, emotional, behavioral or physical issues (no need for urgent professional case) C-Awake and an appearance of mental, emotional, behavioral, or physical distress (in need of urgent professional care, notify appropriate discipline and specify concerns in at least one progress note or more frequently as needed each day) D-Appearance of sleep or resting, no appearance of distress, check for breathing at least hourly on midnight shift E-Other observational note (enter progress note and notify disciplines as appropriate)

B-2

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Page 2 of 2

B-3

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RECOVERY SERVICE PLAN NUMBER ___________ DATE ON WHICH OBSERVATION BEGAN: _______________ CHECKS: Q 15 min.

CFOP 155-26

REASON/PHYSICIAN: ________________________________________________________________________________________ TIME OBSERVATIONAL CHECKED STATUS LOCATION/BEHAVIOR OBSERVED CHECKED BY: (SIGNATURE)

INSTRUCTIONS: Chart the location and behavior of persons requiring documented clinical observations. All clinical observations, with the exception of Seclusion/Restraints, will be documented on this form. At the end of each shift, staff will document an end of shift summary. Incidents requiring more detailed documentation will be documented on Progress and Event Notes form. To be filed in the Flow Sheet section of the residents chart. Reference Operating Procedure(s): CFOP 155-26.

ADDRESSOGRAPH:

** CONFIDENTIAL & PRIVILEGED INFORMATION *** FOR PROFESSIONAL USE ONLY **


FACILITY NAME, LOCATION, FL ZIP COPE

Appendix C to CFOP 155-26

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CFOP 155-26

CLINICAL OBSERVATION PROGRESS NOTE


Office of Primary Responsibility: PDMH 2 Page 1 of

INSTRUCTIONS: Chart the location and behavior of persons


requiring documented clinical observations. All clinical observations with the exception of Seclusion/Restraints will be documented on this form. At the end of each shift, staff will document an end of shift summary. Incidents requiring more detailed documentation will be documented on Progress and Event Notes form. To be filed in the Flow Sheet section of the residents chart. Reference Operating Procedure(s): CFOP 155-26. DATE TIME CHECKED OBSERVATIONAL STATUS

ADDRESSOGRAPH:

LOCATION/BEHAVIOR OBSERVED

CHECKED BY: (SIGNATURE)

** CONFIDENTIAL & PRIVILEGED INFORMATION *** FOR PROFESSIONAL USE ONLY **


Facility Name, Location, FL Zip Code

C-2

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Office of Primary Responsibility: PDMH

CFOP 155-26

CLINICAL OBSERVATION PROGRESS NOTE


Page 2 of 2

C-3

August 1, 2011
Florida Department of Children and Families Mental Health Treatment Facilities

CFOP 155-26

SPECIAL OBSERVATION FLOW SHEET Document Every 15 Minutes Date:________________________

ADDRESSOGRAPH
Check Level of Observation: [ ] Continuous Visual Observation (CVO) @ __________ am/pm; [ ] One-to-One @ ___________ am/pm; [ ] One-to-One with Additional CVO Coverage @ ___________ am/pm; [ ] Two-to-One Observation @ __________ am/pm Check Reason for Special Level of Observation: [ ]Elopement/Escape [ ] Sexual Precautions [ ]Suicidal Precautions [ ]Falls [ ]Withdrawal [ ]Seizure [ ]Assaultive/Combative/Violent Behavior [ ]Other (Specify) _________________________________________________________________ [ ] Serious Medical Condition: Identify: ___________________________________________________________________________________________ STAFF INITIALS STAFF INITIALS MONITORINGSUPERVISORY MONITORINGSUPERVISORY MONITORINGSUPERVISORY STAFF INITIALS STAFF INITIALS MONITORINGSUPERVISORY

TIME 12M-5:59A

TIME
6A-11:59A

TIME
12N-5:59P

TIME
6P-11:59P

CODES

CODES
12:0012:14 12:1512:29 12:3012:44 12:4512:59 1:001:14 1:151:29 1:301:44 1:451:59 2:002:14 2:152:29 2:302:44 2:452:49 3:003:14 3:153:29 3:303:44 3:453:59 4:004:14 4:154:29 4:304:44 4:454:59 5:005:14 5:155:29 5:305:44 5:455:59

CODES
12:0012:14 12:1512:29 12:3012:44 12:4512:59 1:001:14 1:151:29 1:301:44 1:451:59 2:002:14 2:152:29 2:302:44 2:452:49 3:003:14 3:153:29 3:303:44 3:453:59 4:004:14 4:154:29 4:304:44 4:454:59 5:005:14 5:155:29 5:305:44 5:455:59

CODES
6:006:14 6:156:29 6:306:44 6:456:59 7:007:14 7:157:29 7:307:44 7:457:59 8:008:14 8:158:29 8:308:44 8:458:59 9:009:14 9:159:29 9:309:44 9:459:59 10:00 10:14 10:15 10:29 10:30 10:44 10:45 10:59 11:00 11:14 11:15 11:29 11:30 11:44 11:45 11:59

6:006:14 6:156:29 6:306:44 6:456:59 7:007:14 7:157:29 7:307:44 7:457:59 8:008:14 8:158:29 8:308:44 8:458:59 9:009:14 9:159:29 9:309:44 9:459:59 10:00 10:14 10:15 10:29 10:30 10:44 10:45 10:59 11:00 11:14 11:15 11:29 11:30 11:44 11:45 11:59

Appendix D to CFOP 155-26

August 1, 2011

CFOP 155-26

CODE EXPLANATION (Must include the individuals location/activity and behavior/general status) List at least one code from each category:
Location/Activity 1. Sitting 2. Standing 3. Resting 4. Sleeping 5. Talking 6. Reading 7. Writing 8. Watching TV 9. On Phone 10. With Physician 11. With Therapist 12. With Nurse 13. With Rehab 14. Team 15. Group 16. Meds 17. Personal Room Behavior/General Status 18. Dayroom 35. Outside Activities A. Agitated R. Paranoid 19. Hallway 36. Snacks B. Angry S. Resting 20. Bathroom 37. Eating C. Anxious T. Restless 21. Laundry 38. Walking D. Apologetic U. Seeing Things 22. Fresh Air 39. With UTRS or MHT E. Assaultive V. Self Harm 23. Lobby 40. Bathing F. Calm W. Self Harm Thoughts/Feelings 24. Meal on Unit 41. School/Work Therapy G. Cooperative X. Uncooperative 25. Meal off Unit H. Crying Y. Ventilating Feelings If individual is 26. Gym I. Demanding Z. Withdrawn off unit while J. Guilty Thoughts/Feelings 27. Quiet Time on Line-of28. Seclusion K. Happy Sight or One29. Restraints to-One Obs., L. Hearing Voices 30. Appointment M. Hyperactive FLOW SHEET 31. Visitors N. Interacting with Others must 32. Tx Mall O. Isolating Self accompany 33. Off Unit with Staff P. Intrusive the individual. 34. On Unit Activities Q. Pacing

TRANSFER OF INDIVIDUAL RESPONSIBILITY


STAFF INITIAL TRANSFER FROM : STAFF INITIAL TRANSFER TO: TIME NURSE DESIGNEE APPROVAL CODE* STAFF INITIAL TRANSFER FROM : STAFF INITIAL TRANSFER TO: TIME NURSE DESIGNEE APPROVAL CODE*

*Code: 1 = Break

2 = Reassignment during Shift

3 = Change of Shift

Initials ______ ______ ______ ______ ______ ______ ______ ______

Full Signature _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________

Title __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________

Residents Name ______________________ Reference CFOP 155-26

Hospital Number__________________

D-2