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					           DOMINION HOSPTTAL
-l      2960 Sleepy Hollow Road
        Falls Church, VirAinia 22044
        Phone (703) 536:2000




                                                   DISCHARGE PLAN FORM
       Discharge Status
       Admission Date:           tclTo/o7       Discharse     Date: lO /7/          o   ,t   Discharge   ro:,Ha-nee      T ,"i] ,F
       FOLIOW-UP APPOT NTMENTS                                                                              3c


3



      Mental Health/Social /Medical lsJues




       I    Patient has been advised of the potential for Metabolic
                                                                    syndrome and the n""o           t* rottoffiiln
            Psychiatrist and primary Care physician.                                                                    ln"

     DISCHARGE DIAGNOSIS:




     Attending   enysician: DY.                    lf?    qfl\             phone    #, aO3 - E tl- t3 37
     Physician Signature:
                                                                                                   oare:       f 0-3t-Og
     Patient/G uardian Signature:
                                                                                                   Date:
     SocialWorkerSignature:!ietttrnPirtient's
                       ,r'Y,/ ;l-d;tt                      ,rt   f jr ,'e '/                      ---Y:oicarionsupon ciischat'ge
 rH,01.r7   riz,,c8)                         originar -   chart   yerow copy to   patient
                                                                                                  --ypelongings
                                                                                                  __r   --.&'aluabies
       JdAlqov'               < <       k                                                                                                              Drno.
                                                                                                                                                       ! s:v.         T


   Unit #:                    J000018122
 Account# :                   J84090218118                                                 Roth, Richard L
 Admicted:                                                                       Dominion Hospi-tal- Patient Care          INITIAL SAFETY ASSESSMENT:            ADU



                                                                            Coded      Allergies/Adverse ReacEions
        af--^
                                                                                          Category     Severity Ver? DaE.e                 Time User
                ReacL        ion
  ll    I crai      oc
        I ruoxef']-ne                  H.u1                                                er    qJ                             L0/30/09 L240   HEB
                RASH

                                                                                 AduLt Partiaf Safety Assessmnt                            l-l/04/09 1548       EMW



 What are i'our goals for this hospital-ization: 'rAdequately address any concerns about                                                               my
                 : ability to return to work and cope with stress"
 Anw Hi sl-clrv                    nf        Ahrrsc     nr    Neol ecg;            N


-History                 of Aqqressive/Assaulcive                                  Behavior:          None
,$..""' co t "ii-r Means ;
'rtt- --                                                      N
  lr Ypq nlPaqF  eXplain:
 Patients                    Social i^Jorker notif ied:                            N

 'FTi qt-^r1r        of        Crri ci ria           Al. rcmniq.           t\T




 F)oes rhe nafiernl- h:rre:nrr    rhnrrohfs of srli cicle:DENIES
 f)cres t-he nafienf    hawe anw inrFnc of suicide:        DENIES
     -s t-he n:f i enl- havc a nl:n f nr suicide:          DENIES
  g

 I-)oes l-he narient have a hiscorw nf sel f harm: N
        ur.gPguvgqrrfJuv!1                                  T\mpq nf Sel-f Harm Behaviors:
 Head Banging: N           Scracching/Cutting: N Manipulating others to harm seLf: N
 Fire Secting: N Hanging: N Overdosing: N                                                             Burning: N Sel-f Strangulation:       N
    Jump in front of car, window, metro: N                                                             Poison: N Self Biting: N Other:      N
.Lrigqers: NA
'"tr
 ;;il                    :




 Level- of fmpulsivicy:                                    Low

   Admission hi"story/slmptoms indicate potential for self-harm: N
    Commits to notrify straff of seLf harm thoughts,inLent, or plans:Y
 Patienc's Protective Barrj-ers againstr Suicide,iself Harm: Coping Skills
                                                             Cu::rentrIy EmployedlSchool
                                                             Poeit,ive Attibude
                                                                                                                    Social SupporEs
                                                                                                                    AbiliEy RealfEy Tegt
Prer-inirafino           ennl.i CabIe what doe5 rhc nl- .ident-.i frr 49 the CaUSe
                                        Facfors:Tf
of loss of control or acting out behavior? "lvfY JOB'S CONCERN,AFTER THE ACCIDENT' REPORT
: FOLLOWING MY CAR ACCIDENT ON OCT 27,, 2OA9'

Techni            mrc<        rrqari         l-n   'nal n    nrr   i cnt         control        behavior:    "f IiAVE BEEN IN   CONTROIJ
                                        : OF       MY MOOD. NOT OUT OF COM|ROL. EXCEPT WHEN DTSORIS.NTED FEW DAYS AFTER ACC.

 J Oriented to                              unit.:     Y
                                                                                 <<NURSING ADMISSION NOTE>>

         Appearance: WELL GROOM : PT ADMITTED TO ADULT PARTIAL PROGRAM TODAY. STATES
Additional Comments: SHE WAS DISORIENTED AFTER HER CAR ACCIDENT:FOR A FEW DAYS BUT DENIES
               : LOSS OF CONTROL OF MOOD OR BEHAVIOR RECENTLY. HAS AN INTERVIEW AT WORK
                                                                                  I,JILL]AI4S. LYNNAE
        DOMINION HOSPITAL                                                         J84090217483 rou                  tH
                                                                                                                          D
                                                                                                                              J.222-s
                                                                                  l0/30/09   Roth,Richard            L
                                                                                  Da8:07/09/1976        F/33             MR#J000018122
             Admission Medical History                                                                                            H.spi,a,
                                                                                    illillllllllllillllilllilllllllll,*,,,.,
             and Physical Examination



REVIEW OF SYSTEMS:


Head:.'f,    No Abnormalities     ldentified    fl    RecentTrauma              E   Other


Eves: EF No Abnormalities ldentified fl               Corrective Lenses             fl    Other




Nose:   tr    No Abnormalities ldentified        tr    Rhinitis         n   Other
                                                                                                                                                                 )
Mouth/Throat(withdenta|assessment):F\lgoAbnorma|ities|de


Cardiovascular:    fl-No     Abnormalities ldentified        E         Chest   Pain fl       Other


Respiratory: EI-No Abnormalities ldentified            E Cough fl                Shortness of          Breath            fl       Other


Gastrointestinal:    fL(o     Abnormalities ldentified            fl    Nausea flVomiting               I       Diarrhea                I        Other


Genito-urinary; -.Ef No Abnormalities ldentified             fl        Urinary Frequencv          fl    Urgency               D         Other
                      ./
                         /
Gynecological:    tJ     No Abnormalities ldentified         fl    Vaginal Discharge              fl   Other
                                                                                                                                                                 )
                                                                                  .."                       r[,tp. ]
                                                                                                            Llvll    .        t    /^       1,,'r'-7
                                                                                                                                            Ll    1




Skeletomuscular    (include motor development and functioning):           fI   No Abnormalities ldentified                         fl       Pain n       Other


Skin: tr     No Abnormalities ldentified       D     Other


Neurological: fl,No Abnormalities ldentified                 fl        Headaches         E    Other


                                                                                                                          -
Weight Change / Dietary       Habits: flrNo        Abnormalities ldentified              []    Weight        Loss fl                Weight Gain
n   Appetite   Loss     fl   Increased   Appetite     E   Other
             DOMINION HOSPITAL
                                                                                 |^lILLIAMS, LYNNAE                                      D
                                                                                 J84090217483 eox                              tu        J.222's
                 Admission Medical History                                       10/30/09 Roth,RichardL
                                                                                 DAB:07/09/1976                     Ft33             l"lR#J000018122
                 and Physical Examination                                                                                                *
                                                                                   ill ]il   ilillllll lllllllililllil lll   il o*,,',       H.spi, a,




                                                                       Date:
                                                                                   , ,-)
                                                                                   1 t._-,
  cHIEF coMPLAINT AND PREsENT tLLNEss (TNcLUDE                                  TDENTTFyTNG                     rr.rronn,,,errt..rr:




  GURRENT        MEDICATIoNS:                                     l\ tt t/       i_7_l       t,--r



 PAST MEDICAL            HISTORy:                                    Iti   ll
 (children include birth and maternal history, if   available):                                            I




Allergies:   _
lmmunizations:




Tobacco   Use I      Ves
Drug Use I           yes;
Alcohol Use I        yes


FAMILY HISTORY:
                        DOMINION HOSPITAL
                            Admission Medical History
                            and Physical Examination

             ADMISSION PHYSICAL EXAMINATION
               (Note: Examiner is to cross out any description
                                                                of findings which do not appry to tnrs patient. lf any
                                                                                                                       abnormality is noted
               during the examination, prease describe under
                                                               the "speciiT otherwise" section.)



                GENERAL APPEARANCE
         n      Patient is a well-devetoped, well-nourished
                individual who does not appear to be acutelv
                or chronically ill. posture is appropriate; no



)            - SKIN
         r-r   l,atpauon: warm, moist, elastic. Insoection:


               HEAD
        f3     Scalp is clean. Hair is of normal distribution
               and color, is not significanfly fine or


               FACE
     E         Facial contour, mobility and expression
               are normal. No marked asymmetry or


               EYES
    D        Pupils are equal, round, regular and react to
             light and accommodation. Extraocular
             movements are normal. The sclera is white.
             Conjunctiva are free from infection. The
             comea and lens are clear. The Fundoscopic
             examination reveals sharp disc margins.
             Vessels are of normal caliber. No
                              or exudates are present.
             NOSE
    tr       No obvious deformity. Mucous membranes
          are not inflamed. Turbinates are not swollen.
          Ainrrays are patent. There is no septal
                      ion. There is no significant rhinitis.
          EARS
    F     Canals are clear. Tympanic membranes are
          intact and noninjected. Hearing is adequate
          for normal conversation. Extemal canals are
          free from tophi or other abnormalities.
                                                                                          ,l&lttftg,!yNNAE
           DOMINION HOSPITAL                                                             lf,:!:*iiipf i#Tf          D
                                                                                                                     J .222   .8
                                                                                         ;3{? S',';,
                                                                                                       ;,;i,
                                                                                                        F,','i,:!'
                Admission Medical History                                                  xlwilxxilfflttfililrt,,*,,,:::,0,:::,*u
                and Physical Examination



     I/OUTH                                               E    Soecifv otherwise
p"    Breath odor is within normal variation. There
      is not siqnificant change in the color or texture
      of the lips, tongue or buccal membrane.
      Tongue protrudes in the midline without
      unusual tremor. Teeth are in good repair
      and.tfie qums appear healthv.
      PHARYNX                                             E    Specify othenvise
|J    Mucosa is not inflamed. No evidence of
      swelling or exudate. Tonsils are present
                                                                                                                                       )
      andnot enlaroed or inflamed.
     THYROID                                              fI   Specify othenvise

U     The thvroid is not enlarged. No nodules are
      nresent
      NECK                                                E    Soecifv otherwise
                                                                                                                                     .-t
lJTThere is no increased jugular venous
1     pressure. Carotid pulsations are equal.
      No bruits are heard.
      GLANDS                                              [J   Specify otherwise
r-./-,
l-Jl There is no significant   lymph gland

/     enlargement in the neck, axillae, epitrochlear
      alea, suoraclavicular area or groin                                                                                              3
    ./'CHEST                                              fl   Specify otherwise
tr    Normal contour and movement on insoiration /
     exoiration. No chest wall tenderness
     I..UNGS                                              fI   Specity othenruise
fY   Auscultation: Breath sounds are audible
      No rales. rhonchi. or wheezes are noted.
      Percussion: Resonant in all fields.
     BREASTS                                              [J   Specify   oT.*'t.
tr                                                                                   j
     Free from masses and      tenderness, /
     discharge, dimpling, wrinkling or                                         i''   '' [j ,, \'
     discoloration of the skin.
     HEART                                                fl   Specify otherwise
tl   ruot enlarged. Heart sounds are normal
                                                                                                                                           j
     regular in rhythm and of normal rate. No
     murmur, qallops, clicks or rub are heard.
                 DOMINION HOSPITAL                                                                                                      0,,,,,
                                                                                            i4!!"#ln,LIJX\t'
                                                                                                       cia rd       R J             L
                                                                                           ;8{', \ii\r,,}ith,
                                                                                            "il
                      Admission Medical History
                      and Physical Examination
                                                                                               tiflililil]iliilftilfr'/ilfi   ,*,
                                                                                                                                    "i::   ;:::]:"'
 TANNER STAGES tAdoleEcents Only|
                                                  FEMALE                                                                      MALE


 fl        Stage t             Preadolescent oubic hair and breasts.                     Preadolescent penis and testes, no pubic hair


 !         Stage      2       Sparse, lightly pigmented straight pubic hair;             Scanty pubic hair, slightly enlarged penis;

                              breasts papilla elevated as small mound;                   enlarged scrotum, pink texture altered.
                              areolas diameter increased.


tr        Stage                Pubic hair darker, beginning to curl, increased           Pubic hair darker and curly. Penis, scrotum
                      3

                              amount; breast and areola enlarged, no contour             laroer.
                                                                                                                                                      '3
                              separation.


n         Stage       4       Pubic hair coarse, curly, more abundant; areola            Adult-type pubic hair, penis larger, wider;
                              and papilla form secondary mound.                          scrotum larger, darker.


                                                                                                                                                          J
D         Stage       5        Pubic hair is adult feminine triangle; mature             Adult-type pubic hair distribution; full growth of
                              breast, nipple projects, areola part of general            penis and testes.

                              breast contour.


         RECTAL                                                  D   Specify otherwise

          (All patients, age 45 or older, or if specific
          symptoms indicate need for examination.)
                                                                                                                                                      )
f]        tto evidence of hemorrhoids. fissures,
          bleeding or masses. Prostate is smooth
          of normal size. is non-tender and free from
          nodules (male only.) No masses present.
          Sphincter tone normal.
         NOT PERFORMED                                           I   Soecifu otherwise

      D       Patient less than age 45 and no specific
              symptoms indicating need for examination.
     O/i"*"               exam completed on



,- [J         Patient wishes to have own physician perforn
          ,   exam. Physician name       _.
     I        Patient unable to coooerate because of
              psychiatric condition. Describe:


     fl       otner
                  DOMINION HOSPITAL
                      Admission Medical History
                      and Physical Examination


           ABDOMEN
     t]     Normal contour - no masses to tendemess,
     .      no organomegaly (kidney, liver, spleen.)
            There is no costovertebral angle tenderness
            and no guarding. peristaltic sounds are
           normal. No bruits are heard.
           GENITALIA / PELVTC - FEMALE
     E     No hernias. No lesions of the labia or
           introitus are noted. The vaginal mucosa
                                                   is
           moist and normally elastic. Uterus is
           normal size, shape, position, freely
           moveable. Cervix is without lesions.
           There is no significant vaginal discharge.
          NOT PERFORMED
      tr     Patient less than j g and not sexually active.
      n      Recent exam completed on


     D       Patient wishes to have own physician
            exam. physician name
     D      Patient unable to cooperate because of
            psychiatric condition. Describe:




      GENITALIA - MALE
f]        Both testes palpable. No abnormal masses.
         No hernias. No urethral discharge. No
         lesions of glans or shaft noted.
     NOT PERFORMED
     E     Patient less than 1g and not sexually active.
     n     Recent exam completed on


     D    Patient wishes to have own physician
          exam. physician name
 n        patient unable to cooperate
                                       because of
          psychiatric condition. Describe:
               DOMINION HOSPITAL                                                                                          D,,,,,
                                                                                           i'.!!hdf/fi,Ll#\tE

                                                                                                                     -" :: ;::: :': "'
                       Admission Medical History
                                                                                          "fuiiiffiirjfrrriffi ffi
                       and Physical Examination

  TANNER STAGES tAdolescents Only|
                                               FEMALE                                                                MALE


 tr        Stage   1        Preadolescent pubic hair and breasts.                       Preadolescent penis and testes, no pubic hair


 tl        Stage   2       Sparse, lightly pigmented straight pubic hair;               Scanty pubic hair, slightly enlarged penis;
                           breasts papilla elevated as small mound;                     enlarged scrotum, pink texture altered.
                           areolas diameter increased.


 tl        Stage   3       Pubic hair darker, beginning to curl, increased              Pubic hair darker and curly. Penis, scrotum         ,)
                           amount; breast and areola enlarged, no contour               Iaroer.

                           seoaration.


 D         Stage 4         Pubic hair coarse, curly, more abundant; areola              Adult-type pubic hair, penis larger, wider;
                           and papilla form secondary mound.                            scrotum larger, darker.


 n         Stage   5       Pubic hair is adult feminine triangle; mature                Adulttype pubic hair distribution; full growth of
                                                                                                                                                 j
                           breast, nipple projects, areola part of general              oenis and testes.
                           breast contour.


       RECTAL                                                 []   Soecifu othenvise

       (All patients, age 45 or older, or if specific
       symptoms indicate need for examination.)
                                                                                                                                             )
 EI    t   to evidence of hemorrhoids. fissures,
       bleeding or masses. Prostate is smooth
       of normal size, is non{ender and free from
       nodules (male only.) No masses present.
       Sphincter tone normal.
       NOT PERFORMED                                         n     Soecifu othenrrise

       D    Patient less than age 45 and no specific
            symptoms indicating need for examination.
                       exam completed on
   "/ir*"
;'fl        Patient wishes to have own physician perforn
       ,    exam. Physician name      _,
   D        Patient unable to cooperate because of
            psychiatric condition. Describe:


  E        other
                             DOMINION HOSPITAL                                                                                                0,,,,,
                                                                                                      i'.llh,tffin.LlJltlfE
                                                                                                      10/30/09 Roth,Richard               L
                                                                                                      -fi
                                Admission Medical History                                                   nlffililiiilfrfifurlIifi   ,-, "i::   ;::   :]:
                                                                                                                                                              "'
                                and Physical Examination



         NEUROLOGICAL EXAM (cond.)
         ,D         Eyelid Elevation: Able to retract eyelid fully.         n     Specify othenvise


            fJ      Fundi flat, discs not elevated; no arteriovenous        n     Specifu othenvise
                    nicking, no hemorrhages, no retinal
                   prgmentation.

                 ,,[il,
                          IV, Vl Movement   of Eyes (oculomotor,            I     Specify otherwise
                   trochlear and abducens nerves):
         /
        '-lJ       ^
                   smooth, symmetrical movement through
                   alf positions of gaze; no nystagmus                                                                                                             )
                   present.

                          Trigeminal (ophthalmic branch, maxillary      n        Specify othenvise
                 /,V.
         //        Orancn, mandibular branch).
        fl         Witn eyes closed, indicates facial and
                  aural tacticle perception.

    I             ,Movement of muscles of mastication:                  fl       Specify othemise                                                                      J

        t/         Symmetrical tension in muscles of
         "        clenched jaw; able to move jaw laterally
                  against resistance; symmetrical muscle
                  mass of temporalis and masseters;
                  absence of lip tremors, involuntary
                  chewing movements and trismus; chews
                                                                                                                                                                   )
                  Symmetrically.

             i    Vll. Faciat                                          fl       Specifu othenrise
    [l            Normal facial inspection, frowns, and
                 elevates eyebrows symmetrically (upper),
                 tight closing of eyes (upper), adequate
                 saliva production; able to show teeth;
        /^       smiles svmmelrically (lower).
/                Vlil. Acoustic                                        U        Specify othenvise
    E            Cochlear branch: Hears finger rubbing and
                 snapping equally in both ears.
                 Vestibular branch                                     fl       Specifu othenvise
ll               Finger to nose or finger to finger without
        i        past-pointing; normal tandem walk: stands
                                                                                                                                                                       )
             with feet together without posture deviation
             (absent Romberg)
                     DOMINION HOSPITAL
                                                                                          L0/30/09 Roth,Richard                        L
    )                      Admission Medical History                                      JaB.0-7-/09/re76                 F/33            rlR#J00001g122

                           and Physical Examination                                         lll   illillil|illlilllllillllilllllff   o*,,,,,   H.sp,a,




              CIRCULATION                                       fl    Soecifv otherwise
               No significant varicosities. Pulses are
        ,fL
               palpable and regular in neck, wrist, groin,
               popliteal, and tibial arteries. No audible

               bruits.

              EXTREMITIES                                       fI   Specify otherwise

        E      futt range of motion   of   joints. No
               discolorations, tendemess, edema or
               evidence of imoaired function.
3             BACK                                              fl   Specify otherwise
        fl     There is normal curvature of the spine.
               There is no tenderness of the cervical,
               dorsal and lumbar soines.


              HEUROLOGICAL EXAMINAITOTTG
)             Level of Consciousness                            B'Alert E Drowsv fl Stuoor E                                                   Coma
              Knowledqe                                         E Specify otherwise
        fi'   Appropriate to age, education, cultural
               backoround. life exoeriences.
              Speech and Lanquaoe                               fI   Specify otherwise

        I     Clear articulation; no slurring, no stuttering,

)             or other difficulties or imoediments of
              speech; no bizarre intonation; able to use
              and interpret language with ease; no
              difficulty sending or receiving verbal or
              qestural messaqes.

              Examination of Cranial Nerves: ll - Xll           n    Specifu othenruise
              ll. Optic:
        n     Visual Fields: Full with no deficits on con-
              frontation; able to distinguish number of
              fingers in central field; distinguishes move-
              ment in oerioheral fields.

        -     Pupillary Reactivity: Pupil size symmetrical;     D    Specify othenvise
              pupils neither widely dilated nor pinpoint in
              average room light; prompt constriction in
              reaction to direct liqht stimulus.
                   DOMINION HOSPITAL
                                                                                                               0,,,,,
                        Admission Medical History
                                                                                   liii,t#irr|,fijf:
                        and Physical Examination                                    ilil'trlt,tllilti,ltrtftilfr,",,J:;::l:1',"



     NEUROLOGTCAL EXAM (cond.)
             lX, X,Glossopharyngeal and Vagus Nerves:

     E'      Normal midline elevation of uvula and palare;
            laryngeal contour rising with swallowing;
            phonates without hoarseness or articulation


            XL Accessory Nerve:
     I      Normal strength and symmetry on tuming
            head and elevation of shoulders.
           Xll. Hypoglossal Nerve:
     E     Tongue protrudes in midline with absence
           of fasciculations, tremors or atrophy, normal
           muscte strength of tongue; normal lingual


          Cerebellar Function;
           Balance:
 n         ruo abnormalities of gait (tandem and

 ".        heel-toe.)
          Coordination:
 fJ       nUte to touch finger to nose and heel to shin
          and vice versa rapidly and accurately with no
          past pointing; able to perform rapid
          alternating movements (supination and
          pronation of forearms) quickly and


         Motor Functions:                                  D   Specify othenvise
I        Symmetrical on inspection; good tone
         without spasticity or rigidity; no contractures


         Muscle Strength:
fI       Adequate and symmetrical muscle
         strength (5/5) on resistance to opposing
         force for upper and lower body muscle
         group on flexion and extension, abduction
         and adduction.
                                                                                                                                         I\J
                                                                                 WILLIAMS, LYNNAE                 D
            DOMINION HOSPITAL                                                    J84090217483 rDH tH               J.222'8
                                                                                 r0/30/09  Roth,Richard       L
                                                                                 DAB:07/09/[976                Ft33 rlR# J000018122
                 Admission Medical History                                        illlilllilililllfiillillillllilllfl ,*,.,." H.spi,a,

                 and Physical Examination



       Invofuntary Movements:                             f]   Soecifu otherwise

|-l,   Absence of tremors, twitches, tics,
/      fibrillations, fasciculations, athetoid
       or choreiform movements, mvoclonus
       or mvotonia.

i      Range of Motion:                                   !    Soecifu othenvise

fl     futt range of motion with no restrictions   in

       uoo-ei and lower extremities, spine.

     ,'Sensory Svstem:                                    E    Specify otherwise

E      Normal and svmmetrical response to touch.
                                                                                                                                               )

       Other Reflexes and Siqns:                          E    Soecifu otherwise

       Babinski's sign:
D      Absent (great toes downgoing on right
       and/or left.)
fl     Present (toes upgoing on right and/or left.)
n      Non-reactive or equivocal.
       Meningeal Signs:                                    E   Soecifv,otherwise
                                                                ''it,-T                       i

n Present: fl Kernig fl                   Brudzinski                l+ /'t  1.-.,-            |




       Deeo Reflexes:                                                                                                                          )
       Please note results of tests of biceps, triceps, radial, quadriceps, and Achilles' reflexes.


       0=Absent 1=Diminished 2=Normal 3=lncreased 4=Hyperactive 5=Hyperactivewithclonus


                                                                LEF'I'     '                      RIGFIIF,1i

                              Biceos
                              Triceos
                                                                      lt   .1-           ,-\'1_z
                              Radial
                              Quadriceps
                              Achilles
                   DO}TINIONI HOSPTTAL                                                   l,IILLIAMS, LYNNAE                                         D
                                                                                         J840902I7483 nor                               ru            J.zzz.a
                                                                                         I0/30/09   Roth,Richard                               L
                                                                                         DaB:07/09/r976                         F/33                ilR# J000018122

        I
        t                                                                                  lll ill       fiililil
                                                                                                     llilllllllilllllillllill   ill   ff o*,       ",,.   H.spi,a,




                                                    PA R   r L{raH os P t                              o           R{           }I
                                                                            lS   lt#:r?I#                    "
                  To be completed by attending physician at the time of dischar-ee
                                                                                   from inpatient level of care to the
                  partial hospitalization program.

                  Current Diagnosis: Axis L
                                             Axis 2:
                                             Axis 3:
                                             Aris   4:
                                             Aris   5


    3            Prgsenting                 (target symptoms and behavio                   avala-                                       ccclQTTt


                                                            I
                lt,lental Status:             n(<_       Ccd,n+tSJltUt           m?   AvW+ CqoQ*(<

    1           Treatment Planning:

               ;'Hff::T":[: i:l':::* **i::l::':':l*r:TL1'f""rlies, rvhrch require change in order ror the patient
               to function in a less restrictive setting, require
                                                                 rr:
                                                                                rsqurre cnange rn
                                                                  that the patient
                                                              r":,ii,""'_l')l!u
                        ^t:rI'                                                          5h4"v s4alQ

              PHY        S     ICL{ N TREA T}IE NT P LANN I]YG t\TE R\TENTIONIS
    3
              Therapeutic Interventions:




             Estim:rted Length of     q hJ f /Cu, S / t-
                             ,Scay                       O/fyfl
                            y'LL.r'!
             Discharge vton          / rLt { :f f VX-

                                                                                                                  (o-3(-oo
            ATTENDI}iG PtrYSICL{I{
                                                                                           DATE:

)
            DH-: i rl ( t{),   {),i
        Age,/Sex: 33              F                                                                                                                                        D:aa.
                                                                                                                                                                           4qJe.
                                                                                                                                                                                   '1



     Unitr #: J0000L8L22
   Account# : J84090218118                                              Roth, Richard L
   Admittred:                                                   Dominion Hospical PatienE Care                                 PSYCHOSOCIAL ASSESSMENf


                                                                 Ps L.rvouular
                                                                    ^L^^^^.i     ^1   no rcs
                                                                                      ^-^^-^   rlTl€flt   -std                        Lt/04/09 1s33 MXS
  Reason For Admission-- :
  Patient was admj.tted to DH on LO/30/Og and left AIvIA on
  LO/3I/09. In days,/weeks prior t.o admission paEienC
  had reporcedly been behaving in a bizarre way at work
  (SEate Dept) and was then in a road traffic accidene
  which she is reported to have deliberately caused-
  Today pac1ent presencs st.aEinq chaE sil'e is not sure                                                      'i i-r c-
  why she has been admitted to pHp except t'that the                                                                                                           \ +i ; ,\.s :,,i
  SEate DepartmenE has ordered this,'.                                                                                                                 --
                                                                                                                                                             \'\     --i

  Does Pati-ent Meet Cri-teria for Current Level of Care: y                                                        t'r.
                                    Supervisor fnformed:
  Primary Language: ENGLfSH ENGLfSH
 \ :pc r al,/ Cul tura],/ Educat ional- Inf luences ^ :
  fatient, is one of Lwo sibs born t.o middle class
  parenf.s, raised in suburb of Atlanta, aEtencied.
  Spellman College for undergrad, progressed to
                                                                                                          L      \,,      b;    r I     ,,   .   .s"   ,,r,-   i -- *1
  grad school aE Georgetown SFS, was then empJ.oyed by                                                                                   t'' l, i i:                  l\* i.,,..
  DOD, sent Eo fraq for four months (2OA'7) , returned
  to DOD where she reports having exceeded work                                                                                              \ \',,'\    ,
                                                                                                                                                                   \'.. ' r.,-'t
 performance e)<pectatj_ons, then moved. to State Dept,
  'n t4arch 09. Patient, has supporEive parents (                                                                                                                  i\y\,,,...,
     Frred educators) Patienc lives alone in apt in DC                                                                                            " ,         C",,  s")
 -.;id currently works for StaEe Dept as an ana1vst..                                                                                        <i, \rL
                                                                                                                                             "                i1r.,_\


                                                                                                                                                 j-..-1,...

                                                                                                                                        -',.-r     .,- .\.     .r- i :'v\,l:r*




                            HTSTORY----
 'r l--FAMILY                Famity psych Hx: y
        FamrIy Psych Relationship:                          Aunt

Describe Family psych Hx^:
Schizophrenia in maternal_ aunt.


                                 i{x of Suicide:            N

ts:ml      l\/   qlrr^1d6         Pal:iinnclri^.
- *"'-*J




Describe Family Hx of Suicide^:

    )
                                 Family            CD Hx:

            Family          CD   Relationship:
  Age/Sex: 33             F
     vrffL    r   r   J000018122
 n^^^r!-F+.
f,uuvqltLf        !   J84090218118                                     Roth, Richard L
Admit.t.ed:                                                    Dominion Hospital Patient Care                                            PSYCHOSOCIAL ASSESSMENT


                                                                Psychosocial     AssessmenE              -std                                          u-/a4/09, 1-s33 Mxs


       Religion:         CHR                      CHRISTIAN

                  SpiricuaL Practices:                        Church


Pt Believes in Higher Power:
Describe Higher Power^:

              Last Grade Completed: GraduaLe, degree
              Degrees/Certificates : Masters in Foreigrt Relati

                        Currentr StudenE:                 N
 3                                             Where:

Change in School Performance:
Describe Change In School Performance


       Problems with Behavior at School:
  )                             Truancy:
Learning Problems/Speci-al Education: N
Describe Learning,/Behavioral Probl-ems^ :


                                                          - ---EMPLOYMENT       HISTORY----
 .\       Currentl w Flmnl owed: Y
   ,             PE Occupation: Anal-yst
 't      Time at Current, Job: 4 . 5 years                               :l       \r"c^';e1-   ,>.^,\-\ i.'-c*.            (
                                                                                                                               a,.   \w1 yti)     r,r'.\
             Job Sati.sfaction: High                                          ,-a1*.g\o,..q...   , ._;.
                                                                                                        .i.,.,. T.".   r
                                                                                                                                       4-:i\':1
     Longest, Tj-me at One Job; 4.5 years
        Frequent Job Changes: N                                         \,>        L ? .t.,           .]i: .--
Reason for Job Chanqes^:                                                                                         :,




    Unemployed in Last Year:                              N
Reason for Unemployment^ :


                      Parenc OccupaE.lon:
                      Spouse Occupation:
                        Financial Needs: Denies, any stressors
                                                          Denies debts
                                                          Denies cornpulsive spendin
  )                                                       SEatres she manages
                                                          money "very' welf and,
                                                          f have good savings'r
                              M'i I i t-:rrr      TJv.    N
                                Elr:nch        IeqI   .
 Age/Sex:33 F                                                                                                        D=no   '   ,l
  UniE #: J000018122
Account# : J8409Q218118                                                    RoEh, Richard L
Admi.eted:                                                         Dominion HospiEaL Pat.ient Care   PSYCHOSOCIAL ASSES SMEN?


I                                                                   Psychosocial Assessment, -std         L7/04/09 1533   Mxs


                                         # of Years:
                               Mi l i j-:rrr Pcqerrra '
                                  l-]i cnhrraa  'ftma. '
                                                 - 1 E-

                                                    Year:
Discharge R/T Substance Abuse:
i-li qnha        rda     p /'F
                         .\/ r     Dcrrah
                                   !vJ  e..    /'nnAi
                                               vv.as    I i nr '




    3
                                                                    ----ARREST HISTORY----
Arrest or Pending Litigation/Civi.1 Charges Hx: Y
          Number of Arrests: 1
          Reason for Arrest: leaving scene of accident
 Arrests Involvinq Violence: N
                                               DUI'/DWI:      N
    )              Public Intoxication:
                                                   When;
                                                              N
                                                   When:
                                       Probation Hx:          N
                                              WhylWhen:
                                          Parole Hx:         N
                                              why/when:
         rilro         Dan"lina         ur ul_gaEl_onl/r:,.:1
                                        T i F.l^-F:^^   ul-v].I       unarges   :
                                                                      ^r.
         above note re. recent charqes.
        ient has reEained, an aEtornev
  Age/Sex: 33 F                                                                                                          Page:      5
   Unitr #: J000018122
 Account#: J84090218118                                                 Dnl-h   Di nh:rA     T.

 Admittred:                                                     Dominion Hospital Patient, Care          PSYCHOSOCIAI ASSESSMENf


                                                                 Psychosocj-a] Assessment         -std       l-L104/09 1533   MXS



                                                           ----NICOTINE HISTORY----
                            NicoEine Hx:                   II



                      Kind of tobacco:
                        Ana E'i rc r      ITc   gd     S


                  D:nlr< /t i rc ner           drrr.

                      How many years:
                    Any Consequences:

                                          When:


 )


Does PatlenL Drink Alcoholic Beverages: Y
            Tlpe of Alcohol: WINE
                  How Often: t - 2 times/month
 )                 How Long: 1O years
 r'                                How Much: gflass
                          Last Drink:
                     Type of Alcohol:
                                  How Often:
                                   TJnr,r T.nrn.
                                  ;;; il;;;
                             Last Drink:
  \.                 T1'pe of AlcohoL:
 '1                         How Often:
  J                          How Long':
                                  How Much:
                             Last Drink:
       Al-coho1 CommenL" :
       Patient denies any abuse of alcohol and states                                      she
       seldom drinks
Pt Believes          ETOH    Use a Problem:                      N
       \Teoa I i rrc trf f qgts     On Lif e :

Medical Problems from CD Use:
                   Longest Sobriecy:
                                         When:
             Sober SupporE System:
                                         wno:
                                       AA/NA:
 .
 \t                      T,ast Cont,acc:
                                    qnnn<^r.
 .J
                         Last      Contact:

ETOH     Sobriety/Support,/Treatment.                           CommenEs^   :

None
  Age/Sex: 33 F                                                                                                                                 Page:    6
   UniE, #: J000018122
 Account# : J84090218118                                                       Roth, Richard L
 Admitted:                                                             Dominion Hospital- Pat.ient Care     HJ I L.FIIJJ\JL   LA.Ir   ftDDllb    JIYIEIV -l




                                                                        Psychosocial Assessment      ^ts1             11/04109 1s33               MXS




 Additionat o'un:,::                                                  use:   N
                                           ::"H::1
                                 How Often:
                             How Long Used:
                                  How Much:
                                 Last, Used:
                                 Trma      nF      l-lrrra'
                                     Often:
                                          How
                             How Long Used:
                                          How Much:
                                      Last Used:
  \                              Trma
                                 ty}Js     n€ !!uy: '
                                           v! T-lrrra
   ,t
 J                                    How       Often:
             How Long Used.:
                    How Much:
                   LasE Used:
Drug Use Comment^:


  \-,Believes
  )          Drug Use a Problem:                                        N
 -/ Negative Effects on Life:
Medical Problems from CD Use:
                       Longest Sobriety:
                                                  When:
               Sober Support System:
                                                    Who:
  ad                                            AA/NA:
  J                           Last ContacE:
                                           Sponsor:
                              Lasc Cont.act                       :



CD SohriLev! v/Srrnnorf /Treaf menl- CommenES^:
          ci- /
Patient denies any CD recent or past



                                                                        ----ABUSE HISTORY----
(Emnrinn:l              Dhrrei     ar'l         lrTaalant              Sexual) Abuse: N
                                   ?hysical:
iJeqr--   i   trc   Phrrsi   r-al Abuse^ :

                                    Emot,i.ona1               :
  \--i  r'-
  /'----.- Emotional Abuse^,
                     Sexual:
Describe Sexual Abuse^:
     Age,/Sex:33 F                                                                                                                                                                   Pece       .     '7
      Unit #: J000018122
    Account# : J84090218118                                                                 Rot,h,           Richard                L
    Admict ed:                                                            Domi-nion           Hospital                      Pat r cni        /-rro   PSYCHOSOCIAL ASSESSME}TT


                                                                                          social Assessment                                   -sLd        a7/   04   / a9 r.s33              MXS



                                                  l\Tca l anF   .

    Fla<ari    4vv Fra     l\Taal aar e ^
                           rreJrse          .




    PaEient Has Hx of Abuse to Others:                                              N
    Describe Hx of Abuse to OEhers^;


              Was CPS,/APS Report Made:                               N
    Describe       CPS/APS Report^ :
    h
     ,9

    Describe CpS/ApS fnvolvement^                                     :




               Comments^:
        I



 stabirity                 of        Home   Environmenr, ;;;;:::ENGTHS/*EAKNESSES----
                                 Motivation for Tx:                       Weakness
 fn-sighc into Current. problems:                                         Weakness
        1
 ..ttfdgement Regarding                         Current problems                     :
 Weakness
Stability                 and SupporL of Employment:
Strength
Funct.i-on of Marriage/Famij_y System :
St.rength
Support System in and Beyond Family:
Q   F rannf     l-r



                       EducaEion Attainment: St,renqth
                          fnteLlectual Skilis: Strenqth
Range of Leisure                       Activitj_es^,                           -L :\hi..-jt i;.r (.,\.r.i:1.;.;
Most Iy exerci se                                                               <: -.-
                                                                                S-c"..--\. :-.., , r... _.;r {:; ...
                                                                                                                    \                                           -l\...:         rl   ^
                                                                                                                                        _-
                                                                                  ,-._r._1.r'- ."
Type of Recent Leisure AcEiviEies^:                                                                      :     :,.
                                                                                                               ^.\'l:   : :)c ;::                                      r:.(,\
                                                                                                                                                                                            j -1
                                                                                                                                                                -!
    rnr i ra
    'urrlllg          ..,^-Li
                      {(Jlr<l-ng       uuL      .; *                 \                                              t\._.
               '
                               '.a     ^!,ts    In     gyTn
                                                       -.-          A\ s:) -, *^r ,, j              , ,.,.                   ,- _
                                                                                                                                                                (-{-i_-_..,,< \-',
                                                                    \\ .- j,.- .>r....*, ,. ._\
    J                                                                                               \   \,:_   LJ q..,. , ..i.          ,.
                                                                                 \..-';\5         sr ':' \-)'*'',                   .i'                          -ir'.\u,,-.-            / .5i) { r
i^rhat Do you Do when Borea/i,..rr.',.il.| :.'ri                                              1                                                                                                       ),.
                           , --..--!                                                                                                                                 .'.    "ir,,,
Go running on the ma1I          -L S.-..A
  AgelSex:33 F                                                                                                                                                                                                        D:aa.
                                                                                                                                                                                                                      rs:v!             A

   Unj-E #: J000018122
 Account# : J84090218118                                                                                9Arh       pl       tn)fd          t_

 Admictred:                                                                         Dominj-on HospiEal- PaEient Care                                                             PSYCHOSOCIAL ASSESSMENT


                                                                                         Ps     hosocial             Assessment                        ^rJ                                  77/04/09 r.533                  MXS



Does Your Work Schedule fnterfere WiEh Your Leisure Acti.vi.ties:                                                                                                  N
    Do You Belong to Any Social Groups/CommuniEy Organizations:                                                                                                    N

 Tmnr-rzFmFni                          \Tcarfgd                in       ANY Of     thc        fnl I nw.ind         rrpag:
 PaE.i-ent denies

                                                                                                                                                                                                        \
                                                                                                                                                                               j -t,'-1"'.,.
                                                                                                                                    ,. -;..,-.\s -.i..ct1; :-'.".,1.,"1;'' --t                                                    "''
PL Perception of lllness^:                                                                                                          '\i,... ,.. i,- , t.                            :
                                                     ..;,.,,-. *-.']-- \)< 'N r"!r^\'.''                      -r:'\ c.'
                                                                        _-
Patient is bewild.ered as to wh1, she is here.        .-5:.                                         .-"'-t
                                                                                                         1l;-\"
Patient states that her co-worker who reported. her          --.r\': , \--''!-\c i:-' { :)')."i'r'i
bizarre behavior aE work is disgruntl-ed, leaving
his job and movj.ng to California.  She contends that :'
        had a conflictual relationship with this co-                               ''ts'''\'-\ *' '., -L"-,-+,.-r..
.)-3::                                                                                                                                          \   I v\r -]., ,": ttt        ' o-      w                                               J
pt- E Lr uu;;Lrurr
    Dcrcenr i nn nfur                                  Needs^ :
                                                       N€€dS i                                                                                                                                   'N ;.-' r-r
                                                                                                                                                                                                       -r                     \
                                                                                                                                                      .t
                                                                                                                                                             .
                                                                                                                                                             r   -': ,,:
                                                                                                                                                                 i\.,
                                                                                                                                                                      '-'.k  ' "-^- ''r'\" TY,;.A \ c\..\
                                                                                                                                                                                       .
PatienE staces she will "do whaE,ever vou tell                                                                              me here                   '- '-.,-.-                               r.rr r\r
and. whatever f need to get back to my- jq5'r
                                                                                                                                                       t': \-"r'l"r',   b*, Y-L-t-o..'                     -t|r'")
Pt's Goa]s for Treatment.^:                                                                                                                            ':'{ -'; t "            -r :;; .',:.
                                                                                                                               \ tr-                     J \ n-\         v'j' , i,\'\.                i ir I r''i.,. E
                                                                                                                                                                                                             Y)^ -
Return to work
Return to work                                                                                                                        \                          ^.  \. " '' \') .3 r-r'\. 1*-''' '\
Have attorney advocate that legal charges be oroppe\.                                                                                                    ';..;.-*) ' 'c ?t:'"r..,a i-'.\c'\-r'."i!L-.,.,g.!:,(.
                                                                                                                                                                                                        -,
-e able to clnvince her boss, that she is stable ---- -\..                                                                                                               i).           , ",:.,
                                                                                                                                                                                                                                            ,.,

                                                                                                                                                          .,.\i
  \.!.\(!.!(::r.\\':\Y'^\1<.\\.\--:.L'-.\\!..^.-t'*.''.\:-'\-,r---);,...:.r                                                                                                    "-.-.


rurL!srlJqLsu                         ItqdLl[srIL                     lrgt    KUf C a]t       !fL/ DU     .t,Id.IlIIII.t9           I ....._        . ,                    ...
                                                                                                                                                --                     :
t luvlt _L Y
FAMILY COMTACT
          I'AC'I     CON                                                                                                              .,_.,':-*- -'. - - ,
                                                                                                                                      .u
                                                                                                                                        .., .- '- -.                   ,: .,.
                                                                                                                                                                        -
CooRDTNATION OF CARE/OPP
                                                                                                                                                                                'l avri tr-,.,. -'
                                                                                                                                                                       .r.
                                                                                                                                                                       c\\(.,.-        \ - \':,



                                                                                                                                                                                            {-    t_,       !-
                                                                                                                                                                              ,u<\-.i            t,.. .,i'kt        i:i<-i'- :
                                                                                                                                                                                                                 \ "-,,1 .: 1!ic

                ram Init,ials                                        Name                                               Nurse
   MXS                        J. NIIR . MFS1 SANDTFORD,                              MARY                               SW
  -Age/sex: 33 F                                                  TAMS,LYNNAE            D (DIS       RCR)                                          P:aa.
   Un]-L #: J0000:-8L22                                                                                                         11 /1t
                                                                                                                                                    _ ..J-.           1


                                                                                                                                            //^o
                                                                                                                                               v/   qL        n -^r
                                                                                                                                                              v /u{
 Accourrt# : J84090218119                                            P-rh         Pi nh:rd   r                    Period endrng LL/L2/og at olot
  lmi   +-F6.1.
                                                     Dominion Hosprt.aI patient. Care                                ADMTNTSTRATIVE DATA SCREEN


                                                                  Administrative
 TEMPORARY LOCATTON

 HOLD TRAY: DATE                                  iNEfLL      KEL.E,AIJ,E;                       HT     fr
 CONDITION                                            VISTTORS AI,LOWED                          WT          lb                          Vn
                                                                                                                                         ,.:J
 CMT
 VI5Il' }<EASUN PHP
      Observat.ion patient.                 -
 DL r-n             Tm in
 Dt out             Tm out

                                                   Coded Allergies,/Adverse                    Reactions
   Name                                                            ('al   aaanr              Severicy Ver? Date
        Reaction                                                                                                             Time User

i$r-'si-t
   F"l rtnvol-    i na   ua   l
                                                                                                                    L0/30/09 ]240   HEB
        RASH

 Monogram fnitials                      Name                                        Nurse    TIT)e
  HEB              U .1\UK.       NEb   DHLI\,   LLLLI\EE   IH.                     RN
rl-ln                              1327
                                                                                                                                              Prl nted by
                                                       DISCHARGE Patients Medi cat-ion L.ist
                                                               I"1EDICATION RECONCI LIATION

                                                                       I^II LL IAMS ,   LYNNAE   D

        ATTENDING: Rorh,Richard      L                                                  78 ks
        'fLLERGIES: Fluoxerrne l-tCl (From prczac)                               60,                  134 l bs                                 i 840902 I 7483
        J     ADRs: **ll0 ADRS sNT[RtD***


                                                            'ications
           'la Hare Vo,1r.::r 'nc UULUI] qI - r
                                  inn -^-- LCU




3



    1




3



                    *** This is            list of your-
                   *** doctor's a complete)Prescrioiions med'lcations. Brirlg thls I jst to your next ***
                                appt.' (                  provldeo t0 pattgnt/guardian at discharge ***
                   *** ( )No presbr"iptions requirbd
                   iil Patient/Guardian Signatdre: _         ( )Presqijftrffis-cat teO rnio^ pnaltuii r.**
                                                   .         .i LT LLJ               Date: l.ll3f      ***                         il_
                                                                                                              I^JILLIAMS, LYNNAE D
                                                                                                      AC# .i8409021i.r83 ADt4 iN    i.222 g
                                                                                                      t'lR# J000018122 ADl',l 10/30/09 SCH
                                                                                                     Roth.Ricndrd L
                                                                                                     AGE 3       DOB J7l09//5 SIX        F

                       ************r.******* ThiS jS   a   permanent   part of the record.           PleaSe dO nOt diSCard.    *****************

                                                               @
RUN   DATE:    11,/1.   1i09                                           DOMINION HOSP ADI'4ISSiONS
RUN   TiilE:   1.21l                                           PARTIAL |IOSPITAL IZATION DISCHARGE LIST
RUN   USiR: J.    NUR. il'1i42




    WI LLIAMS . LYNNAE D                                                DOCT0R:   Roth.Richard    L




 Allergies: Fluoxerrne HCI (From Prozac)
          ADRS: ***N0 ADRs ENTERED*#




                                                                      Patient   Med'icat'ion   List
Medicat.ion                                                                            Dose                   Frequency              Route

 'k
    t'l   D




I   have reviewed the Medications          listed   above and understand       that this is                               to       be taken         after   Djscharge.

Pdtient/Fdmi lylGuardian          Signature:     --.,   tfia-vt:z- t-c"t 1'(p.'                                           (
                                                                                                                          ))   '' /7,^l
                                                  t"-                                                                               -
              Nurse     signatune: ,t,.';1 ..;1 ''/r:'r"'7t'',4!/,      4n,t                                                   !   .:.   ..   -.5


                i,rD    sisnature:                            fu6lt0.U^M0 0.r.. rtltlo
                                                               Copy   to Patient. 0riqrnal to         Chart
                      DotlrrNroN HOSPTTAL
1
,f
                   PH}.S iCIAN ADNIISS
                                       ION I\               TR    UCTION S HEET
                   .\DULT pARTI.*t, pnoCn               S
                                                                         _
                                                              I
                                                                                   _

                                                        r_l
                  (CIRCLE THE AI*S$,ER,
                                        i.ES OR NO)
             ir!             )J
               ?                     i,';Ii   :$l:: i.T::'":::l     i   ta   iizatio   n Pro sram
               Y'
              l'             rt,t
             DUAL DTAGNOSIS
                                              il*,Hi,THill
                                    )lt1':1ifJruT,T'-
                                    vr"r

                            EDUCATION GROUPS
                                                                  fii                                             ADrirrssroN)




) Y .;
            YN
                                    #ffi"'*'

          I certify ,n^,
                         jl1 services idenfified              ,partial
*h        decompensation                                as    hosoir
                                    and'"b'"q";;uomi.rion;;il:u,,|:1i1rfffl.fr:medicarrv
                                                                                                    necessary ro pre'enr
I                                                                                                                        turther


                                                                    T\r el U
                                                                    _!:_:__:_ ' k
                                                                  ehysi.'un-NiE                         _J;,n) .'it,)51 ,,
                                                                                                        ,
                                                                                                          -;-REa B""k- (RN Initiats)



                                                                                                        r
                                                                                                         ;i..-D
                                                                                                          Ime

         )'slclan Signaturi
                                                                                                      ;-'--!-
                                                                                                       r lma
    DH   :0- t;0,aJ)
             rl   r)_)
            , i /).   t)1)




)
                                                   ]
                                                  ./
                                                          eotrur   neru ,r FTRMLY j1
                                                                        1                                                                                  1,
                             ''t,nanzaton
                                                                                                                                                           1i4003              -1

                                            ts i'erebv qiven to.'/spense   he Senenc ?qu\alent unless otnerwse 'noic.trprl kv rhc            nkvste tan


       Dale i Time I Complete top portion                  with each Level of Care change. lndicate order with a Check ildark.

\                            LJ UUtpaltenI Hroceoure:                                                 lprocedurel for                                            tmedtcal reason
J
                        i tr     ptace in Outpatient Observation Services for
                                                                                                                                                                \medical reason)

                             n   eOmit as Inpatjent for                                                                                                         (nedical reasan:


      Physician Signature:


       Date      Time    Additionai Orders. (DateslTimes required)
     t,,a.?    ,z-.)         -f 0 , D- Rn1 / U4lrgZUl4 /,N€D
                                     fi - ,o'i (, >..:t^,-Lr- '?.o-+,- ,l-
                                            Ao.-',                                                                   ,,,.j^-{aLi,1.^,

                             -r;t/ - Tilt*, a^'t U/,"1d lL

       trf{or
                              {. rtft/$ ,no *tr(*Y-lrts-
                                  a- Cor^v F                                                                        (r,n      t < cot/t
                             )r*l
                -




    Allerqies & Sensitivities                 I   ivrcq



                                                                                                           ryJL"LIAH, LYNNAE                    D
                                                                                                           i;il;;"'hli,.n..l'1                "* r        rPA


                                                                                                           "
                                                                                                               ft   illiiltttiuriifirfifiiltil,-#   ;:::,::"'
                                                                                         DO }]OT \,!RITE
    Physician's Orders                                                                 {JFIJEFS UI.]LESS
                                                                                        irED # APPEARS
     DO}TINION HOSPITAL                                                                                                                           I.lILLIMS.
                                                                                                                                                  J84090217483 nor
                                                                                                                                                                               LYNNAE
                                                                                                                                                                                           tH
                                                                                                                                                                                                        D
                                                                                                                                                                                                         J.222'8
                                                                                                                                                  I0/30/09 Roth,RichardL -^^^^,^.^^
                                                                                                                                                                      vrrf
                                                                                                                                                      (lB 07/09/1976             Fr33                             JUUUUIdII4

                                                                                                                                                       ill   illffiXlilllililffilll[t      *'.'..                 Hospi'iar
]


                                                                     PA      RTL-\L HOSPTTAL TZAT ION PROG R\.}I
                                                                                   AD}IISSION SU}I}L{RY

     To be completed by attending physician at the time of discharge lrom inpatient lev'el of care to the
     partial hospitalization program                                                                     (t- t-"'i
                                                                             T u-*S \\'l'"jgr c;Yar\
                                                                                         *! iu^"' i\'-''ao\b:\\ 'J- -
     Current Diagnosis: Axis l.
                                                                             1g.u.'o'.
                                                                                                     I'q        s, J              ila5                                           v-t    :t-       -toi
                                                                                                                                                                                  d.\c,,r"-ri:'- r5 r&r\i \ -iu..r
                                                                                                                                                                                                                  \          -\\r.,r          \-P .a\ r'n
                                                                                                                                                                                                                                                                     ( ''*'
                                                          A.xis 2:
                                                          Axis 3:                                                                                                                    l-A c-.'*                    {. !; ,,1 --'b:r.u )                     1.1\1 '
                                                          .{xis 4:                                                                                                                   \ :, ' ',t. ! .^rr-* i c t, , -,'-1 ,31{
                                                          Axis 5:           GAF:                  (oO                                                                                 { .. c.5 ni5,1s -lr<' l;:\ dr.,:r
                                                                                                                                                                                                                 i'fl
                                                                                                                                                                                          -\ r-   ,:   *   ,i-          --   .i t


3                    ting         P              m (target sym                     oms and behav                                                                  vaie                  tuccr.Q'v{T
                                                                                (/.



     l[ental Status:


     Treatmentrlannirlg:                                            i.-.-rr.'>                                                                   ,'^',
                                        ^bi q\-,5r.*ssc.,\ '-'-t'^           \:-iL'1.5';-l.:{':.;-,rJ,,ln"ol,'-',ri",o
     Trcatment Problem Statement: The behavior/relationship difficulties, rvhich require change in order for the patient
     to function in a less restrictive setting, require that the patient                                                                wirt
                                                                                                                                         rr:                  t
                                                                                                                                                  5fun^l sla^tQ
     "i>i'                                                                 -i'r-ad-Y-''."-                    -}"r-.
                 'i-'a!1         "r. ,<\ -\v1.{ a\!a''                                              -'::1              F\oi\t.:              *.:r".,: lc^..1q i,r..'.                     }-',\'.-j              '-',. -)a-             -^.     !       \-{?41


     PHYSICTAIY TREAT}IENT PLANIYII{G                                                                       INTERvTNTIONS
                                                                                                                          ---T.:.,i* !                                                                 VI(.'1..-U\',-                   ar          1"_<     i ,   r-

.\
J
     Therapeu tic Interventions:                                                                                                        I uzalr-a(
                                                                                                                                                      i"i.:          U^        _ v:ijr
                                                                                                                                                                                                             ,, i
                                                                                                                                                                                        '-"i-     1          !r              s\i! uVru. :-,*l t                    !-.o-
                                                                                                                                                                                        I' s- ilp-




     Dischrrge Plan                                htut                           (l-\                        ff*
                                                                                                                                                                               (a- j(^o2
     ATTE         ].{D     ITG            P    HY'S       TCL{N                                                                                                   DATE:
                                                            ,:l       ilir. r\-.        Z-. -''r--
             \           tr           l   \c                      :,J\.}       ,J---s          ..--,r,.r.,1
                                                t:*I
                     - i'-.-                                                                                               -f      ...v:!-       : i\i               :.,...   ,,'\      1...,     ,          _                  .d      ,.r.__*
             ,J.:.             (-:,             -i-,.r\     \       s ,: v--.-.: i       r:)       d..,, ]_i.,._.,,-i            th?_         'or-(
                                                                                                                                                                                                                  ",.*\
                                                                                                                                                             _ .-.,,_ ,-        _-.!              c..               .._ -:.               --        .
                                                                                           )-1\-ifl\:-i1*\a                     *:'^>         (.='r:.-_r.\,                   ,,._..i
                                                                                                                       )                                                                        \v\o1\                       \,\:r\^,           vi:t
     Age,iSex: 33            F                                                                                       page: 1
   unit #: J0000L8L22                                                                                    d, LL/L2/09 ar, O7o1
 Account# : J84090218118                                      Roth,Richard L                 period ending LL/L2/og at O7OI
   \.ifri   iF6rl.                                    Dominion HosprE,al Pat,ienE, Care          ADMINISTRATI\iG DATA SCREEN


                                                             Administrative
 TEMPORARY LOCATION

 HOLD        TRAY:          DATE                                                   fr
 CONDTTION                                             VTSTTORS AI,LOWED      WT        1b                      kg
 CMT
 VISIT REASON PHP
 --- Observat,ion Patient ---
 Dt i-n           Tm in
 Dt out           Tm out

                                                    Coded   Allergies,/Adverse React, ions
          Name                                                  Caeegory     SeveriEy Ver? Date          Time User
            Reaction
j':-l.l
Jlergies
  F'l rtnvcl.        i na   I-Il-l
                                                                                               L0/30/09 L240   HEB
            RASH

   Monogram           Initials               Name

                      U . NUI(.      N,E.E   BLACK, ELIZABETH




 3
       Age/Sex:33 F                                   LTTi r r
                                                      ,,'J I!IJJ.IUq5,       IJYNNAE D (REG RCR)
        UniE #: J000018122                                                                                                                         D:aa.
                                                                                                                                                   -*Js.             T


      Account.# : JB4O9O21811B                              Roth, Ri_chard L
      AdmiEted:                                     Dominion Hospital patient                    Care   r$rr. r
                                                                                                        TITTNTA?
                                                                                                                   rA!             r
                                                                                                                         sAr..h1,y ASSESSMENT: ADU
                                                                                                                         ^iTFFI'




                                                   Coded   Allergies/Adverse Reactions
            Feant-    i an
                                                              fr: l- ann-. '
                                                                 v5vg:,vrj   Severity Ver?                      Datre           Time User
      AIJ-ergi-es
        F1uo-xecine HCI
                                                                                                                \0/30/oe 1240 HEB

                                                              PartlaL Safet                Assessmnt                            1.1   a4/og 1548          EMW

  what are vour                  soar;ri:;.i:",:ff:;.;ir;:i;"];u 'rAdequaEely address
                                                                                      cope with stregsr'   -.
  Any History                of A-buse or NeglecE:   N

  .{istory  of Aggressive,/Assaulcive Rch:vinr.                              rTana
                                                                             irerrs
           co Lethal ivreans: N
  }cess pLease
   rr yes         explain:
   Pati_ents SociaL Worker notifi-ed.: N
  Hist.ory of Suicide Attempts:                N

         s the patient have any thoughts
         s the pati_ent have any intent of of suicide:DENIES
                                            suicid.e: DENfES
      .\ s tkre patient have a plan for suicide:       DENIES
      J



 Does the patient have a history of self
 Head Bangttn'                             harm: N     Trapes of ser-f Harm Behaviors:
               T __ scratching/cutting: N Mani.pulating others to harm seLf: N
 Fire setting: N Hangi-ng: N oierd.osin!: N Burning:
   Jump in front of car, wi-ndow, metro: N             N self scrangulat.j_on:
                                               poison: N ser.f eiiirrg, N other: N
 Q:iggers: NA                                                                    N
 Ji
 LeweI of fmpulsiviry:                   Low
       Admission history,/srrmptoms ind.icate potential
                                                        for serf -harm:                                    N

 "".::#::="::.:::,':5 ;:::i.:: :;1i"5'r"::ru:i!:r;{::ii':i"ri;:;i,;":,,ri;,::ir,.:;,";l\':
                                                                                              Currently Employed/School                      1..(!.!\::
                                                                                              positive Actitude
                                                                                              Social Supports
Freni n j r.ri -- f actors:rf appli-cable _ ,
rrsu-LPr'Ldtrr-ng -r.-,- nrq. rF rn*..r .i ^_Li ^                                             Ability   Reality          Test
of loss of contr:ol or acting out behavior? the pt iaettriiy-Js tn" cause
                                                  what does
; FOLLOWING My CAR, ACCIDENT ON oCT 27,     "rvry JoB's coNcERiI AFTER THE AccrDErrr                                                   REpoRT
                                        ZOA|,

Techniques used to help patient control
                                                  behavior: ,'r HAVE BEEN rN coNTRot
                OF MY MOOD, NOT OUT OF CONTROL. EXCEPT
                                                                  WHEN DTSORIENTED FEW DAYS AFTER
                  -v''{ r} ''|q('- *'"''=                                                                ACC. ),-.,
 )                                        ,..i,;:\ia*$*rrr*.o";;t;"i;: ,.,1,n,*....,.,,.. .-!:i.-..- "^- ^"'
      ^
      Ori ortozl
      vrlsrrLsu      r^ ,clnit.:
                     uu              y                                                                       l,'','
                                                                                                                                      '^r::-*r                ,.r,
        Appearance; I'EIJL GRooM : PT ADMTTTED                                                                                                            {
Additional comments: sHE ooAS DT'.RTENTED AFTERTo ADULT pARTrAr pRosRAM ToDAy.
                                                HER cAR
                                                                                                                                 srATEs                   i"_,
                                                                       A..TDENT FoR A FEw DAys BUT
                             :   LOSS OF CONTROL OF MOOD OR BEHAVTOR
                                                                     RECENTLY. HAS AN TNTERVIEW;;
                                                                                                                                        DENTES i.,.
                                                                                                                                        ;;ffi"- , ,I            ':
       Age,/Sex: 33 F                                                                                                                                                D:na.          )

        UniE #: J000018122
  AccounE#               :   J84090218118                               a^fh         I   1 nhard   I



  Admicted:                                             Dominion Hospit.al PaE.i.ent Care

                                                           Psychosocial Assessment                                ^ts1                          L7/04/09 1533                 MXS



  uescr:.De ram].J-v uu tix                  :




  Patient Psych/CD Treatment Hx:                           Y

 Describe Treatment Hx^:
 Oucpatient treaementr aE. Georgetown Univ Counseling
 Center for depression, auiety, sl"ep distrt.l'.rc€        '-\--r<      .t.: , y.,
 in 2005. Overnight in DH &-10/30/09 and E.hen               r.(l_ _...-*,"..,'.   ' r\'r..-,.\ \                                                                         .

 AlvlA discharge. i \.r,.., +-\i \>_. L>i. V,--;.. a\r-* -i.r,{_ :.;,:,
 Addirional suicide ?l';;-;i);.J[':r;i;:i                                      ;*l
                                                   Y.;;i;l:,l_:"i:","_:.:,.;.1.,..'l:..
                                                                                                                                                           ,'l.l'.'..-.
                                                                                                                                                           '
                                                                                                                                                                                    c'



  kl::i"l1Yl:1""" Risk Factors:
                                                                                                                ----trlj,"''-, +-''-'\;                        \i.'l'i:,;,:lr
 r€Erent denLes                                                                                                 -r'j     k                      "--,':
                                                                                                                                                '-.:)\.,,)-.
                                                                                                                                                                 t.--.:
                               Marital Status:         SingJ-e
                         Sexual Orient.ation:

 # of Marriages: 0           How Long/ Current:                                 0

  \ V Lonq Prev:-orrs Marri aocs^.


Number             of ChiLdren: 0                               Aq.",      0


                         Living Arrangement:          Own Place

Nqeds             Alt Living Arrangement:              N
  J
   ?
              Social Support Network:                 Good

                   Support Person(s) : Family
                                       Friends
              Treacment Parcicipants: Patient's parents
                                                      who      are in town
Support Comments^:                                                                                     _   L,                    i-\f
rrMlr naronF                       irer.,arrse   mv cnrrgin
  "z                                                             in   Ba]_timOfg
calIed t.hem. Mv cousin took me to t,he ER aE                                                              1.
Georqetown two i^.r= ofi-er mrr :ceidentr because ..I did                                                                        -^.   i-   !
not receive any medical treaLment . I was jusL taken
by the police and put :-n a celL, finger printed..
and then charged wiEh leaving the scene of an                                                                            rl,-.
rnni        dan   F ll



                  Describe Tlpical Day: Wake at 7.0 am
                                        Work by 8.30 - 5.30
       \j                               Evening - outdoor running
                                        or work out in gym
                                        Dinner alone or wi.th
                                                     a friend
                                             Bed 11.0                 pm
                         Uobbies/Incerests : Exercise
                                                                      I




                            AUTHORIZATION FOR RELf,ASE OF PROTECTED Hf,ALTH NFOR}IATION

                                                                 i;i-i                                                           Date ) l 't I i ''r -l rt
                                      l

       patient's n3mg. .-               I ir                                qr-',^';                                     Birth
                         Ytrn(^t-
       Social Secunt', Number:
                               (-rOl C''-7 lirZ                                                                          Phone      Number: 7        02 - E77 -i:'l f                    I
       Date(s) of Sen rce

       I authorize:
                                                                to release or disclose the follotving information to:
             .                ^,-           i          1r
             r^t't c.^ e'
             L-r--{
                           L'--: i I 1 t rlnrr .:'
       \ame df pcrson. phr srcian or agenc\ to receile informatlon
          -7
            -- I St                               A   ,;'+ / I ), -,               \    'I,   .,\.,   1.,,   ,+C,r            DC                          Z':r3 a         3
       Srrect Address                                                                   Cir.n                                   State                       Zrp Code

       Informrrtion to be Released Dirlosed:
             fl       Admission Histor.v                                         o       lfedication Rccords                               tP    Psrchological Eraluation
               d      Discharge Summar.v                                        F        Nursing       .A,sscssment                        e     Ps1-cho-Educational Reports
              rq      History & Physical                                        .q      Nursing Progress Notes                             q     Phlsician hogress Notes
                o     Operati+e RePort                                           tr     Transfer Forms                                     o     fvledical Abstract
               q      Consultation                                              .'E.l   Psr chosocial Asscssment                           a     Itemized BiltLlB-92
              ;t      Phvsician Orders                                           o      Emergencl Room Record                              f    Other
               c      Labs,EKG's X-ravs

         Purpose:
             tr Nledical Follorv-up                                             .Y      Individual Use                                     a    Insuance
             o Attomey                                                          o       Disability                                         B    Other

         Patient adyised            ofcharges:                    {       Yes                                 oNo                               O    N,A
         O I prefer           to pick up records                            o I wisb to review                records (by appointment only)                       a       Please mail
 I acknowledge. and hereby consent to_suct\ that the released information may contain alcohol. drug abuse. psl chiatric,                                              HI!'testing. HIV
 results or AIDS idormation.                       (Ioitial)
 I rrnderstand that:
 l     I ma1 refi:se to srgn this ruthonzation and that it is stnctly voluntcry
 3     \fy lreolment, palment. enrollment cr eligrbrliry for benetits mav not be conditioned on srgning thrs authorization.
 I     I mov rerokc this authonzation at rnl tlme rn r,vnting, but if I do, it rrill not hale unl affect on an\ tctlons taken prior                              tc
         recet!lng the revocalion. Further Jetcils mu1'be lbund in the Notice ot'Pnrac_v Practices
 'I    ,lf the rcquester {ir rccei!er is not.r health plan or heclth cure pro\rdcr. lhe ruleased rnlbrmution ma-\ no lu.nger
                                                                                                                             be prctectcd                                 br ledtjrlrl
         pn\3c! rcguhtrcns and mav be rudrsclosed.
j      I rrnJerstrnd th"t I mav sec,rnd cbturn a copl the rntbrmltr,ln descnbcd,rn thrs form, for I rc;.rstrnable ctrpt tee

i hr"e   rertd llte.rbt:,.u lnJ.r,rthonze the Jrsclosure of the prtJtec!eJ heulth tnll-.rr:rJtl,rn Js st!tL,d



                                                                                                                                          ll crprrc 5 m,tnths tff<r:atc


\l!r.Jf ,rc .j; ll.lt:nr_         lrir.rn
                            (_;
                                                rf lppilcabic                                                               R.clJ   ltinshlF tc Fstldnt
       2q6O SLEEP}                 HOLLOI\ ROAD:                      F   \LLS CHT RCH                                PHOf E: '0J-5J6-2000 F.{-X; -0J-5J5-6IJ!
       r.UJT-' AL -5L

C rmpleted br
                                                                                                                            Dare
DOMINION HOSPITAL            WiLLIAI''IS, LYNNAE D                               11
                             J84090217483 ron rH J.zzz.B
                             10/30/09 Roth.Richard       L
                             D0B 07 /09t1976   F          /33 l'1R# J000018122
 Admission Medical History
 and Physical Examination      illlil,llllllllillllililillllfr o*'"'"" Hosp*al
       Age,/Sex:33 F           I                                                                   D (REG RCR)        I               D:aa.
                                                                                                                                      r s:Je   .   1

        Unit #: J000018122                                                  ''IILLIAMS,LYNNAE
      Accountr# : J84090218118                                                       pof h. Ri r:harci L
      Admitted:                                                           Dominion Hospital Pat.ient Care        PSYCHOSOC   IAL   ASSESSMENT


                                                                           Ps   chosocial Assessment     -s Ed            LL/04/09 1533    MXS

      Reason For Admlssion-:
      Pat.ient ',vas admitted to DH on L0/30/09 and lefL AMA on
      lo/3L/09. In days,/weeks prior Eo admission patient
      iead reporcecily been behaving in a bizarre way aE work
       (State Depc) and was then in a road eraffic accident
      wh:-ch she is reported to have deliberately caused.
      Tociay patient, presencs stating t.haE ehe is noE sure
      '.rl"rrr qhp hac hccn aCimitted
       ""f                                                          tO PHP exceDt       lthat   the
      SEate DepartmenE has ordered thig,,.
  Does Pati-ent MeeE Cri-teria for Current. Level of Care: y
                                    Supervisor fnformed:
  D-irrr,,         T.:F-!,3^e:             ENGLISH                       ENGLTSH

:.Fcia1/Cultural/Educational fnf luences^,
 il


€abienc is one of two sibs born to mid.dle cLass
 parents, raised in suburb of At.lanta, atEended
 .Sncl Im:n            f-nl I cce         for     rrnjeroraj
                                                          Yras,
                                                                           nrncrcq<cj
                                                                           y!vY!s--Eq      Fn
                                                                                           uu
 grad school ac GeorgeEown SFS, was chen employed by
 DOD, sent co Iraq for four monchs (20O-/) , returned
 Eo DOD where she reports having exceeded work
 performance expecEations, E.hen mowed Co Stace DepE,
  ' March 09. Patienc
                                has supportive parents (
        .i rori odr:-:-^rs) patient ]iveS qrurre rrt qHu rr DC
                *-*:*"                      :lnne in :nl- in
  '. {:"    --
 -,r[d currently works for StaEe DepE as an ana]-yst.




Er
itl|- -FAl\lILY HTSTORY----
                 r-amiiy Psycie i{x: y
       Family Psych Relationship: Aunt

Describe Family Psych Hx^:
Schizophrenia in maternal aunf.


               k tmr     I \r   Hv
                                     ^l         Suicide:             N

trami l v Srr i ci de Pal:t-                    i nnchi n       .




Descrj-be Family Hx of Suici.de^:


 j                              Fami       lv CD Hx:                 N

          b   amr-ry uu Relatlonsnlp                        :
   Age/5ex:             JJ    t'
      UniE #: J0000l-8]-22
 Account# : J84090218118
 AdmieEed:                                                                 Dominion Hospital Patient Care       rD r ur.].rJD\JL l_ft!     ftJ Jtis   JlYl.ll_L\   I



                                                                            PsychosociaL Assessment. -std                j-L   /   04,/   09   r_533    MXS


 llcqr-rl     nr      ! eml t1' uu HX               i




 Pati-ent Psych/CD Treatment Hx:                                           Y

Describe Treatment. Hx^                             :

OuEpat.ient treaCment, at GeorgeEown Univ Counseling
Center for depression, anxiety, sleep disturbance
in 2006. Overnight in DH on LO/30/09 and t.hen
AI4A di scharge .

Additional Suicide Risk Elements: Hx of riskv behavior
--pni-.ia"l /Violence Risk Factors                                         :
rtScient denies
                              Marital- Status: Single
                     Sexual- Ori-entat.ion                    :




            Ma rri    acleq        .   O                HOW       uv..3t


        T.ana        Drarri   nrrc         M:rri.-oo^




Number of Children:                           0                                 Ages:      0

                     Living Arrangement: Own Place
Needs AIc Livincr Arr,anoemPnl-'
   --                                                                 N
 ih
 'g         Social Support Network:                                Good

                      Support Person(s) : FamiIy
                                    Friends
            TreaLment Participants: Patienc's parents
                                                                   who         are in town
Support. Comments^:
"My parenLs came because my cousin in Baltimore
called them. My cousin took me to Ehe ER at.
GeorgeEown trwo days, after my, accideni because . . I did
not receive any medical treatment . . I was just taken
by the police and put in a ce1l, finger printed..
and E.hen charged with Leaving the scene of an
accidenE        "

              Describe Typical Day: Wake at 7.0 am
                                    Work by 8.30 - 5.30
                                                                  E'rrani na
                                                                  ! v srrrrr:,    -    nrrFAn^-
                                                                                       vu Lsvv!   -rrnni   na
                                                                  or work out in gym
 "J                                                               Dinner aLone or with
                                                                  a friend
                                                                  Bed 11..0           pm
                     Hobbies/Interests : Exercise
 AgelSex:33 F
  Unit #: J0000L8L22
Account# : J84090218118                          Roth, Richard L
Admiteed:                               Dominj-on Hospital Patient Care     TNITIAL   SAFETY ASSESSMENT:

t-
I                                        adult partj-a1 Safety Assessmnts                 1:-/04/og 1s4g   EMw

                      :    TODAY; VERY ELEGANTLy AND NEATLY DRESSED   IN   BUSTNESS SUTT. DENfES   ST/ttt/SIB
                      :    GIVES SL=10
                      :

                      :

                      :


     Mono   ram Initials                                Nurse

         EMW    J.NUR.EMW2     WITTING, ELIZABETH      RN
         HEB    J.NUR.HEB      BLACK, ELIZABETH        RN




3



     )




3




     1
    Age,/Sex: 3 3                   F                                                                                                P:no.   ?
   Unit #;                   J000018122
 AccounE# :                  J840902L8118                                                          Roth, Richard L
 Admitted:                                                                          Dominion HospiCal Patient Care   PSYCHOSOCTAL ASSESSMENT


                                                                                     Psvchosocial Assessment              L7/04/A9


           Religion: CHR                                          CIIRISTIAN
                     Qni ri         l-rr:    l   Drarl'      i nac.             /-]rrrrnlr



 Pt Believes                    in Higher Power:                                Y
 I)ocnri      l-ra     t{i afrar             Dnr^rar^



                Last Grade Completed: Graduate degree
                Degrees,/Certificates : Masters in Foreigm Relati

 'h
  p                            Currenc Student.:
                                                          Where:
                                                                               N


f-l-r:nao      i n       School- Performance:
Describe Change In School Performance^:


       Problems with Behavior at School:
      .r                                                                   Truancy:
"g
Learning Problems,/Special Education: N
Describe Learninq,/Behavj_oral problems^ :


                                                                               - - - -EMPLOYIVIENT HISTORY----
                     f-1 t   rran     l- I rr    E'mn I n"-.1          .
                                                                           Y
i ,".;9               pt OccupaEion: Analyst
 .F
  -            T]-me at Current Job: J q \/P: rq
                   Job Sati-sfacti_on:
           Longest Time at One Job: 4 q \/cara
              F'remrcnF                  .Tah        f-l-r:naac        .   AT

Reason for Job Chanqes^:


    Unemployed in LasE Year:                                               N
Reason for Unemployment^ :


                      Pa     rFn     r rn: r i on :
                                            Or-r'r
                     Snorrse         cr:n:t. i 1n;
                                            Oe
                             FinanciaL Needs: nenicq                                         :nv   qfrrgggfs
                                                                           Denies debt.s
                                                                           Denies compulsive spendin
J                                                                          States she manages
                                                                           money rrvery well and
                                                                           f have good savings"
                                      Mi 'l i t-arrr         IJv.          N
                                            Branch (es)            :
 Age/\'e'<: JJ r.       I                                                       WILLIAIVIS,LYNNAE   D (REG RCR)         I
                                                                                                                                         D:ao.        A

  UniE #: J000018722
Account# : J84090218118                                                               Roth,Richard L
AdmiEted:                                                                     Domj.nionHospital Pat,ient Care      PSYCHOSOCIAI, ASSESSMENT


                                                                               Psychosocial Assessment      -std            trla4log   1s33   r.{xs


                                      # of Years:
                   Mi I i F:r1r               Pacarlra.
                           F)   i q ah:     rna      'frma
                                                      .I EV
                                                                   .
                                                                   '



                                                     Year:
u].scnarge K/ l Substance Abuse:
t ll c^nar-6     p /   t        Dcrrah       l-nndirian.




 ,b
'g
                                     ----ARREST HISTORY----
Arrest  or Pending Litigation/Civil-      Charges Hx: Y
           Number of ArresEs: 1
           Reason for Arrest: leaving scen€, oI accloenE
 Arrests Involving Violence: N
                                            r'\TTT
                                            vvLI     /nT^tr , ht
                                                      utrL.

                                                     When:
B9             Public f ntoxi-cation:                                   N
                                                     When:
                                Probatlon Hx:                          N
                                          WhY,/When:
                                      Parol-e Hx:                      N
                                          wnyl wnen:

      cribe Pending Lit.igacion/Civil Charges^
       above note re. recent charges.
      ient has retained an attorney


                                                                       ----CAFFEINE HISTORY----
                   Pt Use Caffei-ne                           .!



                i"rmaq           aF       Ca ffoi       no    : Coffee

                                 Aml-      nar       f)rrr.            1 -)




;
  Age/Sex:33 F                                                                                                     D:ao.     q

   Unit #: J000018122
 Accoun!#: J84090218118                                                  Roth,Richard L
 AdmieCed:                                                       Dominion Hospital Patient Care   PSYCHOSOCIAI ASSESSME}Tf


                                                                  ?sychosocial AssessmenE -sEd         LLlA4l09 1s33   MXS



                                                             ----NICOTINE    HTSTORY--   --
                           Nlcotine Hx:                      N

                    Kind of E.obacco:
                      Age First             Used:
                Drclrq /tin<
                         r*^'-     nar
                                   r--         rl
                                               -3Y:

                      How many years:
                  'Anw
                   -'r  Cnnscmrpn.es:

                                            .)rli   l-   .

                                            When:

 ,p


 Does Patient Drink Alcoholic Beverages: y
             Trrpe of Alcohol: WINE
                    HowOften:1 - 2 times/month
                     How Long: 10 years
 ,g                  How Much: glass
                        Last Drink:
                   Tlpe of Alcohol:
                             How Often:
                              How Long:
                              How Much:
                           Last Drink:
                   Type of Alcohol:
                         How Often:
                                 How Long:
                                 How Much:
                       Last Drink:
         Alcohol Comment^:
         Patient denies any abuse of alcohol and states                             she
         seldom drinkg
Pt Believes ETOH Use a Problem:
   Negative Effects on Life:
Medical ProbLems from                CD Use:

                 Longest Sobriety:
                                      When:
            Sober Support          SysLem:
                                         Who:
                                    aa,/UA:
                       Last Contact:
     t                           qn^ic^r.
 J
                       Last Contact:
ETOH      Sobriety/Support,/Treat,ment                           Comments^
None
   Age,/Se-x: 33 F                                                                                                         D:no '      e
    Unit #: J0000L8L22
  Accounc# : J84090218118                                                    Roth, Richard L
  AdmiEEed:                                                          Dominion Hospiral PaE ient, Care      PSYCHOSOCIAI, ASSESSMENT


                                                                             hosocial Assessment   -st.d        71,/04/09 1533   MXS




 AddiEional Druqs or Chemical Use:                                       N
                Ty;>e of Drug:
                               How Often:
                           How Long Used:
                                How Much:
                               Last Used:
                               Tlpe of Drug:
                                How Often:
                           Hovl Long Used:
                                 How Much:
                                Last Used:
                               Tlpe of Drug:
 ,p                          How Often:
                      How Long Used:
                              How Much:
                             Last Used:
 flrr rn   use    Lommenr: :



      Re'l i errcq    f)rrra     ITca        :    Drnl-rl      o-.
 -/meqative           Effects               on Life:
Medical Problems from CD Use:
                     T,-roPql-        Qnhri            eFrr.
                                                  When:
            qnirar      errnnarr        c"Siem:
                        suuHv!        e u)/
                                                       Who:
                                                 AA/NA:
                               Last         ConE.act:
                                ann
                                -Y_nsor:
                           Last Contact.:
CD Sobriety/Support/Treatment Comments                                         ^   ;

Fatient denies any CD recenc or past



                                                                      ----ABUSE HTSTORY----
i trmnr i on: I      Dhrr< i n: I       ,
                                             lToal anF
                                             rr9Y4u9l          /     SexuaL) Abuse: N
                                   Physical:
Descri-be Physical Abuse^                          :




                                 Emotional
  jcrTbe EmoEional                 Abuse^               :




                                            Sexua]:
Describe Sexual Abuse^                       :
        Age/Sex: JJ I
         Unir #: J000018122                         WILLIAIv1S,LyNNAE   D   (REG RCR)
                                                                                                                      Page:    1
       Account#: J84090218118                              Roth, Richard L
       AdmieEed:                                  Dominj_on Hospital patient Care          pqvalJncn-7
                                                                                           - v !..vevurf,!       r ASSESSMENT
                                                                                              -              ^


                                                      hgsocial. Assessment         -ct-A            77/04/oe 1s33        MXS



                                 Neglect
      Describe Neglect^:



      Patient Has Hx of Abuse Eo Others:              N
      Describe Hx of Abuse Eo Others ^;


              I{as CPS/ApS Report Made       iT
     Des cribe      CpS/ApS Report^:
     p
     Describe CpS/ApS Involvement^:



           rse Comments^,
     .,9


     sLabiJ_iry of      Home Envi_ronmenr  : ;;;:1ff-crHs/wEAKNEssEs----
                       ivlotivati-on for Tx: Weakness i.
       e i ^l-'r   rnEo Current probl-ems:    Weakness
          t Regarding Current problems:
 Weakness
 StabiliEy and Support of Employmenr:
 Strength
 Function of Marriage/Family System:
 Strength
 Support SysEem in and Beyond. FamiIy:
 SErengEh

                   Education AtEainment : Strength
          fntel]ectual Ski11s: St-rencrh
Range of Leisure Act.ivities^;
Mostly exercise
T.'ne of Recent Leisure ActiviEies^:
    ring, workj.ng out in gym
 j
i{hat. Do you Do When Bored/Lonely^:
Go running on Ehe ma1l
                                                                                                                            D:no.        A
 age/Sex: 33 F
  uniL #: J0000181-22
Accounc# : J84090218118                                  Dnrh    Di nl-r:rd   L
a.lmi   t.   t ed   :                            Dominion Hospicaf Pat ient Care                 I15 I UITUbU\-.LA.L   /+JDEJ JI'II1I\   T




                                                     chosocial Assessment             ^Fl                L1/A4l09 1533           MXS



Does Your l^Iork Schedule f nEerf ere WiEh Your Leisure Activities:                         N
    Do You Belong to Any social Groups'/communiEy organizaEions:                            tt



ImprovemenE Needed                in ANf of che following areas:
PatienE denies



Pt Perr-enf i on of Illness            ^    :

PaEienb is bewildered as Eo why she is here.
Patient stat.es that her co-worker who reported her
bizarre behavior at work is disgruntrled, leaving
his job and moving Eo CaLifornj-a. She contends EhaE
..fu has had a conflictual relaEionship wich this co-
,$it"..
Pt Percepcion of Needs^:
PatienE states she wilL "do whatever you tell me here
and whatrever I need to get. back to my job"
Pt's Goals for Treatment^:
Return to work
Have attorney advocate thaE legal charges be dropped
    able to convince her boss that she is stable
 'nd
;fnmuniEy Resources Current/Neecied                  :

Unable to assess
Anticipated                Treatment Mgr Role in TX/DC Planning:
FAMILY         CO\]:TACT
COORD]NATION OF CARE/OPP
DISCI{ARGE PI,ANNING
REFERRAL TO COMM. RESOURC
 ;b,
rS
 "t                     Goal-s of TreatmenE: STABILIZE    MOOD
                                                IMPROVE COPTNG SKTLLS


 Mnnooram Tni r i aLs                Name                            Nurse    Tlape

     MXS                J,NUR.MFS1   SANDIFORD, MARY                 SW




 )
                      DO}IINION HOSPITAL                                                                                                                D
                                                                                                              i4bbJAHd,LI#rYfE
                                                                                                              ru/ Ju/og pntr o;^e- ' .                   J.222-B

                     Physician' Admission Instruction                                                         -,liffrltttiti,ltlfiffitilil/fi
                                                      Sheet
         )           Adult Seryices (Inpatient)                                                                                                 ,",-,ji;::::':'"
                                   THE ANSWER, YES OR NO)
                      e     N
                            N
                      "4,*aa,g        ADMIT Trl 'rrrc ADULi LNIT
                                      A DMrr TO THE A h, ,,
                                                                -
                                N     RECULAR DIET (SPECrFtOrunn,
                                1\-
                                 N    MFnIcar Lrrc'.r^na/ ^ r
                                      MEDTCAL HTSTORY AND                                      prrvsic-ffi
                              O)      PATIENT MAY SMoKE:
                                      Rationale:
                                              Poly-Drug Withdrawal Treatment
                                                                               Complications
                                              E.racerbates psychiatric Symptoms
                                             Deviates Focus of Inpatient Treatment
                                                                                                             Goals

                P
                     UAPryGNOSIS.                     S ERVICES:
                    Y                            DUAL DIAGNOSIS EDUCATION
                          ry                                              GROLIPS
    3           PRECAUTIoNS: ALL APPLY
                             LOCKED LINIT
                                                                                              YES OR NO
                             15 MINUTE CHECKS
                             B E LONGINGS/CLOTHES
                                                                                S   EARCH
                             SHARPS RESTRICTIONS

               LABSi.l
              Y
    )
              Y IINI
                  r.rl
                                           CBC rvith differential
                                          CMP (fasting)
              Y lt"l                      TSH
              Y         / rul             {PID PANEL (fasting)
              Y         I r.rl            LI-RINE DRUG SCREEN
              Y
3
              YV        lNi               SERUM BETA HCG (rvomen of
                                          OTHER:
                                                           ___v \!yvrrrsu ur childt
                                                                             unloDeanng potential)

              OTHER:




           I certify that Inpatient psychiatric
                                                services are medicalry necessary
                                                                                 to prevent turther decompensation.



          I   dlcpnone Order Received
                                      bv:                                                  Physician Narne                                      'fime
         (RN Si*unature)                                                                                     Date
                                                                                                                                                                        Read Back
                                                                                                                                                                        {RN Initials)

         franscribcd gy,
                                                                                                              ii)i i'r)u'l
                                                                                                              i ',     I

                                      IRN S,g";ur")

                                                                                       W                     Date                               -
                                                                                                                                                'f ime
I
I
                                                                                                                 ,lt
        Ph-vsician Signature
                                                                                                               Io          ljloe                   Sf,nt           {t   *
                                                                                                             Date                               Time
        l)l/-:()j   1.1,t),1) 7g,,, lt)   r)-j   r,,v \:,07 tev lt),Q7   |py,   111,11r1
    f                                                                                              )        potNT     pEN          \       FtRMLy       .i                                   \     _
                                                                  )uthorizaion        is                                                                                                           T4o03
                                                                                           nere[y givento drspense tne qenJic
                                                                                                                              equivarent unress otnerwii iraicated                           ]
                                                                                                                                                                   by the     physi"i"n.
                                     Date r           Time


                                                                                                                                                                                                        i,neotcal reasc
                                                                  ,' 'qu€ r \Juluauenl
                                                                  I I Pleno ;nr f'\,,i^-+;^-+               /
                                                                                                            Obsenration Services for
                                                                                                                                                                                                       \medtcal reasar
                                                                i I   ROmit as Inpatient for
                                                                                                                                                                                                       \rnedicat reasa,
                                 Physician Signature:


                                                  Time          Additional Orders: (DatestTimes requireo)
                                                                  ,Lr
                                                                  /L'   t(>c nd                              ,l.t-t   f f t fo .,4-,/rcc, T (                1",r"'&     tfl Lrt z {c.lL
                                                                                                                              ,1 /(9_i(i_
                                                                                                                            -/ :,//r,f1 ! ctz E                      /-
                                                                         ':l//
                                                                                                                                                                                I          -1 "\       ,/
                                                                                                                                                                     r-))
                                                                                                                                                                                         lw /,)
                                                                        e:- t /-)*
                                                                         2-- ,'/35
                                                                          t-      '        :   I    J   '              '/**7g+
                                                                                                                    7'c-
                                                                                                                                                                                                   v



                                                                                                                      be   t!'{a

                                         fl
                                 lo     lttlog                        hsr6.oyfrrer"
                                                                      O[lain c"( (y,t-u( p PttO d4aatta
                             I




   )l                    I
                                                                                                                                        i t:l
                         I
                                                                                                                                           {


                     j


                     I


                     I


                 i

\t?!tl           I




             I



         I
         I


         i




             Allergies & Sensitivitiei                                           [-r ruxn



                                                                        ,'l 5                  'i
                                          iHeiqht
                                          |              , tt
                                 l        It(/
                                 7        L-,
                                                 ')     !
                                                                                                                                   ri
                                                                       "-1i D,5.1,;li                             ry           '/ i t f-;.O
                                                                                                                                 t<-'(- )         1,,,,-
                                                                                                                                                                   ,)
                                                                                                                                                                        .rf         /r
   Physician,s Orders
   I.1003 Rev                    4/00   IRC# 091404j)
                                                                                                                           ,
                                                                                                                                 DO I]OT WFIIE
                                                                                                                               I]RDERS UNLESS                                       I            ' '-J
                                                                                                                                RED # APPEARS
                                                                                                                                                                              /Cttv              '--{ L}
     Age,/Sex: 33                  F                           WIL,IAMS, LYNNAE
      Unit #:              .T000 Oi-8722
                                                                                  D   (DIS JNI
                                                                                                                                   D:aa.   1


    Account#:              JB4O9O2].7483                          Roth, Ri_chard L
                                                                                                           Prinred Lt/02/0s
Admrtt.ed         :        L0 / 3o / Og ac t15     I     Dominj-on Hosprt.al pat.ient Care
                                                                                                     Period ending a!/02/og
                                                                                                        ADMINISTRATIIE      DATA


                                                                 -\drlinrstrative     Daca
TEMPORA.RY LOCATION

HOLD      TRAY:               DATE                     MEAI,     RELEASE
CONDTTTON
                                                         VTSTTORS ATLOWED             .'.IT 134 lb    B in L72.'72 cm
CMT                                                                                                   0.02 az 60.782 kg
VTSIT REASON IP DEKVIU.trs;
- - - Observat.ion Patient
Dt in
Dt out

     Name
                                                       Coded   Allergies/Adverse Reactions
                                                                   Category         SeveriE,y Ver? Dar.e
       Feraf      i
                      ^-                                                                                       Ti.me User

}"tsi."
    Fluoxetine                HCl
      RASH                                                                                            L0/30/09 1240   HEE

Mo        r:m
          +qrrr       TFi     tl
                      rfr!uI4l5    -r   -   Name                           Nurse
    HEB               T   lTt1n
                      u . NUK. r'F*
                                i:l-Ull     BLACK, ELTZABETH               RN




3
  J-A
  - -Jv/
                      qAV.
                    / uvrt             < <   ts                                                                                                                               D:aa   '   1


        Unic #:                    J000018122
AccounL#      :                    J840902L1 483                                                              a    tn   w 1 -nzrd

Admicted1. La/30/09 at. 1158                                                                          Domi-nion   Hospital Pacienc      Care               PSYCHOSOCIAL ASSESSI'{ENT

        lr
| -tl
  -                                                                                                    PSyCnOSOCLaI ASSeSSmenE           -SE(l                  LU/ 5L/   Uv Uv4U AXZ        I




R.eason For Ad.mission^                                                :

Pt rs psychotrc.


Does PaEient Meet Criteria                                                               for Current Level of Care:                 Y
                                                                                               Supervi.sor Informed:
Primarv Lanquaqe: ENGLISH                                                                        ENGLfSH

Socialz'CuIEurai/Educat.ionaI Inf l-uences^'
Pt works rn the State Department. She gratuatred from
GTU from the School of Forei-gn Services. She was in a
aer aaai.len; Io/)1 ioq ehc renorl- pd l-rl nolice that she
                                                   |   4   t /   vJ.        s..e         reyv!

wanEed to know what it would fee] fike to be in a car                                                                                      1"    t',   -
-ar-ident- . T,ef 6+r she did not resal-} saying Ehat. Pt
 Jsuspicicus,      talking to herself, and is exhibiting
anxietw. Pt cienies A/V hal lucinations.




                                       HlSTORY----
                                                     Hx:
                                        Familv Psvch ""
                                               ''r-"                                             Y

        trami I w Psvch Rel:t- i onsh in'
        !   q'.,f       !   1
                                                                                                 MA ATINT C SCHIZOPHRENIA


T-]acari               l-ra      E-:mi I rr Pqruch                         Hx^:


                    ABOVE


                            Famj-112              Hx of Suj-cide:                                N


Fami-Iy Suicide                                    Relat.ionshi-p:                               N/A


fieqe ri he Fam-i Iv Hx of Suicide^:
|r/A

                                                   !   ama       Iy LU             H.X   :       1\


                     :':m.i
                     - dlLlai'
                                 lrr     r,-I't pal:ri^--hjn.
                                                           rUlI-lIIP.
                                                                                                 ]\T/A
                                                                                                 IY/ n




Doqerrbe                         Familv                CD Hx^:

    I


Pat i enL Psych,/CD                                        Treatment Hx:                              N

Describe Treatment Hx^:
      Age/Sex: 33 F                                                                                                           Drno.
                                                                                                                               qJv.      1
       Unit. #: Jo0oo1-aL22                                                                                                   ^


     Account# : J84090218118                                   Pnih   tri nh:rrl   T

     A.lmi Fl-a.l.                                  Dominion Hospital Pat rsrrL l-rro
                                                                          ianf  vqls                T\TTTT
                                                                                                    ..'.rrAL   SAFETY ASSESSMENT: ADU


                                                     AdulE Partial Safet               Assessmnt                   LL/04/A9 1548   EMW

                                     TODAY; VERY ELEGANTLY AND NEATLY DRESSED                IN    BUSTNESS SUTT. DENIES   SI/HIISIB
                                     GIVES SL=10




               ram Initi.als
         EMW         J.NUR. EMW2 I.IITTING, ELIZABETH                     RN
         HEB         .J . NUJ(   .   HEB   ,BLACK, ELIZAEETH              RN




     g




l,B




 j
    1-6
    s3e/
               / Jvr\,
                 Qsv             .
                                       33       F                                                                                                                              D:ao.   a

        UIAI        L       f    .    J000018122                                                                      .2A-J.22
l   aanrrnf                 #    .
                                      J84090217483                                                            Rot.h,Richard L
^Jm.i
               rf       o/l      '     L0/30/09 at                      115   B                  Domi-nion       Hospital Patient.                  Care     PSYCHOSOCTAL ASSESSIVIENT


I   J                                                                                             psychosocial- Assessment                           -strd        L0/3L/ 09 O94B N<z

N/A


AdditionaL suicide Risk Elements: Hx of risky behavior
                                  Sev. anxieEy/panic/agj-Eat
                                                                                                       I.TJ5 j/!UI(I\    AD        J   T   KEJDUK
'Jnmi n i d: I /Vi ol ence Risk                                             Factors               :

N/A

                                                MariEaf Status: Single
                                     Sexual- Ori-entaLion:

++ ^F               Marriages: 0                                            How Long/Current:                           N/e
               r ^n-
               lvrrr                 Dra\ri
                                     !              arrc       M:
                                                               ..-rrlages               :




Number of Children:                                                0                                   Ages: N/A
                                     Livj-ng Arrangement: Own Place )                                                        !"

                                                                                                        l
Needs Alt                             Li-ving Arrangement                               :t
    \J              snr-' .: l SnnDort Network                                      :       Excellent
    _/
                                      Qrrnnnrl-
                                      J ut,yv!                 Darq-niq).                   t. amr-   r-y
                                                                                            Friendg
                    TreaEment ParticiPanLs                                          :       Parents
Q1r^h^7f                        a^f,mani-c.
pt -scates thaE she expects to be d/c today, but if
JUUUU!                  L       !vrrLlrlu-!Lr              '
                                                                                                                                              she
 \rF ro srav. she wouLd like her parents to De
  .r-
 Jvolweo in her tx here '
                            ]-)acnri            l-ra   'Frmi       c: I     I):w:           work, shower, eat, Lalk
                                                                                            wich friencis on 'Lhe Phone
                                      Hohhi eslTnceresEs: Reading
                                                          Exerci se
                                                                                            i^t^ts^]..i
                                                                                             eYausfrrrrY --   *^.'i     ac

                                                                                            SEudying languages

            Religron:                           CHR                         ^rrnTnmfllt I lru\
                                                                            LNKf     J


                                Spiritual                      Practices:                   None


    ?: BeIie'res in i{rgher Power:                                                          Y
    -'lPqcrr be Hioher Power^:


        I                   LasL Grade ComPleted: MS
                            Deqrees /Cert if icaLes : FOREIGN SERVTCE                                                             FROI\,I
                                                                                            G?U

                                          r-rrrrani-               QFrrrlani.               \T
   lna/Qav.                33      F                                                                                                                               D:aa.          1

                          J000018122
                                                                                                       p^rh
 f,^^^,,nts+.
-1LUUU1!L         f   .   J8109021_1483                                                                              P1 -n:rd       L

Admitted              I    L0/30/ag at                115 8                 unmi ni nn ifnsni tal-                              Patieni   Care    PSYCHOSOCTAL ASSESSI'{ENT


                                                                                                                                            ^Fl        L0/3L/09 0948       A:(Z

                                                     i,Ihere: N/A
r'-l.rrnna        in    Qn]-ranl        Performance: N
F)acnri         1-ra l-l:rnao          In School, Performance^                                           :




         Problems with Behavior at School:                                                         N
                                  Truancy:                                                         N

i arrni nc Prnirl e'ns /Sneci al Erirrcal-ion: N
Describe Learninq,/Behavioral Problems^ :
N/A


                                                                        ----EMPLOYMENT HTSTORY----
                 Currencly Employed                                     t
                       Pt Occupation                                    E nrai               an.   Qarrri       ae

                Time at Current Job                                     5 months
                    Job Satisfaction
          r.nn.rrq1- Time ai One JOb                                    )     q \r3ar<
                 Fradlrant-
                 ! -vyusrrL            ,fnh
                                       uv!       VIIdIIYcJ
                                                 ^L                     N
Reason for Job Changes^:

   \t
          ITnemnloved in Last Year:                                     N
Pa:can            inr        ITncmnl     nrmenr          ^   '




                          D: rcn t       Or-r-trn.a f i r)n        :

                          Snnrrqa        Or-crrn:l- ion:
                               Financial- Needs: Finances are                                                   noE
  )                                                                     nr^lal
                                                                        P5v!ru.rr
                                                                                             am    fnr        nl-
                                       Mi I i i:rrr L{X: N
                                        Pr:nal-r 1oc) .

                                         # of Years:
                            MiIil-erv      Rescrve:
                               li qci-:*oe    Tv.ne:
                                               -f r

                                                       Year:
Di cchercre R/T Srlbstance                                   Abuse:
f-l i cnh:
ur-errq!YU rno            ? /Tr. D<rrnh
                          r\/       ).v14        Cnnri       i F i nn   .




    I


                                                                                    ----.qRREST HlSTORY----
a--^^F
                 ^e
                          r^-rl--
                          rgllurrr\j
                                              r r F.l--F.:nn/Civivrv
                                              !rLf                                  !r   I    Ch:rcreg
                                                                                              vrlq!Yv;              HX: N
                                                     YdLrurr/
     Age/Sex:33 F
      Unitr #: J000018122
    Account.# : J840902 L'7 483                                           Poi-h       Piahrrd          T.
    Admirtredz I0/30/09 at 115 B                              Domlnion Hospital patient Care                            Pb YUHUSOC]AI, ASSESSMENT


                                                                Ps ^1.^-^^.i
                                                                   urrvrvurqr   ^1     nooqsllll€flt
                                                                                       ^^^^^-               -J -Fl LU        t0l3t-109 0948 .AXZ
             Number of Arrests:
             Reason for Arrest:
    Arrests Involvi_ng Violence:
                                     DUI,/DWf :
                                         When:
            Public fntoxication:
                                            When:
                          Probation Hx:
                                  Why/When:
                                Parole Hx:
                                  Why/When:

Describe Pending Lirigarion/Civil                                  Charges^       :




3
                                                          ---   -T'AF'F'ETNI: T{TSTORY- - -            -
                   Pt Use Caffeine:                       N

              Trmcq       aF      (-rf    foi     n-.     None


                          Amr nar               T-1:rr.




3

                                                          ----NICOTINE HISTORY----
                         Nicotine Hx:                     N

                 Kind of tobacco:
                   Aoe Fi rsf llsed:
            Dackq/tin< *----      nar
                                  r--       rl
                                                -dY:
                   Frow r:nv             \/crrS:
                                         f -*.
               ,Xnrr
               _ *'f   /-ancaffran-oe.




                                          When:


)
     Age/Sex: 33                       F                                                                                                         D:co.      q
             Uni-C   #:       J000018122                                                   J. 2A-J .222-B
Account# :                    JB4 A902L7 183                                                   Krcnard L
                                                                                                   KOEn.
Admirred:                     ro/30/09 aL 115                     B             Domi-nion Hospical Patienc Care                  PSYCHOSOCIAL ASSESSMENT


                                                                                         ^L^^^^i         -l   l^^^^--^-!
                                                                                                                           ^rl        LA/3r/09 0948   AXZ


Does Patj-ent Dri-nk Alcoholic Bsver:ae<.                                                            N
             T1,pe of Alcohol:
                    How OfLen:
                     How Long:
                                                  How Much:
                                       Last Drink:
                                  Tlpe of Alcohol:
                                        How Often:
                                                  How Long:
                                                  How Much:
                                       LasE Drink:
                                  Tlpe of Alcohol:
                                        How Often:
                                                  How Long:
 \                                                How Much:
 I                         Last Drink:
             Al-cohol Comment^:


Pt Believes                       ETOH       Use a Problem:                          N
             Neo^rirre            iFFaarq          on T.'ife.                }rT/A

     rdi ca I Prohl e.ns f rnm Cn                                            .N/ \
         r*-**
         t
                                                                TTqF

                              I                           aFrr.
                                                  Qahri tsej.
                                  ^n-a<i
                                                            When:
                     Qnhar         qrlnn-rt-
                                   JqP}Jv!u             Qrrcf cm.
                                                        uIouu"r.
                                                              Who:
                                                         AA/NA:
                                           Last Contact:
                                                 Sponsor:
 '!r                                       uast ^^-! -^F
                                                 Contacc:
 \                                         r -^!                         -




                       rsel
                                       qrlnn^yr    u/      r.ra:rn6nr
                                                        / !!eqe,,.grru               UOmmenES        :
                                   /

N/A




\,4.'li r i on: l f)rrroq or Chemj-cal- Use: N
                                        Tipe of Drug:
                                           How Often:
                                       How Long Used:
                                                  How Much:
                                            Last. Used:
                                        T1,pe of Drug:
                                            How Often:
                                       How Long Used:
                                                  How Much:
                                           Last Used:
     \                                  Type of Drug:
'/                                         How of ten:
                                       How Long Used:
                                                  How Much:
                                             Last Used:
 Agei/Sex:33 F                                                                                                                         F:co.
                                                                                                                                       '*Js.      A
  UniE #: J000018122                                                                       J . 2A-J - 222 -B
.Account# : J84090217483                                                           p^Th        vl   dn^Yd   L

AOmrcEeo i Lv/ 3 u/ uy atr 115I                                            Dominion Hospital Patient Care              PSYCHOSOCTAL ASSESSP1ENT


                                                                               chosocial Assessment             -std        L0/3L/09 0948   AXZ
F)rrrn     TTce     f-nmment           ^   .




Pt Belj-eves Drug Use a Problem: N
   Negat:.ve Ef f ects on Life:
Medical Problems from                                 CD Use:

                          Longest Sobriety:
                                                          When:
                Snl-ra-      Qrrnnnrr             q\rqFam.
                                                L Jf/ o Ls"r       ,

                                                           hJno:
                                                     AA/NA:
                                   Last Contact:
                                                 Sponsor:
 3                                 Last Contact:
CD    e^irvr      at-
                    s   ', //'q"n^^-ts_ /Treatment
                         I    vslJ}/vr                                     Comments^   :

N/A




                                                                            ----A3USE HISTORY----
 }.otio,.rt                trhr;ei c:I           /
                                                     Neoi ect-
                                                     lru:Jrv9u,            Sexual) A-buse: N
                                    Physical:
Desr-ri he         Phwq i     r-al Abuse^ :

                                           Emotional-:
Describe EmotionaL Abuse^:
 \
 ,g
                      Sexual:
Descri-be Sexual Abuse^:

                                                hTan l aat-    .

l-Jacnri   ha      NTaa l arf      ^   .




PatienL Has Hx of Abuse t.o Others:
Describe Hx of Abuse to Others^:


                CDS/lDq            Renorl-            Made:            N
                                                     ,A
Describe          I p\    / A p\       kan^rr

  I



Describe uPS/APS rnvol-vemenc                                          :

N/A

				
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