cfop - clinical obeservations 8-1-11

8/3/2019 CFOP - Clinical Obeservations 8-1-11

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CFOP 155-26

STATE OF FLORIDADEPARTMENT OF

CF OPERATING PROCEDURE CHILDREN AND FAMILIESNO. 155-26 TALLAHASSEE, August 1, 2011

Mental Health/Substance Abuse

SAFE AND SUPPORTIVE OBSERVATIONS OF RESIDENTSGuidelines for Healthcare Staff in Mental Health Treatment Facilities

1. Purpose. This operating procedure describes guidelines for observing individuals who are at riskfor harming themselves or others.

2. Scope. This operating procedure applies to individuals hospitalized in state mental healthtreatment facilities, whether operated by the Department of Children and Families or by contract withprivate entities. The operating procedure does not apply to the Florida Civil Commitment Center.

3. References.

a. Chapter 394, Florida Statutes (F.S.), Florida Mental Health Act.

b. Chapter 916, F.S., Forensic Client Services Act.

c. Chapter 65E-20, Florida Administrative Code, Forensic Client Services Act Regulation.

d. Jennings, A. (2004), The Damaging Consequences of Violence and Trauma: Facts,Discussion Points, and Recommendations for the Behavioral Health System, Alexandria, Virginia,National Association of State Mental Health Program Directors, National Technical Assistance Centerfor State Mental Health Planning.

e. Section 65E-5.602, Florida Administrative Code, Rights of Residents of State Mental HealthTreatment Facilities.

4. Definitions. For purposes of this operating procedure, the following definitions apply:

a. Clinician. A Physician licensed pursuant to Chapter 458 or Chapter 459, F.S. or AdvancedRegistered nurse Practitioner (ARNP) licensed pursuant to Chapter 464 F.S

b. Clinical Risk Assessment Guide (CRAG). The CRAG is located in Appendix A to thisoperating procedure. This guide provides some basic areas to consider and report on whenassessing a residents risk of harm to self or others in the facility. The CRAG also includes someitems related to medical risks. The guide is an adjunctive tool which, in some cases, may assistclinicians in developing a more broad-based review of a residents status. The tool may also assistwith tracking issues related to risk which need to be in recovery plans. The CRAG is employed at the

discretion of clinicians or as directed in facility based policy.

c. Key Indicators. Signs or symptoms associated with, but not limited to, aggression, assault,suicidality, self-injury, homicidal ideation or behavior, arson, escape/elopement, seizures, falling, anddifficulty swallowing. The indicators direct staff toward the need to implement special observation andprecautions.

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


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d. Recovery Team. An assigned group of individuals with specific responsibilities identified onthe recovery plan including the resident, psychiatrist, guardian/guardian advocate (if resident has aguardian/guardian advocate), community case manager, family member and other treatmentprofessionals as determined by the residents needs, goals, and preferences. Other treatmentprofessionals may include but are not limited to psychologists, behavior analysts, and social workers.

e. Resident. A person who receives services in a state mental health treatment facility. The

term is synonymous with client, consumer, individual, patient, or person served.

f. Special Observation and Precautions.

(1) Observations consist of Routine Observation, Close Observation, GroupObservation,One-to-One (1:1) Observation, and Two-to-One (2:1) Observation.

(2) Precautions consist of any actions needed to maintain safety during observations.Examples of precautions are searching a bed area for harmful items, searching a resident for harmfulitems, restriction to a ward, determining the number of staff needed to observe the resident,establishing the proximity of staff to the resident, following a Personal Safety Plan (form CF-MH 3124,available in DCF Forms) to employ calming strategies.

g. Trauma-Informed Care. Trauma-informed care is mental health treatment directed by athorough understanding of the profound neurological, biological, psychological and social effects oftrauma and violence on an individual, and an appreciation for the high prevalence of traumaticexperiences in persons who receive mental health services. Trauma-informed care is based on anunderstanding of the vulnerabilities and triggers of trauma survivors that traditional service deliveryapproaches may not recognize and may exacerbate.

5. Levels of Observation.

a. Routine Observation. This level of observation consists of visual observation which is notthe result of a special written order in a residents medical record. It involves at least thirty (30)-minuteface checks completed by direct care staff in settings which residents generally occupy such asbedrooms, wards, pods, restrooms, dining rooms, activity rooms, classrooms, and enclosed yardsattached to buildings. Supervisors will ensure that staff members are vigilant and aware of eachresidents whereabouts and status. Exceptions for some residents occur at times as they acceptgreater responsibilities, gain unescorted freedom of movement, and have time away from routineobservation. Each facility will maintain Residential Area Coverage Sheets (Appendix B to thisoperating procedure) on a daily basis.

b. Close Observation (CO). This level of observation requires that staff monitor a personscondition, location, and/or behavior every 15 minutes. The person is not continually watched, and thisprocedure should be used for issues of a less than serious nature where Routine Observation wouldnot be frequent enough, and 1:1 observation would be too intensive. Close observation will occur insettings residents generally occupy such as bedrooms, wards, pods, restrooms, dining rooms, activity

rooms, classrooms, and enclosed yards attached to buildings. Close observation consists of visualobservation which is the result of a special written order in a residents medical record. Supervisorswill ensure that staff members are vigilant and aware of each residents whereabouts and status.Authorization for Close Observation is by clinician order as defined in this operating procedure. Thislevel of observation must be reviewed and renewed at least every seven (7) days and include a face-to-face examination by a clinician. The clinician will document whether changes have occurred, noteadditional concerns, if any, write a new order and document justification for continuation ordiscontinuation of an order.

c. Group Observation (GO). This level of observation requires a staff member to remain withinvisual contact and close proximity of up to three (3) designated residents, in order for the physical,

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medical, emotional or security needs of the residents to be met. The assigned staff maintains visualcontact with the assigned residents at all times. Should a resident need to separate from the groupobservation for medical care or the bathroom, additional staff assistance will be called to maintain therequired observation. Documentation of behavior, activity, and location is required every 15 minutes.Authorization for GO is by clinician order as defined in this operating procedure. This level ofobservation must be reviewed and renewed at least every seven (7) days and include a face-to-faceexamination by a clinician. The clinician will document whether changes have occurred, note

additional concerns, if any, write a new order and document justification for continuation ordiscontinuation of an order.

d. One-to-One (1:1) Observation. This level of observation requires one staff member tomaintain uninterrupted visual contact of a resident while remaining within arms length at all times. If itis determined by a clinician that within arms length creates a danger to staff members or is nottherapeutic for the resident, the clinician may write an order indicating a variance from thisrequirement. The clinician will document justification for the variance. Staff assigned this coveragecannot be assigned to more than one resident at a time. One-to-one observation requiresdocumentation at least every 15 minutes. Authorization for One-to-One Observation is by clinicianorder as defined in this operating procedure. This level of observation must be reviewed and renewedat least every 24 hours and include a face-to-face examination by a clinician. The clinician will

document whether changes have occurred, note additional concerns, if any, write a new order anddocument justification for continuation or discontinuation of an order.

e. Two-to-One (2:1) Observation. This level of observation requires two staff members tomaintain uninterrupted visual contact of a resident while remaining within arms length at all times. If itis determined by a clinician that within arms length creates a danger to staff members or is nottherapeutic for the resident, the clinician may write an order indicating a variance from thisrequirement. The clinician will document justification for the variance. Staff assigned this coveragecannot be assigned to more than one resident at a time. Two-to-one observation requiresdocumentation at least every 15 minutes. Authorization for Two-to-one observation is from a clinicianas defined in this operating procedure. This level of observation must be reviewed and renewed atleast every 24 hours and include a face-to-face examination by a clinician. The clinician will document

whether changes have occurred, note additional concerns, if any, write a new order and documentjustification for continuation or discontinuation of an order.

6. Trauma-Informed Care. All direct care staff and treatment professionals will be trained in Trauma-Informed Care. Staff will review each residents Personal Safety Plan (form CF-MH 3124, available inDCF Forms) in his or her assigned area. Staff will continue to reduce trauma when employingalternative solutions for residents in crisis or in potentially harmful situations. Staff will use calmingstrategies and avoid triggers, as indicated on the Personal Safety Plan, when residents are in dangerof harming themselves or others.

7. Key Indicators of the Need to Employ Special Observation and Precautions. Key indicators thatspecial observation and precautions may be needed include but are not limited to:

a. Suicidal/Self-Abuse. Residents who display or who have a significant potential for suicidalor self-injurious behavior.

b. Homicidal/Assaultive. Residents who display or who have a significant potential forassaultive behavior toward others.

c. Arson. Residents who threaten to or have deliberately attempted to set fires.

d. Escape/Elopement. Residents who have significant potential for leaving hospital groundswithout authorization.

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e. Medical. Residents who have significant medical problems which require special monitoringand documentation (e.g. seizures, choking, falling, special diets, grabbing food from others, excessivedrinking of fluids, etc.)

8. Assessment of Risk and Orders for Special Observation and Precautions.

a. Clinicians may authorize observation and precautions for individuals who are estimated to

be at increased levels of risk to demonstrate harm against themselves or others. Orders forobservation may also be related to the collection of information for diagnostic purposes. Observationand precautions may be authorized for medical, psychiatric, or behavioral concerns following face-to-face examination. Authorizations for special observations and precautions are generally providedafter a clinical assessment, and to the extent possible, assessment should involve members of therecovery team.

b. If a situation exists where special observation and precautions must be initiated, renewed ordiscontinued after hours, during the weekend or on state approved holidays, a Registered Nurse may,after a face-to face assessment, seek verbal authorization from a clinician. All verbal authorizations(orders) must be signed by a clinician within 48 hours.

c. All written orders for special observation and precautions, at a minimum, shall:

(1) Identify and describe key indicators or other problems;

(2) Delineate type of observation and precautions needed to maintain safety;

(3) List evaluation or treatment goals aimed at lifting the observation and precautions;

(4) Include the time limit of the order; and,

(5) Include signature, credentials, date, and time.

d. At the end of the specified duration, a new order must be written to continue the special

observation and precautions (if continuation is warranted) . The clinician must write a progress notewhich includes justification for the previously mentioned decision.

e. Observers will use either the Clinical Observation Progress Note sheet in Appendix C to thisoperating procedure or the Special Observation Flow Sheet in Appendix D to this operating procedurein accordance with facility policy.

9. Longer-Term Use of Special Observation or Precautions. In rare cases where an individualrequires observation on a longer term or chronic basis (defined as two months or longer) to ensuresafety of the individual or others, an order for longer-term observation may be written. Beforeimplementation, the Clinical Director must approve this intervention. This intervention must be part ofthe recovery plan and must be reviewed by the recovery team on a weekly basis. Once implemented,

the physicians order must be renewed on a weekly basis.

10. Discipline Responsibilities for Special Observation and Special Precautions.

a. Clinician Responsibilities.

(1) Assess and evaluate the status of residents risk to self or others.

(2) Assess and evaluate the resident for need to implement, continue or discontinuespecial observation and precautions.

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(3) Sign orders to initiate, continue, or discontinue special observations andprecautions.

(4) Conduct face-to-face examinations within the frequency required by the particularobservation or precaution.

(5) Document justification for initiation, continuation or discontinuation of an order.

(6) Notify the Recovery Team leader of the residents status.

b. Direct Care Staff Responsibilities.

(1) Observe resident for change in behavior and/or condition.

(2) Immediately report any changes to the unit nurse or the most senior recovery teammember available.

(3) Document observations as ordered.

(4) Make documented recommendations to Recovery Team for change in treatment.

(5) Report changes, interventions, or preventative measures utilized during eachchange of shift report.

c. Nurse Responsibilities.

(1) If a situation exists where special observation and precautions must be initiated,renewed or discontinued after hours, during the weekend or on state approved holidays, a RegisteredNurse may, after a face-to face assessment, seek verbal authorization from a clinician. All verbalauthorizations (orders) must be signed by a clinician within 48 hours.

(2) The registered nurse will evaluate and document the residents behavior and/or

condition while on any special observations and precautions as authorized by a clinician as defined inthis operating procedure. The frequency will be dictated by facility policy based on individual need.

(3) The registered nurse will notify the clinician of any changes in behavior and/orhealth status of resident.

d. Recovery Team Responsibilities.

(1) Meet with residents who are on special observation or precautions, assess theneed for continuation, and document the review in the clinical record.

(2) During normal duty hours, the recovery team leader shall notify members of the

Team of the residents status. The team will decide the extent to which a holistic approach to theresidents problems is needed, and whether to meet with the resident to determine any additionalneeds for treatment planning.

(3) The assigned staff person will ensure that the residents Personal Safety Plan iscomplete and up to date.

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BY DIRECTION OF THE SECRETARY:

(Signed original copy on file)

DAVID A. SOFFERINAssistant Secretary for

Substance Abuse and Mental Health

SUMMARY OF REVISED, ADDED, OR DELETED MATERIAL

The definitions of various types of observation have been deleted from paragraph 4 and a newparagraph 5 has been added to describe levels of observation. A sentence has been added toparagraph 8b requiring that the verbal orders described in that paragraph be signed by a clinicianwithin 48 hours. A new paragraph 9 has been added describing longer term use of specialobservation or precautions. In paragraph 10, a few changes have been made to the responsibilities

described in that paragraph.

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Appendix A to CFOP 155-26

Clinical Risk Assessment Guide Date:____________ Most Recent/Previous CRAG Date:____________

Reason for Assessment--CIRCLE ONE: 1. 120-hr 2. Annual 3. Any Recovery Service Plan (RSP) review w/chg in coding4. Transfer to new service team 5. Restraint 6. Seclusion 7. Placement in Forensic Security Area 8. Return from LOA 9. Other(e.g. FOM review, resident to resident injury): ___________ 10.Critical Event review Dateof event: ___________ Time: _____

Type of Event defined in Attachment 1: ___Elopement ___Escape ___Suicide Attempt ___Alleged Sexual Battery___Resident Significant Injury ___Staff Injury resulting in hospital admission:

I. FACTORS ASSOCIATED WITH RISK OF HARMTO SELF OR OTHERS

Checklist for Psychiatrist, ARNP, or Psychologist coderCheck ALL that apply

After 120-hr CRAG,code chg in risk Instructions & Comments

RSP IsNo.(s)Statu

1. SELF-INJURY BEHAVIOR Any intentionalact to harm oneself, regardless of stated intent orfunction of behavior (i.e., suicidal, expression ofother needs)

___Any by history___Any w/in 12 mos.___Any w/in 30 days___None

___risk___risk___ no change

Any occurrence within 12 monthsmust be addressed in RecoveryService Plan (RSP)

2. SELF-INJURY THREATS OR IDEATIONAny self reported or observed threats to harm self,including command hallucinations of self injuriousnature



Any occurrence within 12 monthsmust be addressed in RSP

3. VIOLENT BEHAVIOR Any attempt,regardless of outcome, to harm another person, asobserved, documented in records, or self-reported




4. VIOLENT IDEATION Any self reported orobserved, thoughts, daydreams, threats, or urges toharm others

___Any by history___Any w/in 12 mos.___Any w/in 30 days

___None


Specify: persistent or intermittentAny occurrence within 12 monthsmust be addressed in RSP

5. ELOPEMENT/ESCAPE BEHAVIOR Anyact of leaving ward, unit, or grounds withoutpermission, regardless of success of attempt




6. ELOPEMENT/ESCAPE IDEATION Any selfreport or observation of threats or plans to elope orescape




7. SUBSTANCE ABUSE Significant use of illicitsubstances and alcohol. Do not code based onpresence or absence of a substance relateddiagnosis.




___Use of substances at time ofoffense (persons w/ NGI commitmentmust be addressed in RSP)

8. PHYSICALLY VULNERABLE Any identifiedphysical conditions that place person at risk (specifyconditions & whether temporary or enduring)

___No

___Yes

___risk

___risk___ no change

If yes, must be addressed in RSP

9. COGNITIVELY/PSYCHOLOGICALLYVULNERABLE Significant cognitive deficits,significant trauma history, or significant symptomsthat impair cognitive ability

___No___Yes


If yes, must be addressed in RSP

10. RULE VIOLATING BEHAVIOR Pattern ofnoncompliance with written rules of livingenvironment(Note: Limiting grounds access in civilunits cannot be based solely on minor violationsirrelevant to safety & security)

___Monthly___Weekly___Daily___None


___Major ___Minor ___BothBrief description or reference tochart document which details thebehavior issues

11. DIAGNOSIS (As listed in current ServicePlan) This category includes diagnosis factorsidentified in risk assessment literature whichheighten or lessen risk (see definitions in policy)

___Any personality d/o dx___Substance abuse dx___Antisocial P. D. dx___Protective factor/Axis I___None


Specify Axis I, if protective factor:

INSTRUCTIONS:*RSP status codes: A = Active, R = Regulated, I = Inactive

File in the Recovery Plan section of the ward chart.

For critical events, send copy to Risk Management.

Maintain the five (5) most recent Clinical Risk Assessment Guides inthe active chart.

ADDRESSOGRAPH:

Unit: _______ Ward: ______

CLINICAL RISK ASSESSMENT GUIDE Page 1 of 2*** CONFIDENTIAL & PRIVILEGED INFORMATION *** FOR PROFESSIONAL USE ONLY **Office of Primary Responsibility: PDMH


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RESIDENTS NAME AND NUMBER:__________________________________________________

12. SYMPTOMS ASSOCIATED WITHINCREASED RISK: Symptoms identified in riskassessment literature associated with heightened risk ofharm to self or others (check any that are present at aclinically significant level)

___Command hallucinations___Suspicious/paranoid___Anger___Depressed mood___Hopelessness___None

___ risk___ risk___ no change

Any selected symptomsmust be addressed inpsychiatry documentation

Supporting documents:

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

RSP IsNo.(s)Statu

13. MEDICAL ISSUES: Circle all that apply:a. None g. Blood/Body Fluid Precautionsb. Potential for falls/fractures h. Above/below IBWc. Diabetes/Seizures i. Nutritional issuesd. Potential forChoking/Aspiration j. Skin integrity issuese. Cardiac k. Bowel/bladder issuesf. Serious longterm illness l. Other (specify): ____________________

Any circled items must beaddressed in RSP

14. PSYCHOTROPIC MEDICATION ISSUES I: Circle all that apply:a. NewAbnormal Involuntary Movement Scale (AIMS) score >3 on single itemb. NewAIMSscore> 5 total d. >3 medication refusals in 30 daysc. >3 psychotropic emergency injections in 30 days e. None of the above

Any circled items must beaddressed in RSP

15. PSYCHOTROPIC MEDICATION ISSUES II: Circle all that apply:a. >1 anxiolytic d. >1 anti-Parkinsonb. >2 antipsychotics medication

c. >3 antipsychotic/mood stabilizers in combination e. None of the above

Any circled items must beaddressed with rationalein psychiatric progressnote documentation

CLINICAL RISK ASSESSMENT SUMMARY AND RECOMMENDATIONSOVERALL, considering frequency & severity of all risk factors, persons current risk in comparison to most recent CRAG is (circle one):Increased Decreased Unchanged Referral to UD/MSD made? Yes No Purpose of referral? Information only Request forassistance

Referrals: For the 120-hour CRAGI, refer if any occurrence of self-injury, violent, or escape/elopement behavior in past 30 days (items1,3,5); if any yes on items 8 or 9; if any significant issues in items 13, 14, 15; OR if any occurrence of significant behaviors prior to, orsince, admission. For all other CRAGs, refer if the overall risk is increased. In summarizing, the team may find it useful to considerthree aspects of risk: (1) Risk to Others, (2) Active Risk to Self. and (3) Passive Risk to Self through Personal Vulnerability. If overall riis increased, summarize on this form using specific data & behavioral examples, and refer. If team makes a referral for purposes ofinformation only, briefly describe how current risk factors are managed. If team makes a referral for purposes of requesting assistancspecify the nature of the request on the referral form. If the overall risk is rated as unchanged, and some boxes are checked risk,

justify the overall rating of unchanged in the summary.

Signature/Title of Coders: Section I: _______________________________ Section II ______________________________

Other members of quorum at team meeting (Signature/Title): ________________________ ______________________

Team Leader Signature: ____________________________________________________ Date: ___________________

CLINICAL RISK ASSESSMENT GUIDE Page 2 of 2*** CONFIDENTIAL & PRIVILEGED INFORMATION *** FOR PROFESSIONAL USE ONLY **Facility Name:

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RESIDENTIAL AREA COVERAGE SHEET

INSTRUCTIONS FOR COMPLETING RESIDENTIAL AREA COVERAGE SHEET: Enter day, date and circle shift hours. Each ward coverage staff must sign theirname in the observer block, and enter the time when receiving the board, and enter the time when the board is relinquished to the next staff (lunch & breaks included).Midnight shift observer enters resident names for the next shift's ward coverage sheet. Observer #1 should record hour (e.g., 0900) in blank square with 30 blocks indicative half-hour intervals (e.g., 0930). Enter appropriate codes for the residents Area/Status (all codes are on page 2). Supervisor signs ward coverage at end of shift after review oform for completeness and submits to UTRSSIII or equivalent for further review and filing.

Unit: Ward/Pod: 7--3:30 3--11:30 11:00--7:00 11:00--7:30 11:15--7:15

_________________________________Observer # 1

Time Begin _______Time End ________


__________________________________Observer # 2



__________________________________Observer # 3



__________________________________Ward/Pod Supervisor

DAY: _____________________________

DATE: ____________________________

Resident Name EvacuationSymbols 30 30 30 30 30 30 30 30 3

Flity NameOffice of Primary Responsibility: PDMH

Appendix A to CFOP 155-26


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Appendix B to CFOP 155-

RESIDENTIAL AREA COVERAGE SHEET

Unit: Ward/Pod: 7--3:30 3--11:30 11:00--7:00 11:00--7:30 11:15--7:15

__________________________________Observer # 1



__________________________________Observer # 2



__________________________________Observer # 3



__________________________________Ward/Pod Supervisor

DAY: _____________________________

DATE: ____________________________

Resident Name EvacuationSymbols 30 30 30 30 30 30 30 30 3

CODES FOR AREAS/BEHAVIORS:

Evacuation Symbols (H=Hearing Impaired, W=Wheelchair orOther Mobility Limitations, B=Blind or Impaired Sight,

S=difficulty speaking English, ? = e.g., confusion, difficultyfollowing instructions)

Areas

1-Bedroom2-Day Room3-Quiet/Comfort Room4-Bathroom5-Shower6-Dinning Room/Area7-Therapeutic Area on Ward/Pod8 Therapeutic Area Off Ward/Pod9 -Yard10- Community Medical Setting11-Medical Setting Off Ward in the Facility

Areas (Continued)

12-Legal Setting on Campus13Visitors Area14 -Seclusion Designated Area15- Restraint Designated Area16-Hallway17-Treatment Mall18-Patio19-Recreation/Gym20-Religious Services21-Administration22-Security Office23-Beauty/Barber Shop24-On grounds (e.g., freedom of movement)25-Off Campus (Authorized, e.g. Town Pass, Furlough)26-Off Campus (Unauthorized, e,g., elopement/escape)27-Out of Facility (LOA)28-Other

Status

A-Awake and no appearance of mental, emotional,behavioral, or physical distress (no need forurgent professional care)

B- Awake and some appearance of mental, emotional,behavioral or physical issues (no need for urgentprofessional case)

C-Awake and an appearance of mental, emotional,behavioral, or physical distress (in need of urgent

professional care, notify appropriate discipline andspecify concerns in at least one progress note or morefrequently as needed each day)

D-Appearance of sleep or resting, no appearance ofdistress,

check for breathing at least hourly on midnight shiftE-Other observational note (enter progress note and notify

disciplines as appropriate)

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Appendix C to CFOP 155-26

RECOVERY SERVICE PLAN NUMBER ___________

DATE ON WHICH OBSERVATION BEGAN: _______________ CHECKS: Q 15 min.

REASON/PHYSICIAN:________________________________________________________________________________________

TIMECHECKED

OBSERVATIONALSTATUS

LOCATION/BEHAVIOR OBSERVEDCHECKED BY:(SIGNATURE)

INSTRUCTIONS: Chart the location and behavior of personsrequiring documented clinical observations.

All clinical observations, with the exception of Seclusion/Restraints,will be documented on this form. At the end of each shift, staff willdocument an end of shift summary.

Incidents requiring more detailed documentation will be documentedon Progress and Event Notes form.

To be filed in the Flow Sheet section of the residents chart.

Reference Operating Procedure(s): CFOP 155-26.

ADDRESSOGRAPH:

** CONFIDENTIAL & PRIVILEGED INFORMATION *** FOR PROFESSIONAL USE ONLY **FACILITY NAME, LOCATION, FL ZIP COPE


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CLINICAL OBSERVATION PROGRESSNOTE

Office of Primary Responsibility: PDMH Page 1 of2

C-2

INSTRUCTIONS: Chart the location and behavior of personsrequiring documented clinical observations.

All clinical observations with the exception of Seclusion/Restraints will

be documented on this form. At the end of each shift, staff will documentan end of shift summary.

Incidents requiring more detailed documentation will be documented onProgress and Event Notes form.

To be filed in the Flow Sheet section of the residents chart.

Reference Operating Procedure(s): CFOP 155-26.

ADDRESSOGRAPH:

DATETIME

CHECKEDOBSERVATIONAL

STATUSLOCATION/BEHAVIOR OBSERVED

CHECKED BY:(SIGNATURE)

** CONFIDENTIAL & PRIVILEGED INFORMATION *** FOR PROFESSIONAL USE ONLY **Facility Name, Location, FL Zip Code


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CLINICAL OBSERVATION PROGRESS NOTEOffice of Primary Responsibility: PDMH Page 2 of 2

C-3


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Check Level of Observation: [ ] Continuous Visual Observation (CVO) @ __________ am/pm; [ ] One-to-One @ ___________ am/pm;

[ ] One-to-One with Additional CVO Coverage @ ___________ am/pm; [ ] Two-to-One Observation @ __________ am/pmCheck Reason for Special Level of Observation: [ ]Elopement/Escape [ ] Sexual Precautions [ ]Suicidal Precautions [ ]Falls [ ]Withdrawal

[ ]Seizure [ ]Assaultive/Combative/Violent Behavior [ ]Other (Specify) _________________________________________________________________

[ ] Serious Medical Condition: Identify: ___________________________________________________________________________________________

Appendix D to CFOP 155-26

Florida Department of Children and FamiliesMental Health Treatment Facilities

SPECIAL OBSERVATION FLOW SHEETDocument Every 15 Minutes

Date:________________________

ADDRESSOGRAPH

TIME12M-5:59A

STAFFINITIALS

SUPERVISORY

MONITORING

TIME6A-11:59A

STAFFINITIALS

SUPERVISORY

MONITORING

TIME12N-5:59P

STAFFINITIALS

SUPERVISORY

MONITORING

TIME6P-11:59P

STAFFINITIALS

CODES

CODES

CODES CODES

12:00-12:14

6:00-6:14

12:00-12:14

6:00-6:14

12:15-12:29

6:15-6:29

12:15-12:29

6:15-6:29

12:30-12:44

6:30-6:44

12:30-12:44

6:30-6:44

12:45-12:59

6:45-6:59

12:45-12:59

6:45-6:59

1:00-1:14

7:00-7:14

1:00-1:14

7:00-7:14

1:15-1:29

7:15-7:29

1:15-1:29

7:15-7:29

1:30-1:44

7:30-7:44

1:30-1:44

7:30-7:44

1:45-1:59

7:45-7:59

1:45-1:59

7:45-7:59

2:00-

2:14

8:00-

8:14

2:00-

2:14

8:00-

8:142:15-2:29

8:15-8:29

2:15-2:29

8:15-8:29

2:30-2:44

8:30-8:44

2:30-2:44

8:30-8:44

2:45-2:49

8:45-8:59

2:45-2:49

8:45-8:59

3:00-3:14

9:00-9:14

3:00-3:14

9:00-9:14

3:15-3:29

9:15-9:29

3:15-3:29

9:15-9:29

3:30-3:44

9:30-9:44

3:30-3:44

9:30-9:44

3:45-3:59

9:45-9:59

3:45-3:59

9:45-9:59

4:00-4:14

10:0010:14

4:00-4:14

10:0010:14

4:15-4:29

10:1510:29

4:15-4:29

10:1510:29

4:30-4:44

10:3010:44

4:30-4:44

10:3010:44

4:45-4:59

10:4510:59

4:45-4:59

10:4510:59

5:00-5:14

11:0011:14

5:00-5:14

11:0011:14

5:15-5:29

11:1511:29

5:15-5:29

11:1511:29

5:30-5:44

11:3011:44

5:30-5:44

11:3011:44

5:45-5:59

11:4511:59

5:45-5:59

11:4511:59


16/16

August 1, 2011 CFOP 155-26

CODE EXPLANATION (Must include the individuals location/activity and behavior/general status) List at least onecode from each category:

Location/Activity Behavior/General Status

1. Sitting 18. Dayroom 35. Outside Activities A. Agitated R. Paranoid2. Standing 19. Hallway 36. Snacks B. Angry S. Resting3. Resting 20. Bathroom 37. Eating C. Anxious T. Restless4. Sleeping 21. Laundry 38. Walking D. Apologetic U. Seeing Things5. Talking 22. Fresh Air 39. With UTRS or MHT E. Assaultive V. Self Harm

6. Reading 23. Lobby 40. Bathing F. Calm W. Self Harm Thoughts/Feelings7. Writing 24. Meal on Unit 41. School/Work Therapy G. Cooperative X. Uncooperative8. Watching TV 25. Meal off Unit H. Crying Y. Ventilating Feelings9. On Phone 26. Gym I. Demanding Z. Withdrawn10. With Physician 27. Quiet Time J. Guilty Thoughts/Feelings

11. With Therapist 28. Seclusion K. Happy12. With Nurse 29. Restraints L. Hearing Voices13. With Rehab 30. Appointment M. Hyperactive14. Team 31. Visitors N. Interacting with Others15. Group 32. Tx Mall O. Isolating Self 16. Meds 33. Off Unit with Staff P. Intrusive17. Personal Room 34. On Unit Activities Q. Pacing

TRANSFER OF INDIVIDUAL RESPONSIBILITYSTAFFINITIAL

TRANSFERFROM:

STAFFINITIALTRANSFERTO:

TIME NURSEDESIGNEEAPPROVAL

CODE* STAFFINITIALTRANSFER

FROM:

STAFFINITIALTRANSFER

TO:

TIME NURSEDESIGNEEAPPROVAL

CODE*

*Code: 1 = Break 2 = Reassignment during Shift 3 = Change of Shift

Initials Full Signature Title ______ _______________________________________ __________________

______ _______________________________________ __________________

______ _______________________________________ __________________

______ _______________________________________ __________________

______ _______________________________________ __________________

______ _______________________________________ __________________

______ _______________________________________ __________________

______ _______________________________________ __________________

Residents Name ______________________ Hospital Number__________________

Reference CFOP 155-26

If individual isoff unit whileon Line-of-Sight or One-to-One Obs.,FLOW SHEETmustaccompanythe individual.

cfop - clinical obeservations 8-1-11

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