Unit	Axis I	Axis II	Axis III	Axis IV	Axis V	Medical Concerns	Discharge Considerations
K2	"Schizoaffective Disorder, BiPolar Type"	Deferred	H/O Crohn's Disease; H/O TIA; Rt. Foot drop and gait dysfunction due to trauma	None noted	GAF: 40	Unsteady gait at times due to foot drop; independent in ADL's; regularly requests PRN pain medicine for foot pain; not compliant with 1500 cal. Diet	"Sister is his legal guardian and is supportive of patient and treatment. He has a slight gait disturbance. He continues to make delusional statemtents and evidences little or no insight into his illness; tends to refuse group home placement and says that he wants to live by himself in his own apartment. (This is not a clinical possibility). He has day passes with sister when she is visiting, which always go without incident. He has level B grounds privileges. "
S3	"Schizophrenia, undifferentiated type, continuous"	No diagnosis	Angle Recession Glaucoma right eye; Obesity; Macular Degeneration Cataract	Chronic Mental Illness	GAF: 40	Recently in hospital for Pneu-monia; Hx of Glaucoma and stares at people until they are uncomfortable; hygiene is adequate but needs reminders at times to take baths; 1500 cal. reducing diet (obesity)	"He continues to respond to internal stimuli and demonstrates an inappropriate affect at times; he continues to stare inappropriately at female staff; he has disorganized thoughts occassionally; no recent record of verbal or physical aggression. His sight loss is increasing but refuses recommended treatment. Resistive to group home services, but family, who regularly host him for passes, continue to support group home placement. History of intimidation toward females, but much reduced, because of treatment, in recent years. He was recently treated  for Nephrogenic Diabetes Insipidus secondary to Lithium; while he was in hospital he refused recommended PT and and MRI. Continues on !:1 observation for medical reasons. Level B grounds privileges when 1:1 reduced. "
K2	"Schizoaffective Disorder, BiPolar Type"	None detected	HTN; History of heart murmur	"Social, Occupa-tional"	GAF: 35	Independent in ADL's; no acute medical issues	"He remains goal-oriented, is able to maintain conversation without distracting thoughts or delusional statements; no bizarre behaviors and is eager to be discharged. He has a history of wandering away from services. Psychosis was involved in his reasoning for leaving. Little preoccupation with wandering at present and he maintains level D grounds privileges."
S3	"Schizoaffective Disorder Bipolar Type, MRE Manic"	Deferred	Hypertension Hyponatremia Hypokalemia Constipation Gastroesopho-geal Reflux Disease	No insight regard-ing illness	GAF: 25	Currently Q 15 min. for fluid intake restrictions	"Currently he maintains level B grounds privileges, however he is on q15 special precautions concerning fluid intake--he drinks too much and has decreased sodium levels. He is showing medical improvement. Presently he has agitation, is argumentative about treatment, has little or no insight into illness; he continues to affirm that he wants to be discharged but sustained inprovement is needed for success. "
S3	"Schizophrenia, Paranoid Type"	Deferred	Hyperlipidemia Obesity Constipation	History of incarcera-tion; lacks familial and social supports	GAF: 30	Constipation and receives prune juice and Ducolax; high cholesterol 	"He maintains level D grounds privileges. He is generally good with self-care skills, compliant with prescribed treatments and unit rules/routines, and is interactive in treatment programs. There are no observed delusional statements, but has little or no insight into his illness. No violence or aggression noted."
S3	"Mood Disorder, NOS; Attention Deficit/Hyperact-ivity Disorder, Combined"	Mild Mental Retardation Borderline Personality Disorder 	Overweight	Chronic Mental Illness	GAF: 40	Cooperative with medical treatments as prescribed	"He has level D grounds privileges and continues to follow prescribed treatment and unit rules/routines; at times continues with intrusive behavior, and has a history of in-trusive behaviors, manipulation, impulsivity--all significantly decreased in recent months. He has occassional day passes with family. Intrusiveness is now limited to impinging on someone's personal space, and he is redirectable. "
S3	"Schizophrenia, Paranoid Type"	None	Hypertension Hyperlipidemia	Isolated from Com-munity	GAF: 30	"ADL's monitored to insure com-pliance; controled CHO, low sodium and low cholesteral diet; requests and receives PRN medication for Rt. Leg and hip pain, and meds. For anxiety."	"He maintians level D grounds privileges and has identified that he wants to return to a group home as part of community service to him. He was at group home and returned to DPC as a result of his not cooperating with medication--he became aggressive and walked away from the group home. He has delusions and some paranoid ideas from time to time, however, he is cooperative with medications, expresses himself without anger, manages his anger appropriately, and recognizes why his previous group home placement did not work for him."
S1	"Schizophrenia, Chronic Undifferentiated Type; Dementia, NOS; History of Alcohol Abuse"	No diagnosis	Seizure Disorder; Hyperlipidemia; DJD; Vitamin B12 Defiency; Abdominal Hernia	Isolated from Family	GAF: 30	Occasional forgetfulness; talks to himself and objects occasionally; compliant with medications; hernia	"He maintains level B grounds privileges and wants to be discharged and to live by himself. He has a history of aggression and unmanaged anger, which he reports he used alcohol to try to calm--leading to increased agression, anger and violence. He has incarcerations for violence and unchecked anger. He shows little insight into his illness or his personal history. Denies hearing voices, but is observed talking to himself when no one is around."
S1	"Schizoaffective Disorder, BiPolar Type"	No diagnosis	Hypothyroidism Hyperlipidemia Overactive Bladder; Osteopenia;  Dry eye Syndrome; Hypertension  Nasal Stuffiness  Agranulocytosis secondary to Zyprexa; foot fracture; Cataracts  Fuch's Corneal Dystrophy  Psuedophakia	Chronic Mental Illness	GAF: 45	"Slow, steady gait with no falls during current report period; slightly high risk  for falls  and is monitored for falls; incontinent of urine at night, and toilets during day with staff reminders; needs staff support to complete ADL's; mechanical, restricted, soft diet"	"She maintains level B grounds privileges. At present she is somewhat delusional--in lengthy conversations she voices illogical or delusional ideation; she reports hallucinations which she admits are bothersome to her. However, she participates in therapies and groups including off grounds trips. A ""fall risk"" is noted but no falls are observed in the past month. There is some nighttime urinary incontinence. She is compliant with prescribed treatments. No family contact for several years. "
K2	"Schizophrenia, Undifferentiated type; History Polysubstance abuse--Alcohol, opium, crack cocaine, cannabis"	Mild Mental Retardation  	History Seizure Disorder; Obeisty; History of Neuroleptic Malignant Syndrome; S/P recent radical mastectomy for CA breast; Hyperlipidemia; chronic renal insufficiency; possible H/O Hypertension	Unkempt; Home-less	GAF:40	"Nocturnal enurisis, with bladder taining; no fluids after 7PM; occasion- al reminders for ADL's; 1500 Cal diet; Tamoxifen for CA"	"She maintains level D grounds privileges. Presently, she has periods of agitation resulting in verbal aggression, generally toward peers who are agitating or harrassing her; occassional episodes of pushing/shoving peers. She has a history of threats and aggression but episodes have diminished significantly over the past several years. "
K2	"Schizophrenia, Chronic Paranoid type"	Personality Disorder NOS	"HTN; Hypercholester-olemia; S/P CVA; Hemiparesis, Lt. UE and LE"	Social; Chronic mental illness	GAF: 30	See Axis III	"She maintains level B grounds privileges.  She is ambivalent about discharge. Generally her behaviors are appropriate, demonstrating decrease in lability, increase in ability to manager her anger. She seems apprehensive with people at times and holds them at a distance. She can be demanindg and intrusive at times. Compliant with medications and forms of prescribed treatment. "
K2	"Schizophrenia, Paranoid type, Chronic"	Pervasive Develop-mental disorder	Hyperlipidemia; Hypertension; GERD; Hx Seizure; Obeisty; Arthritis	Chronic mental illness	GAF: 35	Cooperative with HTN medicines; falls due to loss of balance	"She is presently being considered for group home services and has a long history of demanding, ""needy"" behavior. She often cries and whines to get what she wants, and does not see the problem in this behavior. However, these behaviors have significantly decreased in recent months; she is showing increasing affective stability. She has been very dependent upon her mother for physical and emotional care for many years. Mother provides emotional support, offering behavioral limits. "
K2	"Schizoaffective Disorder, BiPolar Type; H/O Alcohol, Cannabis Abuse"	borderline Personality Disorder; Impulse Control Disorder	"Low grade Squamous Inter-Epithelial Lesion on PAP, resolved"	None 	GAF: 40	Nursing reports episodes of yelling and screaming particularly with regard to being restricted or restrained. Behavioral plan in place. 	"Lability and impulse control issues, especially episodes of yelling and screaming in response to not getting what she wants, when she wants it. She has the ability to work, and has done so successfully through the State workshop, and she also has the ability to get what she wants in a controlled fashion. The current behavior plan is for physical aggresssion with Pod C restrictions, working her way back to returning to work, in step-fashion, based on her behavior. She understands the program but finds it difficult to follow. She has a history of sexual preoccupation. She has somatic delusions about her body; she also is successfully dealing with ""personal space issues"". "
K3	Cannabis Abuse; R/O Dysthymia; R/O PTSD	Borderline Personality Disorder 	R/O Seizure Disorder; R/O Pseudo-Seizures	Social; Legal; Substance Abuse; Poor coping skills	GAF: 35	Independent self care skills; takes prescribed medications without difficulty; has been on 1:1 for safety of self (ended 7/31/08) and again now on 1:1 for personal safety; presently complaining of tremors and agitation. No noted medical problems	"On and off 1:1 for personal safety. Behavior plan indicates that she has not hurt herself or others for at least 4 days. The plan includes Issues related attack on others, destruction of property, attempts to leave the facility by running through locked doors, and attempts to cut and scratch herself. Historically, she was in an SAS after; cut herself, with suicidal indeation. She is presently responding to the behavior plan as adopted. "
K2	Substance Induced Mood disorder (resolved); Alcohol dependence; Dysthymia	Borerline Pesonality Disorder	Paroxsymal Atrial Fibrillation without Pacemaker; Obesity; Edentulous; Healed lacerations of arms and amdominal wall.	Poor community rapport	GAF: <30	She is not on any Cardiac medications and was terminated from Cardiology secondary to noncompliance with treatment. Her pacemaker was removed due to self-mutilating behavior.  She is edentulous but tolerates a regular diet. Manages her own ADL's; sporadically not compliant with treatments.	"Shehas had repeated admissions to DPC, generally due to cutting and significant alcohol consumption. At DPC she has periodic episodes of threatening behavior and attacking peers. She has inconsistent success on passes. While she has a long history of alcohol dependence and aggression toward others she denies that she has an alcohol problem, refuses any treatment, especially inpatient treatment."
K3	"BiPolar Disorder, NOS; N/O Anorexia; H/O Impulse Control disorder"	Borderline Personality Disorder	Hyperthyroidism GERD	Cannot live with family due to violence	GAF: 25	"Presently in stable mood, cooperative with treatment and has level B grounds privileges. Recently monitored on q. 15 minute observations for rage attacks and agitation."	"She has periods of clam, cooperative behavior, and times where she is on the edge seemingly looking for a reason to be upset, and times where she is yelling, disruptive, destructive. Her insight seems to be limited in that she questioned how long she has to be good before she can go to a group home. As she continues to improve she will be referred to DPC sheltered work programs and given increases in grounds privileges. Recently, in an aggitation as a response to being yelled at by another patient, she kicked and broke glass in hallway door, attempted to cut herself, attempted to assault staff. She remained calm after intervention. Her adoptive parents are in DE. Her biological parents, in another state, have significant mental health and substance abuse problems. She has been in hospitals, almost continuosly, since she was an adolescent."
K2	"Schizophrenia, Paranoid type; Polysubstance Dependence (cocaine, Marijuana)"	Antisocial Personality traits; Borderline Peronality Features	Hyperlipidemia	Homeless; Untrained; Violence	GAF: 40	"Client displays marginal insight into her mental health; judgement, decision-making and problem-solving remains impaired. She is independent in ADL's, which are fair when completed. "	"She has episodes of verbal aggression, agitation and bullying of peers, loudness and screaming when asked to perform a task she does not want to do, like making her bed. She vacilates from level A grounds privileges to level C grounds privileges (current). Generally she refuses to accept any responsiblity for her behaviors--yelling about other people and how they are the problem. No physical aggression. Loud and angry-sounding at times; angry moods and little acceptance of her tole in difficulties. She has day passes with her aunt, which generally go without incident. She has a prostituition history."