Notes

ADMISSION NOTE
15 YEAR OLD AFRICAN AMERICAN FEMALE ADMITTED TO 2 WEST FROM COPLEY ER VIA AMBULANCE AND ACCOMPANIED BY SECURITY AND MEDICS. PT AND BELONGINGS CHECKED, NO CONTRABAND FOUND. PT IS CALM AND COOPERATIVE DURING ADMISSION. PT ORIENTED TO UNIT AND TIME. MOM ACCOMPANIED THE PATIENT AND GAVE VERBAL CONSENT TO KANDEE AT INTAKE AT COPLEY, MOM WAS INSTRUCTED TO COME EARLY TOMORROW TO SIGN PAPERWORK DUE TO INTAKE NOT AVAILABLE AT THIS TIME. PT WAS COOPERATIVE WITH THE BODY SEARCH AND WITH ANSWERING ADMISSION QUESTIONS. PT STATES SHE IS STILL FEELING DEPRESSED AND ANXIOUS. STATES SHE IS HAVING INTERMITTENT SUICIDAL THOUGHTS BUT NO PLAN. VIA PATIENT AND INTAKE, TODAY AT SCHOOL SHE TOOK 8 200MG IBUPROFEN TABLETS IN AN ATTEMPT TO OD. PATIENT DID STATE THAT SHE DOESN'T THINK SHE REALLY WANTED TO DIE THOUGH, BECAUSE SHE HAD MORE PILLS AND COULD HAVE TAKEN THEM ALL, BUT DIDN'T. PATIENT REPORTS THAT THERE WAS NOTHING SPECIFIC THAT HAPPENED TODAY THAT CAUSED HER TO TRY TO OD, BUT THAT SHE HAS BEEN FEELING DEPRESSED AND ANXIOUS FOR A LONG TIME NOW. PATIENT REPORTED THAT SCHOOL IS A BIG STRESSOR FOR HER AND THAT SHE HAS BEEN DOING POORLY IN IT. SHE STATES THAT SHE HAS A LOT OF ANXIETY AT SCHOOL AND TODAY THE ANXIETY AND DEPRESSION JUST "GOT TO HER". PATIENT DOES HAVE A HISTORY OF CUTTING BUT REPORTS THAT SHE HASN'T CUT SINCE THIS SUMMER, AND NO CUTS OR SCARS WERE FOUND ON SKIN CHECK. PT REPORTS HAVING PAST SUICIDE ATTEMPTS BY OD'ING AND CUTTING, BUT IS VERY VAGUE ABOUT THIS AND WILL NOT EXPLAIN THESE INSTANCES STATING "SHE DOESN'T REMEMBER WHAT EXACTLY HAPPENED". PATIENT REPORTS THAT SHE HAS BEEN DEPRESSED FOR A LONG TIME BUT DIDN'T TELL HER MOTHER UNTIL TODAY.
PT DOES NOT HAVE ANY PREVIOUS PSYCH HISTORY. PT IS CURRENTLY NOT TAKING ANY MEDICATIONS AND HAS NO PREVIOUS SIGNIFICANT MEDICAL HISTORY. PT WEARS GLASSES.
SRA IS 7, BROSET IS ZERO, FALL SCORE IS 2, PAIN SCORE IS ZERO. PLACED ON IP FOR SUICIDE. WILL CALL DR NDRIO IN THE AM. WILL MONITOR CLOSELY.