diff --git a/.gitea/workflows/atomicai.yml b/.gitea/workflows/atomicai.yml new file mode 100644 index 0000000..26478c9 --- /dev/null +++ b/.gitea/workflows/atomicai.yml @@ -0,0 +1,77 @@ +name: AtomicAI Mental Health Inpatient Assistant + +on: + issue_comment: + types: [created] + issues: + types: [opened, assigned] + pull_request: + types: [opened, synchronize, assigned] + pull_request_review_comment: + types: [created] + +jobs: + claude-assistant: + runs-on: ubuntu-latest + if: | + github.actor != 'atomicqms-service' && + ( + (github.event_name == 'issue_comment' && contains(github.event.comment.body, '@atomicai')) || + (github.event_name == 'issues' && github.event.action == 'opened' && contains(github.event.issue.body, '@atomicai')) || + (github.event_name == 'pull_request' && github.event.action == 'opened' && contains(github.event.pull_request.body, '@atomicai')) || + (github.event_name == 'pull_request_review_comment' && contains(github.event.comment.body, '@atomicai')) || + (github.event.action == 'assigned' && github.event.assignee.login == 'atomicai') + ) + + permissions: + contents: write + issues: write + pull-requests: write + + steps: + - uses: actions/checkout@v4 + with: + fetch-depth: 0 + + - name: Run AtomicAI Mental Health Inpatient Assistant + uses: https://beta.atomicqms.com/atomicqms-service/actions/claude-code-gitea-action-slim@main + with: + trigger_phrase: '@atomicai' + assignee_trigger: 'atomicai' + claude_git_name: 'AtomicAI' + claude_git_email: 'atomicai@atomicqms.local' + custom_instructions: | + You are AtomicAI, an AI assistant specialized in Mental Health Inpatient Quality Management. + + ## Your Expertise + - Psychiatric hospital accreditation (Joint Commission, CMS) + - Involuntary commitment and patient rights + - Seclusion and restraint policies and documentation + - Acute psychiatric stabilization protocols + - Suicide precautions and observation levels + - Medication administration in psychiatric settings + - Milieu therapy and unit safety + - Discharge planning and aftercare coordination + - Behavioral emergency response (Code Green) + - 42 CFR Part 2 and HIPAA compliance + + ## Document Creation Guidelines + - Place Clinical SOPs in SOPs/Clinical/ + - Place Safety SOPs in SOPs/Safety/ + - Place Emergency Protocols in Protocols/Emergency/ + - Place Nursing SOPs in SOPs/Nursing/ + - Place Patient Rights in Policies/Patient-Rights/ + - Place Assessment Forms in Forms/Assessment/ + + ## Numbering Convention + - SOP-PSY-XXX for Psychiatric SOPs + - SOP-SAF-XXX for Safety SOPs + - SOP-NUR-XXX for Nursing SOPs + - PRO-EMR-XXX for Emergency Protocols + - POL-XXX for Policies + - FRM-XXX for Forms + + Always create branches and submit changes as Pull Requests for review. + Prioritize patient safety, dignity, and least restrictive interventions. + allowed_tools: 'Read,Edit,Grep,Glob,Write' + disallowed_tools: 'Bash,WebSearch' diff --git a/Forms/Admission-Forms/.gitkeep b/Forms/Admission-Forms/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/Forms/Assessment-Tools/.gitkeep b/Forms/Assessment-Tools/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/Forms/Assessment-Tools/FRM-MHI-002-Safety-Assessment.md b/Forms/Assessment-Tools/FRM-MHI-002-Safety-Assessment.md new file mode 100644 index 0000000..05659d9 --- /dev/null +++ b/Forms/Assessment-Tools/FRM-MHI-002-Safety-Assessment.md @@ -0,0 +1,287 @@ +# Inpatient Safety Assessment + +| Form ID | FRM-MHI-002 | Revision | 1.0 | +|---------|-------------|----------|-----| + +--- + +## Patient Information + +| Field | Entry | +|-------|-------| +| Patient Name | | +| MRN | | +| Date of Birth | | +| Unit/Room | | +| Admission Date | | +| Date of Assessment | | +| Time of Assessment | | +| Assessor Name | | +| Assessor Credentials | | + +--- + +## Suicide Risk Assessment + +### Current Suicidal Ideation + +| Question | Response | +|----------|----------| +| Are you having thoughts of suicide or self-harm? | ☐ Yes ☐ No | +| If yes, how often? | ☐ Fleeting ☐ Intermittent ☐ Persistent | +| How strong is the urge to act on these thoughts? | ☐ None ☐ Mild ☐ Moderate ☐ Strong ☐ Overwhelming | +| Do you have a plan? | ☐ Yes ☐ No | +| If yes, describe plan: | | +| Do you have access to means? | ☐ Yes ☐ No | +| Do you intend to act on these thoughts? | ☐ Yes ☐ No ☐ Ambivalent | + +### Suicidal Behaviors + +| Behavior | Present | +|----------|---------| +| Recent suicide attempt (within 30 days) | ☐ Yes ☐ No | +| If yes, date and method: | | +| Interrupted or aborted attempt | ☐ Yes ☐ No | +| Preparatory behaviors (writing note, giving away possessions, etc.) | ☐ Yes ☐ No | + +### Historical Risk Factors + +| Factor | Present | +|--------|---------| +| Previous suicide attempt(s) | ☐ Yes ☐ No | +| If yes, number and methods: | | +| Self-harm without suicidal intent | ☐ Yes ☐ No | +| Family history of suicide | ☐ Yes ☐ No | +| Previous psychiatric hospitalization | ☐ Yes ☐ No | + +### Clinical Risk Factors + +| Factor | Present | +|--------|---------| +| Depression | ☐ Yes ☐ No | +| Hopelessness | ☐ Yes ☐ No | +| Anxiety/agitation | ☐ Yes ☐ No | +| Psychosis | ☐ Yes ☐ No | +| Command hallucinations (self-harm) | ☐ Yes ☐ No | +| Intoxication/withdrawal | ☐ Yes ☐ No | +| Chronic pain/medical illness | ☐ Yes ☐ No | +| Recent discharge from psychiatric hospital | ☐ Yes ☐ No | +| Insomnia | ☐ Yes ☐ No | + +### Precipitating Factors + +| Factor | Present | +|--------|---------| +| Recent loss (relationship, job, housing) | ☐ Yes ☐ No | +| Recent humiliation/shame | ☐ Yes ☐ No | +| Legal problems | ☐ Yes ☐ No | +| Financial problems | ☐ Yes ☐ No | +| Anniversary of loss | ☐ Yes ☐ No | +| Other: | ☐ Yes ☐ No | + +### Protective Factors + +| Factor | Present | +|--------|---------| +| Reasons for living | ☐ Yes ☐ No | +| Future orientation | ☐ Yes ☐ No | +| Social support | ☐ Yes ☐ No | +| Religious/spiritual beliefs against suicide | ☐ Yes ☐ No | +| Responsibility for children/pets | ☐ Yes ☐ No | +| Fear of death/pain | ☐ Yes ☐ No | +| Engaged in treatment | ☐ Yes ☐ No | +| Therapeutic alliance | ☐ Yes ☐ No | + +### Suicide Risk Level + +☐ **Low Risk** - No current ideation, few risk factors, strong protective factors +☐ **Moderate Risk** - Ideation without plan/intent, some risk factors, some protective factors +☐ **High Risk** - Ideation with plan, intent, access to means; multiple risk factors; few protective factors +☐ **Imminent Risk** - Immediate danger, requires 1:1 observation + +--- + +## Violence/Homicide Risk Assessment + +### Current Homicidal/Violent Ideation + +| Question | Response | +|----------|----------| +| Are you having thoughts of hurting someone else? | ☐ Yes ☐ No | +| Is there a specific person? | ☐ Yes ☐ No | +| If yes, identify: | | +| Do you have a plan to harm this person? | ☐ Yes ☐ No | +| Do you have access to weapons? | ☐ Yes ☐ No | +| Do you intend to act on these thoughts? | ☐ Yes ☐ No | + +### Historical Risk Factors + +| Factor | Present | +|--------|---------| +| History of violence | ☐ Yes ☐ No | +| History of weapons use | ☐ Yes ☐ No | +| Criminal history | ☐ Yes ☐ No | +| History of impulsive behavior | ☐ Yes ☐ No | +| Childhood conduct disorder | ☐ Yes ☐ No | +| Victim of abuse/violence | ☐ Yes ☐ No | + +### Clinical Risk Factors + +| Factor | Present | +|--------|---------| +| Command hallucinations (violence) | ☐ Yes ☐ No | +| Paranoid delusions | ☐ Yes ☐ No | +| Manic symptoms | ☐ Yes ☐ No | +| Active substance use | ☐ Yes ☐ No | +| Medication non-adherence | ☐ Yes ☐ No | +| Lack of insight | ☐ Yes ☐ No | + +### Situational Factors + +| Factor | Present | +|--------|---------| +| Active interpersonal conflict | ☐ Yes ☐ No | +| Perceived threats | ☐ Yes ☐ No | +| Access to potential victims | ☐ Yes ☐ No | +| History with identified target | ☐ Yes ☐ No | + +### Violence Risk Level + +☐ **Low Risk** - No ideation, few risk factors +☐ **Moderate Risk** - General ideation, some risk factors +☐ **High Risk** - Specific ideation, identified target, plan, multiple risk factors + +### Duty to Warn/Protect + +| Field | Entry | +|-------|-------| +| Is there an identifiable potential victim? | ☐ Yes ☐ No | +| Has duty to warn been triggered? | ☐ Yes ☐ No | +| If yes, actions taken: | | +| Notification date/time: | | +| Law enforcement notified? | ☐ Yes ☐ No | +| Potential victim notified? | ☐ Yes ☐ No | + +--- + +## Self-Harm Risk Assessment + +| Question | Response | +|----------|----------| +| Are you having urges to hurt yourself (without suicidal intent)? | ☐ Yes ☐ No | +| Method typically used: | | +| When did you last engage in self-harm? | | +| What triggers self-harm urges? | | +| How do you typically cope with these urges? | | + +--- + +## Elopement/AWOL Risk + +| Factor | Present | +|--------|---------| +| Expressed desire to leave AMA | ☐ Yes ☐ No | +| Involuntary admission status | ☐ Yes ☐ No | +| History of elopement | ☐ Yes ☐ No | +| Agitation or restlessness | ☐ Yes ☐ No | +| External pressures to leave | ☐ Yes ☐ No | +| Poor insight into need for treatment | ☐ Yes ☐ No | + +### Elopement Risk Level + +☐ Low ☐ Moderate ☐ High + +--- + +## Fall Risk Assessment + +| Factor | Points | Present | +|--------|--------|---------| +| Age 65+ | 2 | ☐ | +| History of falls | 3 | ☐ | +| Impaired gait/balance | 2 | ☐ | +| Psychotropic medications | 2 | ☐ | +| Sedation | 2 | ☐ | +| Confusion/disorientation | 2 | ☐ | +| Sensory impairment | 1 | ☐ | +| Toileting frequency | 1 | ☐ | +| **Total Score** | | | + +**Risk Level:** ☐ Low (0-4) ☐ Moderate (5-9) ☐ High (10+) + +--- + +## Assigned Precautions + +### Observation Level + +☐ 1:1 Continuous (within arm's reach) +☐ 1:1 Visual (constant visual) +☐ Close observation (q5-15 min) +☐ Routine observation (q15-30 min) +☐ Open + +### Additional Precautions + +| Precaution | Ordered | +|------------|---------| +| Suicide precautions | ☐ | +| Self-harm precautions | ☐ | +| Violence precautions | ☐ | +| Elopement precautions | ☐ | +| Fall precautions | ☐ | +| Seizure precautions | ☐ | +| Aspiration precautions | ☐ | +| Assault precautions | ☐ | + +### Environmental Modifications + +☐ Safety room (ligature-resistant) +☐ Remove sharps from access +☐ Remove potential ligature materials +☐ Supervised shaving +☐ Supervised meals (plastic utensils) +☐ Other: _____________ + +--- + +## Plan + +**Immediate Safety Interventions:** + +**Recommended Observation Level:** + +**Rationale for Level:** + +**Reassessment Schedule:** +☐ Every shift +☐ Daily +☐ Other: _____________ + +--- + +## Physician Review + +| Field | Entry | +|-------|-------| +| Physician Name | | +| Date/Time Reviewed | | +| Agrees with Assessment | ☐ Yes ☐ No | +| Orders Modified? | ☐ Yes ☐ No | +| Modifications: | | +| Signature | | + +--- + +## Reassessment Log + +| Date/Time | Assessor | Risk Level Change | New Observation Level | Signature | +|-----------|----------|-------------------|----------------------|-----------| +| | | ☐ Yes ☐ No | | | +| | | ☐ Yes ☐ No | | | +| | | ☐ Yes ☐ No | | | +| | | ☐ Yes ☐ No | | | + +--- + +*Form FRM-MHI-002 Rev 1.0 - Inpatient Safety Assessment* diff --git a/Forms/FRM-001-Document-Change-Request.md b/Forms/FRM-001-Document-Change-Request.md new file mode 100644 index 0000000..55c718a --- /dev/null +++ b/Forms/FRM-001-Document-Change-Request.md @@ -0,0 +1,64 @@ +# Document Change Request Form + +| Form ID | FRM-001 | Revision | 1.0 | +|---------|---------|----------|-----| + +--- + +## Section 1: Request Information + +| Field | Entry | +|-------|-------| +| Request Date | | +| Requested By | | +| Department | | + +## Section 2: Document Information + +| Field | Entry | +|-------|-------| +| Document Number | | +| Document Title | | +| Current Revision | | + +## Section 3: Change Description + +### Type of Change +- [ ] New Document +- [ ] Revision to Existing Document +- [ ] Document Obsolescence + +### Description of Change +*(Describe the proposed change in detail)* + + + + +### Reason for Change +*(Explain why this change is needed)* + + + + +## Section 4: Impact Assessment + +### Affected Areas +- [ ] Training Required +- [ ] Other Documents Affected +- [ ] Process Changes Required +- [ ] Validation Impact + +### List Affected Documents + + +## Section 5: Approvals + +| Role | Name | Signature | Date | +|------|------|-----------|------| +| Requester | | | | +| Document Owner | | | | +| Quality Assurance | | | | + +--- + +*Form FRM-001 Rev 1.0* diff --git a/Forms/FRM-003-CAPA-Form.md b/Forms/FRM-003-CAPA-Form.md new file mode 100644 index 0000000..6790a8f --- /dev/null +++ b/Forms/FRM-003-CAPA-Form.md @@ -0,0 +1,91 @@ +# Corrective and Preventive Action (CAPA) Form + +| Form ID | FRM-003 | Revision | 1.0 | +|---------|---------|----------|-----| + +--- + +## Section 1: CAPA Identification + +| Field | Entry | +|-------|-------| +| CAPA Number | | +| Date Initiated | | +| Initiated By | | +| CAPA Owner | | +| Target Closure Date | | + +## Section 2: Classification + +### Type +- [ ] Corrective Action +- [ ] Preventive Action + +### Source +- [ ] Customer Complaint +- [ ] Internal Audit +- [ ] External Audit +- [ ] Process Deviation +- [ ] Nonconforming Product +- [ ] Management Review +- [ ] Other: ____________ + +### Priority +- [ ] Critical (5 business days) +- [ ] Major (15 business days) +- [ ] Minor (30 business days) + +## Section 3: Problem Description + +*(Describe the nonconformity or potential nonconformity)* + + + + +## Section 4: Immediate Containment + +*(Actions taken to contain the immediate impact)* + + + + +## Section 5: Root Cause Investigation + +### Investigation Method Used +- [ ] 5 Whys +- [ ] Fishbone Diagram +- [ ] Fault Tree Analysis +- [ ] Other: ____________ + +### Root Cause Determination + + + + +## Section 6: Corrective/Preventive Actions + +| Action | Responsible | Due Date | Status | +|--------|-------------|----------|--------| +| | | | | +| | | | | +| | | | | + +## Section 7: Effectiveness Verification + +| Criteria | Method | Result | +|----------|--------|--------| +| | | | + +Verification Date: ____________ +Verified By: ____________ + +## Section 8: Closure + +| Role | Name | Signature | Date | +|------|------|-----------|------| +| CAPA Owner | | | | +| Quality Approval | | | | + +--- + +*Form FRM-003 Rev 1.0* diff --git a/Forms/FRM-006-Audit-Checklist.md b/Forms/FRM-006-Audit-Checklist.md new file mode 100644 index 0000000..45bf0b6 --- /dev/null +++ b/Forms/FRM-006-Audit-Checklist.md @@ -0,0 +1,56 @@ +# Internal Audit Checklist + +| Form ID | FRM-006 | Revision | 1.0 | +|---------|---------|----------|-----| + +--- + +## Audit Information + +| Field | Entry | +|-------|-------| +| Audit Number | | +| Audit Date | | +| Area/Process Audited | | +| Lead Auditor | | +| Auditee(s) | | + +--- + +## Checklist Items + +| # | Requirement/Question | Reference | C/NC/NA | Evidence/Notes | +|---|---------------------|-----------|---------|----------------| +| 1 | Are current versions of applicable procedures available? | SOP-001 | | | +| 2 | Are personnel trained on applicable procedures? | SOP-003 | | | +| 3 | Are training records current and complete? | SOP-003 | | | +| 4 | Are records properly maintained and retrievable? | SOP-001 | | | +| 5 | Are nonconformities being documented and addressed? | SOP-002 | | | +| 6 | Are CAPAs being completed on time? | SOP-002 | | | +| 7 | Is equipment calibrated and maintained? | | | | +| 8 | Are process controls being followed? | | | | +| 9 | Are quality objectives being monitored? | | | | +| 10 | | | | | + +**Legend:** C = Conforming, NC = Nonconforming, NA = Not Applicable + +--- + +## Findings Summary + +| Finding # | Type | Description | Clause Reference | +|-----------|------|-------------|------------------| +| | | | | +| | | | | + +--- + +## Auditor Signature + +| Auditor | Signature | Date | +|---------|-----------|------| +| | | | + +--- + +*Form FRM-006 Rev 1.0* diff --git a/Forms/Restraint-Records/.gitkeep b/Forms/Restraint-Records/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/Forms/Safety-Plans/.gitkeep b/Forms/Safety-Plans/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/Forms/Training/FRM-004-Training-Record.md b/Forms/Training/FRM-004-Training-Record.md new file mode 100644 index 0000000..b66164d --- /dev/null +++ b/Forms/Training/FRM-004-Training-Record.md @@ -0,0 +1,72 @@ +# Training Record Form + +| Form ID | FRM-004 | Revision | 1.0 | +|---------|---------|----------|-----| + +--- + +## Section 1: Employee Information + +| Field | Entry | +|-------|-------| +| Employee Name | | +| Employee ID | | +| Department | | +| Job Title | | + +## Section 2: Training Information + +| Field | Entry | +|-------|-------| +| Training Title | | +| Training Date | | +| Training Duration | | +| Trainer Name | | +| Trainer Qualification | | + +### Training Type +- [ ] Initial Training +- [ ] Retraining +- [ ] Refresher +- [ ] Procedure Update + +### Delivery Method +- [ ] Classroom +- [ ] On-the-Job +- [ ] Self-Study +- [ ] Computer-Based +- [ ] Other: ____________ + +## Section 3: Training Content + +*(List topics covered or attach training materials)* + + + + +## Section 4: Assessment + +### Assessment Method +- [ ] Written Test +- [ ] Practical Demonstration +- [ ] Verbal Assessment +- [ ] Observation + +### Assessment Results + +| Metric | Result | +|--------|--------| +| Score (if applicable) | | +| Pass/Fail | | + +## Section 5: Signatures + +| Role | Name | Signature | Date | +|------|------|-----------|------| +| Trainee | | | | +| Trainer | | | | +| Supervisor | | | | + +--- + +*Form FRM-004 Rev 1.0* diff --git a/Forms/Treatment-Plans/.gitkeep b/Forms/Treatment-Plans/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/Policies/POL-001-Quality-Policy.md b/Policies/POL-001-Quality-Policy.md new file mode 100644 index 0000000..ebd85dd --- /dev/null +++ b/Policies/POL-001-Quality-Policy.md @@ -0,0 +1,57 @@ +# Quality Policy + +| Document ID | POL-001 | +|-------------|---------| +| Title | Quality Policy | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | + +--- + +## 1. Policy Statement + +[ORGANIZATION NAME] is committed to providing products and services that consistently meet customer requirements and applicable regulatory requirements. We strive for continual improvement of our Quality Management System to enhance customer satisfaction. + +## 2. Quality Objectives + +Our organization commits to: + +1. **Customer Focus**: Understanding and meeting customer needs and expectations +2. **Regulatory Compliance**: Maintaining compliance with all applicable regulations and standards +3. **Continuous Improvement**: Continually improving the effectiveness of our QMS +4. **Employee Engagement**: Ensuring all employees understand their role in quality +5. **Risk-Based Thinking**: Identifying and addressing risks and opportunities + +## 3. Management Commitment + +Top management demonstrates commitment to the QMS by: + +- Ensuring the quality policy is appropriate to the organization's purpose +- Ensuring quality objectives are established and compatible with strategic direction +- Ensuring integration of QMS requirements into business processes +- Promoting the use of the process approach and risk-based thinking +- Ensuring resources needed for the QMS are available +- Communicating the importance of effective quality management +- Ensuring the QMS achieves its intended results +- Engaging, directing, and supporting persons to contribute to QMS effectiveness + +## 4. Scope + +This policy applies to all employees, contractors, and processes within the scope of our Quality Management System. + +## 5. Communication + +This policy shall be: +- Communicated and understood within the organization +- Available to relevant interested parties as appropriate +- Reviewed for continuing suitability + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/README.md b/README.md index 9c9681c..9312945 100644 --- a/README.md +++ b/README.md @@ -1,3 +1,133 @@ -# mental-health-inpatient +# Mental Health Inpatient Services Quality Management System -A comprehensive QMS template designed for psychiatric hospitals, inpatient behavioral health units, and acute psychiatric care facilities. \ No newline at end of file +A comprehensive QMS template designed for psychiatric hospitals, inpatient behavioral health units, and acute psychiatric care facilities. + +## 🏥 Designed For + +- **Psychiatric Hospitals** - Freestanding behavioral health facilities +- **Hospital Psychiatric Units** - Inpatient psych units within general hospitals +- **Crisis Stabilization Units** - Short-term acute psychiatric care +- **Child/Adolescent Psychiatric Units** - Pediatric behavioral health +- **Geriatric Psychiatric Units** - Older adult mental health care +- **Forensic Psychiatric Facilities** - Court-ordered treatment settings +- **Residential Treatment Centers** - Extended care facilities + +## 📋 Regulatory Framework + +This template supports compliance with: + +- **The Joint Commission** - Behavioral Health Care accreditation +- **CMS Conditions of Participation** - Psychiatric hospital requirements +- **State Mental Health Authority** - State licensing regulations +- **42 CFR Part 482** - Hospital Conditions of Participation +- **HIPAA** - Patient privacy requirements +- **EMTALA** - Emergency psychiatric presentations +- **State Commitment Laws** - Involuntary treatment regulations +- **APA Practice Guidelines** - Psychiatric treatment standards +- **NPSG** - National Patient Safety Goals (behavioral health) +- **Nurse Practice Act** - Psychiatric nursing regulations + +## Repository Structure + +``` +├── SOPs/ +│ ├── Admission-Discharge/ # Voluntary/involuntary admission, discharge planning +│ ├── Assessment/ # Psychiatric evaluation, risk assessment, treatment planning +│ ├── Safety/ # Suicide prevention, elopement, environmental safety +│ ├── Restraint-Seclusion/ # Use, monitoring, debriefing, documentation +│ ├── Medication/ # Psychotropic meds, PRN protocols, monitoring +│ └── General/ # Document control, training, CAPA +├── Forms/ +│ ├── Admission-Forms/ # Consent, legal status, voluntary/involuntary +│ ├── Assessment-Tools/ # PHQ-9, GAD-7, Columbia, mental status +│ ├── Safety-Plans/ # Suicide safety plans, precaution levels +│ ├── Restraint-Records/ # Restraint/seclusion orders, monitoring logs +│ ├── Treatment-Plans/ # Individualized treatment plans, goals +│ └── Training/ # Competency assessments +├── Policies/ # Institutional policies +├── Work-Instructions/ # Step-by-step procedures +└── Templates/ # Document templates +``` + +## Document Numbering Convention + +- **POL-XXX**: Policies +- **SOP-ADM-XXX**: Admission/Discharge SOPs +- **SOP-ASM-XXX**: Assessment SOPs +- **SOP-SAF-XXX**: Safety SOPs +- **SOP-RS-XXX**: Restraint/Seclusion SOPs +- **SOP-MED-XXX**: Medication SOPs +- **WI-XXX**: Work Instructions +- **FRM-XXX**: Forms and Records + +## 🤖 AI-Powered Assistance + +This repository includes **AtomicAI**, your mental health QMS assistant. Mention `@atomicai` in any issue or pull request to: + +- Draft admission and assessment procedures +- Create suicide risk assessment protocols +- Generate restraint/seclusion procedures +- Develop medication management SOPs +- Create safety and elopement prevention plans +- Review documents for Joint Commission compliance + +### Example Prompts + +- "@atomicai create an SOP for suicide risk assessment using Columbia-Suicide Severity Rating Scale" +- "@atomicai draft an involuntary admission procedure per state requirements" +- "@atomicai write a restraint/seclusion policy meeting CMS requirements" +- "@atomicai create a psychiatric medication monitoring protocol" +- "@atomicai develop an elopement prevention and response procedure" +- "@atomicai create a therapeutic milieu safety checklist" + +## Getting Started + +1. **Align with State Laws** - Review involuntary commitment and patient rights laws +2. **Establish Safety Protocols** - Implement suicide prevention and environmental safety +3. **Define Assessment Standards** - Standardize psychiatric evaluation tools +4. **Set Up Medication Monitoring** - Configure psychotropic medication protocols +5. **Train Staff** - Crisis intervention and de-escalation training + +## Key Documents to Create First + +1. **Suicide Risk Assessment SOP** - Standardized screening and intervention +2. **Involuntary Admission Procedure** - Legal holds and commitment process +3. **Restraint and Seclusion Policy** - CMS-compliant R/S procedures +4. **Environmental Safety Checklist** - Ligature risk and contraband +5. **Elopement Prevention SOP** - Risk assessment and precautions +6. **Treatment Planning SOP** - Individualized treatment plan development +7. **Discharge Planning Procedure** - Safe transitions and aftercare + +## Special Considerations for Psychiatric Inpatient Care + +### Patient Safety +- Suicide risk screening and assessment +- Environmental safety (ligature points, sharps) +- Contraband prevention and searches +- Elopement risk and prevention +- Patient supervision levels + +### Legal and Rights +- Voluntary vs. involuntary status +- Informed consent for treatment +- Patient rights notification +- Grievance procedures +- Advance directives and healthcare proxies + +### Restraint and Seclusion +- Least restrictive interventions +- Physician orders and time limits +- Continuous monitoring requirements +- Debriefing and documentation +- Reduction initiatives + +### Treatment +- Psychiatric evaluation and diagnosis +- Treatment plan development +- Medication management and monitoring +- Group and individual therapy +- Discharge planning and aftercare + +--- + +*This template is maintained by AtomicQMS. For questions, open an issue in this repository.* diff --git a/SOPs/Admission-Discharge/.gitkeep b/SOPs/Admission-Discharge/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/SOPs/Assessment/.gitkeep b/SOPs/Assessment/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/SOPs/General/SOP-001-Document-Control.md b/SOPs/General/SOP-001-Document-Control.md new file mode 100644 index 0000000..b64ef52 --- /dev/null +++ b/SOPs/General/SOP-001-Document-Control.md @@ -0,0 +1,112 @@ +# Standard Operating Procedure: Document Control + +| Document ID | SOP-001 | +|-------------|---------| +| Title | Document Control | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | Quality Assurance | + +--- + +## 1. Purpose + +To establish a procedure for the creation, review, approval, distribution, and control of documents within the Quality Management System. + +## 2. Scope + +This procedure applies to all controlled documents including: +- Policies +- Standard Operating Procedures (SOPs) +- Work Instructions +- Forms and Templates +- Specifications +- External documents of external origin + +## 3. Responsibilities + +### 3.1 Document Owner +- Responsible for document content and accuracy +- Initiates document creation and revision +- Ensures periodic review is performed + +### 3.2 Quality Assurance +- Maintains the document control system +- Assigns document numbers +- Manages document distribution +- Archives obsolete documents + +### 3.3 Approvers +- Review and approve documents before release +- Ensure documents are adequate for intended purpose + +## 4. Procedure + +### 4.1 Document Creation + +1. Identify the need for a new document +2. Request document number from Quality Assurance +3. Draft document using appropriate template +4. Include all required header information +5. Submit for review and approval + +### 4.2 Document Review and Approval + +1. Route document to appropriate reviewers +2. Reviewers provide comments within 5 business days +3. Author addresses all comments +4. Final approval by designated approver +5. Quality Assurance releases document + +### 4.3 Document Numbering + +Documents shall be numbered according to the following convention: + +| Type | Prefix | Example | +|------|--------|---------| +| Policy | POL | POL-001 | +| SOP | SOP | SOP-001 | +| Work Instruction | WI | WI-001 | +| Form | FRM | FRM-001 | + +### 4.4 Revision Control + +1. All changes require documented justification +2. Changes follow same review/approval process as new documents +3. Revision number increments with each approved change +4. Revision history maintained in document footer + +### 4.5 Document Distribution + +1. Current versions available in document control system +2. Obsolete versions marked and archived +3. Training on new/revised documents as needed + +### 4.6 Periodic Review + +1. Documents reviewed at least every 2 years +2. Review documented even if no changes made +3. Reviews may result in revision or reaffirmation + +## 5. Related Documents + +- FRM-001 Document Change Request Form +- FRM-002 Document Review Record + +## 6. Definitions + +| Term | Definition | +|------|------------| +| Controlled Document | Document managed under document control system | +| Obsolete | Document no longer valid for use | +| Revision | Updated version of a document | + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/SOPs/General/SOP-002-CAPA.md b/SOPs/General/SOP-002-CAPA.md new file mode 100644 index 0000000..8dace85 --- /dev/null +++ b/SOPs/General/SOP-002-CAPA.md @@ -0,0 +1,134 @@ +# Standard Operating Procedure: Corrective and Preventive Action (CAPA) + +| Document ID | SOP-002 | +|-------------|---------| +| Title | Corrective and Preventive Action | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | Quality Assurance | + +--- + +## 1. Purpose + +To establish a systematic process for identifying, investigating, correcting, and preventing nonconformities and potential nonconformities. + +## 2. Scope + +This procedure applies to: +- Product and process nonconformities +- Customer complaints +- Audit findings +- Process deviations +- Potential nonconformities identified through risk analysis + +## 3. Definitions + +| Term | Definition | +|------|------------| +| Corrective Action | Action to eliminate the cause of a detected nonconformity | +| Preventive Action | Action to eliminate the cause of a potential nonconformity | +| Root Cause | Fundamental reason for a nonconformity | +| Effectiveness Check | Verification that implemented actions achieved desired results | + +## 4. Responsibilities + +### 4.1 CAPA Owner +- Investigates the issue +- Identifies root cause +- Develops and implements corrective/preventive actions +- Verifies effectiveness + +### 4.2 Quality Assurance +- Manages CAPA system +- Assigns CAPA numbers +- Tracks CAPA status +- Reviews and approves CAPAs +- Reports CAPA metrics to management + +### 4.3 Management +- Provides resources for CAPA implementation +- Reviews CAPA trends +- Ensures timely closure + +## 5. Procedure + +### 5.1 CAPA Initiation + +1. Identify nonconformity or potential nonconformity +2. Document issue on CAPA Form (FRM-003) +3. Classify severity and priority +4. Assign CAPA owner + +### 5.2 Investigation + +1. Gather relevant data and evidence +2. Interview personnel involved +3. Review related documents and records +4. Use appropriate investigation tools: + - 5 Whys + - Fishbone Diagram + - Failure Mode Analysis + +### 5.3 Root Cause Analysis + +1. Identify potential root causes +2. Verify root cause through evidence +3. Document root cause determination +4. Consider systemic implications + +### 5.4 Action Development + +1. Develop corrective/preventive actions +2. Assign responsibilities and due dates +3. Assess actions for: + - Appropriateness to problem severity + - Impact on other processes + - Resource requirements + +### 5.5 Implementation + +1. Execute approved actions +2. Document implementation evidence +3. Update affected documents/processes +4. Provide training as needed + +### 5.6 Effectiveness Verification + +1. Define effectiveness criteria +2. Allow sufficient time for actions to take effect +3. Collect and analyze data +4. Document verification results +5. If ineffective, reopen CAPA for further action + +### 5.7 Closure + +1. Review all CAPA documentation +2. Verify all actions completed +3. Confirm effectiveness verified +4. Obtain approval for closure + +## 6. CAPA Metrics + +Quality Assurance shall track and report: +- Number of open CAPAs +- CAPA aging +- On-time closure rate +- Effectiveness rate +- CAPAs by category/source + +## 7. Related Documents + +- FRM-003 CAPA Form +- SOP-003 Nonconforming Product Control +- SOP-004 Customer Complaints + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/SOPs/General/SOP-003-Training.md b/SOPs/General/SOP-003-Training.md new file mode 100644 index 0000000..22538c1 --- /dev/null +++ b/SOPs/General/SOP-003-Training.md @@ -0,0 +1,123 @@ +# Standard Operating Procedure: Training and Competence + +| Document ID | SOP-003 | +|-------------|---------| +| Title | Training and Competence | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | Human Resources / Quality | + +--- + +## 1. Purpose + +To ensure personnel performing work affecting product quality are competent based on appropriate education, training, skills, and experience. + +## 2. Scope + +This procedure applies to: +- All employees performing quality-affecting activities +- Contractors and temporary personnel +- Personnel requiring GxP training + +## 3. Responsibilities + +### 3.1 Supervisors/Managers +- Identify training needs for their personnel +- Ensure training is completed before performing tasks +- Evaluate competence of personnel +- Maintain department training records + +### 3.2 Human Resources +- Coordinate training programs +- Maintain central training database +- Track training compliance +- Archive training records + +### 3.3 Quality Assurance +- Develop QMS-related training +- Approve training curricula for GxP activities +- Audit training compliance + +### 3.4 Employees +- Complete assigned training on time +- Maintain current qualifications +- Report training needs to supervisor + +## 4. Procedure + +### 4.1 Training Needs Assessment + +1. Identify competence requirements for each role +2. Document requirements in job descriptions +3. Assess current competence of personnel +4. Identify training gaps + +### 4.2 Training Curriculum Development + +1. Define learning objectives +2. Develop training materials +3. Identify delivery method: + - Classroom + - On-the-job + - Self-study + - Computer-based +4. Define assessment criteria +5. Obtain approval from Quality (for GxP training) + +### 4.3 Training Delivery + +1. Schedule training session +2. Document attendance +3. Deliver training per curriculum +4. Assess comprehension through: + - Written test (minimum 80% passing) + - Practical demonstration + - Supervisor observation + +### 4.4 Training Documentation + +Training records shall include: +- Employee name and ID +- Training title and date +- Trainer name and qualifications +- Assessment results +- Signatures + +### 4.5 Retraining Requirements + +Retraining is required when: +- Significant document revisions occur +- Performance deficiencies identified +- Extended absence from job function +- Periodic requalification due + +### 4.6 New Employee Orientation + +All new employees shall complete: +1. Company orientation +2. Quality system overview +3. Job-specific training +4. SOP read and understand for applicable procedures + +## 5. Training Records Retention + +- Training records maintained for duration of employment +- Records retained 3 years after employee departure +- Records available for regulatory inspection + +## 6. Related Documents + +- FRM-004 Training Record Form +- FRM-005 Training Assessment Form +- Job Descriptions + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/SOPs/General/SOP-004-Internal-Audit.md b/SOPs/General/SOP-004-Internal-Audit.md new file mode 100644 index 0000000..749d6a5 --- /dev/null +++ b/SOPs/General/SOP-004-Internal-Audit.md @@ -0,0 +1,136 @@ +# Standard Operating Procedure: Internal Audit + +| Document ID | SOP-004 | +|-------------|---------| +| Title | Internal Audit | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | Quality Assurance | + +--- + +## 1. Purpose + +To establish a systematic approach for conducting internal audits to verify the effectiveness of the Quality Management System. + +## 2. Scope + +This procedure covers: +- QMS process audits +- Compliance audits +- Product audits +- System audits + +## 3. Definitions + +| Term | Definition | +|------|------------| +| Audit | Systematic, independent examination to determine conformance | +| Auditor | Person qualified to perform audits | +| Finding | Observation of conformance or nonconformance | +| Observation | Noted item not rising to level of finding | + +## 4. Responsibilities + +### 4.1 Lead Auditor +- Plans and schedules audits +- Prepares audit checklists +- Conducts audit activities +- Reports audit findings + +### 4.2 Quality Manager +- Maintains audit program +- Qualifies auditors +- Reviews audit reports +- Reports to management + +### 4.3 Auditee +- Provides access to areas/records +- Responds to findings +- Implements corrective actions + +## 5. Procedure + +### 5.1 Annual Audit Schedule + +1. Develop annual audit schedule considering: + - Previous audit results + - Process criticality + - Regulatory requirements + - Changes to processes +2. Ensure all QMS processes audited at least annually +3. Obtain management approval +4. Communicate schedule to affected areas + +### 5.2 Auditor Qualification + +Auditors shall: +- Complete auditor training course +- Conduct at least 2 audits under supervision +- Be independent of area being audited +- Maintain competence through ongoing audits + +### 5.3 Audit Preparation + +1. Review applicable procedures and standards +2. Review previous audit reports +3. Prepare audit checklist +4. Notify auditee of audit scope and schedule +5. Confirm auditor availability + +### 5.4 Conducting the Audit + +1. Hold opening meeting with auditee +2. Execute audit checklist +3. Gather objective evidence: + - Document review + - Personnel interviews + - Process observation +4. Document findings with evidence +5. Classify findings: + - Major Nonconformance + - Minor Nonconformance + - Observation +6. Hold closing meeting + +### 5.5 Audit Reporting + +1. Complete audit report within 5 business days +2. Report shall include: + - Audit scope and criteria + - Personnel interviewed + - Findings with evidence + - Recommendations +3. Distribute report to auditee and management + +### 5.6 Finding Resolution + +1. Auditee responds with corrective action plan within 10 business days +2. Quality reviews and approves plan +3. Auditee implements corrective actions +4. Auditor verifies effectiveness +5. Close finding upon verification + +## 6. Audit Records + +Maintain for 5 years: +- Audit schedules +- Checklists +- Reports +- Corrective action records + +## 7. Related Documents + +- FRM-006 Audit Checklist Template +- FRM-007 Audit Report Template +- SOP-002 CAPA + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/SOPs/General/SOP-005-Management-Review.md b/SOPs/General/SOP-005-Management-Review.md new file mode 100644 index 0000000..dd82006 --- /dev/null +++ b/SOPs/General/SOP-005-Management-Review.md @@ -0,0 +1,114 @@ +# Standard Operating Procedure: Management Review + +| Document ID | SOP-005 | +|-------------|---------| +| Title | Management Review | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | Quality Assurance | + +--- + +## 1. Purpose + +To ensure top management reviews the Quality Management System at planned intervals to ensure its continuing suitability, adequacy, and effectiveness. + +## 2. Scope + +This procedure applies to the periodic management review of the QMS, including all processes and quality objectives. + +## 3. Frequency + +Management reviews shall be conducted: +- At least annually +- More frequently if significant changes occur +- As needed based on quality performance + +## 4. Responsibilities + +### 4.1 Quality Manager +- Prepares management review agenda and materials +- Facilitates the meeting +- Documents meeting minutes and action items +- Tracks completion of action items + +### 4.2 Top Management +- Attends management review meetings +- Reviews QMS performance data +- Makes decisions on QMS improvements +- Allocates resources as needed + +### 4.3 Department Managers +- Provides input data for their areas +- Attends management review +- Implements assigned action items + +## 5. Management Review Inputs + +The following shall be considered: + +### 5.1 Actions from Previous Reviews +- Status of action items +- Effectiveness of implemented actions + +### 5.2 Changes in Context +- Internal changes (organization, resources) +- External changes (regulations, market) + +### 5.3 QMS Performance +- Customer satisfaction and feedback +- Quality objectives achievement +- Process performance metrics +- Nonconformities and corrective actions +- Audit results +- Supplier performance + +### 5.4 Resource Adequacy +- Personnel +- Infrastructure +- Work environment + +### 5.5 Risk and Opportunities +- Risk assessment results +- Effectiveness of risk controls +- New opportunities identified + +### 5.6 Improvement Opportunities +- Process improvements +- Product improvements +- QMS enhancements + +## 6. Management Review Outputs + +Decisions and actions related to: +- Improvement of QMS and processes +- Product improvement +- Resource needs +- Changes to quality policy or objectives + +## 7. Documentation + +### 7.1 Meeting Minutes +- Date and attendees +- Items discussed +- Decisions made +- Action items with owners and due dates + +### 7.2 Record Retention +- Management review records retained for 5 years +- Available for regulatory inspection + +## 8. Related Documents + +- FRM-008 Management Review Agenda Template +- FRM-009 Management Review Minutes Template + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/SOPs/Medication/.gitkeep b/SOPs/Medication/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/SOPs/Patient-Care/SOP-MHI-001-Admission-Assessment.md b/SOPs/Patient-Care/SOP-MHI-001-Admission-Assessment.md new file mode 100644 index 0000000..822c6ef --- /dev/null +++ b/SOPs/Patient-Care/SOP-MHI-001-Admission-Assessment.md @@ -0,0 +1,327 @@ +# Standard Operating Procedure: Psychiatric Inpatient Admission and Assessment + +| Document ID | SOP-MHI-001 | +|-------------|-------------| +| Title | Psychiatric Inpatient Admission and Comprehensive Assessment | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | Inpatient Psychiatry | + +--- + +## 1. Purpose + +To establish standardized procedures for the admission and comprehensive psychiatric assessment of patients to the inpatient psychiatric unit, ensuring safety, regulatory compliance, and appropriate treatment planning. + +## 2. Scope + +This procedure applies to all psychiatric inpatient admissions including: +- Voluntary admissions +- Involuntary/emergency detentions +- Transfers from other facilities +- Forensic admissions +- Medical clearance requirements + +## 3. Responsibilities + +### 3.1 Admitting Psychiatrist +- Conduct psychiatric evaluation +- Determine admission criteria met +- Establish initial treatment plan +- Complete admission documentation + +### 3.2 Nursing Staff +- Conduct nursing admission assessment +- Complete safety assessment and precautions +- Inventory personal belongings +- Orient patient to unit + +### 3.3 Social Worker +- Conduct psychosocial assessment +- Contact family/supports +- Begin discharge planning +- Assess resource needs + +### 3.4 Mental Health Technicians +- Assist with admission process +- Implement observation levels +- Secure patient belongings + +## 4. Definitions + +| Term | Definition | +|------|------------| +| Voluntary Admission | Patient consents to hospitalization | +| Involuntary Hold | Legal detention for evaluation/treatment without consent | +| 1:1 Observation | Continuous direct observation by staff member | +| Elopement Precautions | Measures to prevent unauthorized departure | +| Medical Clearance | Confirmation patient is medically stable for psychiatric unit | + +## 5. Procedure + +### 5.1 Pre-Admission Requirements + +#### 5.1.1 Medical Clearance + +Before admission to psychiatric unit, patient must have: +- [ ] Medical history and physical examination +- [ ] Vital signs within acceptable parameters +- [ ] Laboratory studies per protocol +- [ ] Medical conditions stabilized or treatment plan in place +- [ ] Clearance from ED physician or medicine consultant + +**Minimum Laboratory Studies:** +| Test | Required | +|------|----------| +| Complete Blood Count | ☐ | +| Comprehensive Metabolic Panel | ☐ | +| Urinalysis | ☐ | +| Urine Drug Screen | ☐ | +| Blood Alcohol Level | ☐ | +| Pregnancy Test (if applicable) | ☐ | +| Additional (as indicated) | | + +#### 5.1.2 Legal Status Determination + +| Status | Documentation Required | +|--------|------------------------| +| Voluntary | Signed voluntary admission form | +| Involuntary | Completed legal detention documents, physician certification | +| Court-Ordered | Court order, sheriff documentation | +| Minor | Parent/guardian consent OR court order | + +### 5.2 Admission Process + +#### 5.2.1 Patient Arrival +1. Greet patient and escort to admission area +2. Verify identity with two identifiers +3. Confirm legal status and documentation +4. Apply identification band + +#### 5.2.2 Safety Search and Contraband Removal + +**Required for all admissions:** +- [ ] Wand metal detector screening +- [ ] Personal search (same-gender staff) +- [ ] Belongings search +- [ ] Remove and secure contraband + +**Contraband List:** +| Always Remove | Document Securely | +|--------------|-------------------| +| Sharps, blades | Medications | +| Ligature materials (belts, cords, laces) | Valuables | +| Drugs/alcohol | Electronics (per policy) | +| Weapons | Lighters/matches | +| Glass items | | + +Document all items on FRM-MHI-001 Belongings Inventory. + +#### 5.2.3 Observation Level Assignment + +| Level | Criteria | Monitoring | +|-------|----------|------------| +| 1:1 Continuous | Active suicidal/homicidal, severe agitation | Within arm's reach | +| Close Observation | Recent attempt, high risk | Every 5-15 minutes | +| Routine | Low/moderate risk | Every 15-30 minutes | +| Open | No safety concerns | Per unit routine | + +### 5.3 Psychiatric Evaluation + +#### 5.3.1 Comprehensive Psychiatric Assessment + +**Required within 24 hours of admission:** + +1. **Chief Complaint and History of Present Illness** + - Current symptoms and duration + - Precipitating events + - Previous episodes + - Current stressors + +2. **Psychiatric History** + - Previous diagnoses + - Hospitalizations + - Outpatient treatment + - Medication trials + - ECT or other treatments + +3. **Suicide/Violence Risk Assessment** + + **Suicide Risk:** + | Factor | Present | + |--------|---------| + | Current ideation | ☐ Yes ☐ No | + | Plan | ☐ Yes ☐ No | + | Intent | ☐ Yes ☐ No | + | Access to means | ☐ Yes ☐ No | + | Previous attempts | ☐ Yes ☐ No | + | Protective factors | | + + **Violence Risk:** + | Factor | Present | + |--------|---------| + | Homicidal ideation | ☐ Yes ☐ No | + | Identified target | ☐ Yes ☐ No | + | History of violence | ☐ Yes ☐ No | + | Command hallucinations | ☐ Yes ☐ No | + | Access to weapons | ☐ Yes ☐ No | + +4. **Substance Use History** + - Substances used + - Quantity, frequency, route + - Last use + - Withdrawal history + - Treatment history + +5. **Medical History** + - Chronic conditions + - Current medications + - Allergies + - Recent medical issues + +6. **Family History** + - Psychiatric disorders + - Substance use disorders + - Suicide history + +7. **Social/Developmental History** + - Education + - Employment + - Living situation + - Relationships + - Legal history + - Trauma history + +8. **Mental Status Examination** + | Domain | Findings | + |--------|----------| + | Appearance | | + | Behavior | | + | Speech | | + | Mood | | + | Affect | | + | Thought Process | | + | Thought Content | | + | Perceptions | | + | Cognition | | + | Insight | | + | Judgment | | + +9. **Diagnosis (DSM-5)** + - Primary diagnosis + - Secondary diagnoses + - Medical conditions + - Psychosocial stressors + +### 5.4 Nursing Admission Assessment + +Complete within **8 hours** of admission: + +- [ ] Vital signs +- [ ] Pain assessment +- [ ] Fall risk assessment +- [ ] Skin assessment +- [ ] Nutritional screen +- [ ] Medication reconciliation +- [ ] Allergies verified +- [ ] Current symptoms +- [ ] Functional status +- [ ] Sleep patterns +- [ ] Safety precautions implemented + +### 5.5 Treatment Planning + +#### 5.5.1 Initial Treatment Plan (within 24 hours) +- Provisional diagnoses +- Initial medication orders +- Observation level +- Activity level +- Diet +- Laboratory/diagnostic orders +- Consultation requests +- Initial goals + +#### 5.5.2 Comprehensive Treatment Plan (within 72 hours) +- Multidisciplinary input +- Patient participation +- Measurable goals +- Interventions by discipline +- Discharge criteria +- Estimated length of stay + +### 5.6 Patient Rights and Orientation + +#### 5.6.1 Rights Information +Provide and document receipt of: +- [ ] Patient rights document +- [ ] Grievance procedure +- [ ] Privacy practices +- [ ] Voluntary/involuntary rights specific to status +- [ ] Right to refuse treatment (voluntary) +- [ ] Advance directive information + +#### 5.6.2 Unit Orientation +- [ ] Room assignment +- [ ] Unit layout (exits, bathroom, common areas) +- [ ] Schedule (meals, groups, visiting) +- [ ] Rules and expectations +- [ ] How to contact staff +- [ ] Telephone use +- [ ] Personal belongings policy + +### 5.7 Special Populations + +#### 5.7.1 Minors +- Parental/guardian involvement +- Age-appropriate assessments +- Educational needs assessment +- Child protective services notification if indicated + +#### 5.7.2 Geriatric Patients +- Enhanced medical monitoring +- Cognitive assessment +- Fall precautions +- Medication review for appropriateness + +#### 5.7.3 Forensic Patients +- Legal hold documentation +- Notification requirements +- Security considerations +- Court date tracking + +## 6. Documentation + +- FRM-MHI-001 Belongings Inventory +- FRM-MHI-002 Admission Safety Assessment +- FRM-MHI-003 Suicide Risk Assessment +- Psychiatric Evaluation +- Nursing Admission Assessment +- Social Work Assessment +- Treatment Plan +- Patient Rights Acknowledgment + +## 7. Regulatory Compliance + +| Regulation | Requirement | +|------------|-------------| +| The Joint Commission | Assessment within 24 hours | +| CMS | Treatment plan within 72 hours | +| State Mental Health Code | Involuntary hold procedures | +| EMTALA | Medical screening examination | + +## 8. References + +- State mental health statutes +- The Joint Commission standards +- CMS Conditions of Participation +- Institutional policies + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/SOPs/Restraint-Seclusion/.gitkeep b/SOPs/Restraint-Seclusion/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/SOPs/Safety/.gitkeep b/SOPs/Safety/.gitkeep new file mode 100644 index 0000000..dcf2c80 --- /dev/null +++ b/SOPs/Safety/.gitkeep @@ -0,0 +1 @@ +# Placeholder diff --git a/Templates/SOP-Template.md b/Templates/SOP-Template.md new file mode 100644 index 0000000..2e9f35e --- /dev/null +++ b/Templates/SOP-Template.md @@ -0,0 +1,62 @@ +# Standard Operating Procedure: [Title] + +| Document ID | SOP-XXX | +|-------------|---------| +| Title | [Title] | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | [DEPARTMENT] | + +--- + +## 1. Purpose + +[State the purpose of this procedure] + +## 2. Scope + +[Define the scope and applicability] + +## 3. Responsibilities + +### 3.1 [Role 1] +- [Responsibility] +- [Responsibility] + +### 3.2 [Role 2] +- [Responsibility] +- [Responsibility] + +## 4. Definitions + +| Term | Definition | +|------|------------| +| | | + +## 5. Procedure + +### 5.1 [Section Title] + +[Procedure steps] + +### 5.2 [Section Title] + +[Procedure steps] + +## 6. Related Documents + +- [List related procedures, forms, etc.] + +## 7. References + +- [External standards, regulations, etc.] + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/Work Instructions/WI-001-Template.md b/Work Instructions/WI-001-Template.md new file mode 100644 index 0000000..68167f1 --- /dev/null +++ b/Work Instructions/WI-001-Template.md @@ -0,0 +1,68 @@ +# Work Instruction: [Title] + +| Document ID | WI-001 | +|-------------|--------| +| Title | [Title] | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | [DEPARTMENT] | + +--- + +## 1. Purpose + +[Describe the purpose of this work instruction] + +## 2. Scope + +[Define what activities this instruction covers] + +## 3. Safety Precautions + +- [List any safety requirements] +- [Personal protective equipment needed] +- [Hazards to be aware of] + +## 4. Equipment/Materials Required + +| Item | Specification | +|------|---------------| +| | | +| | | + +## 5. Procedure + +### Step 1: [Title] +[Detailed instructions] + +### Step 2: [Title] +[Detailed instructions] + +### Step 3: [Title] +[Detailed instructions] + +## 6. Acceptance Criteria + +[Define what constitutes successful completion] + +## 7. Records + +| Record | Location | Retention | +|--------|----------|-----------| +| | | | + +## 8. References + +- [Related SOPs] +- [Specifications] +- [Standards] + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] |