Specific Problems Treated: Diagnosis: F32.9 Pertinent depressive D/O, Unspecified ( Provisional), F43.1 PTDS(Provisional), F62.3 Borderline personality D/O. ISP goals are #101 Abuse to Self, #308 Discharge Planning and Readiness Skills/Active, and #113 Depression Interventions Used: Psychiatric assessment, nursing assessments, medication compliance monitoring, individual counseling/case management, Rec, & MH Group activities. The ISP & Patient’s progress were reviewed by the multidisciplinary …show more content…
Patient is meeting his treatment goals for problems areas. Patient has verbalized continuing his current psychotropic medications & counseling on a TCU setting as well as in the community. Patient is eating 3 meals per day, sleeping 7-8 hours, showering when offered, and attending out of cell activities, such as individual sessions with his case manager & psychiatrist. Patient has verbalized a clear understanding of his behaviors and has indicated the capacity to make decisions regarding his care. Currently, he’s a level 2 risk