Exhibit: the psychiatric admission chart, status, orders, and the medication record

TABS: ADMISSION · ORDERS · MEDICATION RECORD · LABS · NURSES' NOTES

ADMISSION

PATIENT 42-year-old, admitted 03/14 at 2210 LEGAL STATUS Emergency involuntary hold, danger to self STATUTORY BASIS State emergency evaluation statute HOLD EXPIRES 03/17 at 2210 unless a hearing is petitioned ADMITTING DIAGNOSIS Bipolar I disorder, current episode depressed, severe RIGHTS ACKNOWLEDGED Yes, signed 03/14 2245 Retains right to refuse non-emergency treatment Retains right to communicate with counsel and family Retains right to a hearing and to independent evaluation

ORDERS

03/14 2230 Suicide precaution: continuous one-to-one observation 03/14 2230 Unit privileges restricted, no off-unit passes 03/14 2230 Behavioral health consult 03/15 0800 Lorazepam 1 mg by mouth every 6 hours as needed, agitation NOTE No seclusion or restraint order on file. PRN seclusion and restraint orders are prohibited.

MEDICATION RECORD

Lithium carbonate 600 mg by mouth twice daily 03/15 0900 given 03/15 2100 HELD, no reason documented 03/16 0900 given Quetiapine 100 mg by mouth at bedtime 03/15 2100 given Lorazepam 1 mg by mouth as needed not given

LABS

03/14 Lithium level 0.8 mEq/L 03/16 Lithium level 1.8 mEq/L [crit] 03/16 Sodium, low end of reported range [watch] 03/14 Creatinine 0.9 mg/dL 03/15 Creatinine 1.2 mg/dL 03/16 Creatinine 1.5 mg/dL [watch] `` → BOOK 07 · P6 for every reference range.

NURSES' NOTES

03/15 2140 Vomited twice since afternoon. Refused evening fluids. Reports nausea. One-to-one observation maintained. 03/16 0730 New coarse tremor of both hands, absent on admission. Speech slightly slurred. 03/16 1015 Unsteady, wide-based gait walking to dayroom. Required staff arm for balance.

The question — CHRT The nurse reviews the record. Which finding requires action before the next scheduled dose?

1. The lorazepam has not been given since admission.
2. No seclusion or restraint order is on file.
3. Vomiting, a rising creatinine, a low sodium, a coarse tremor, and an unsteady gait alongside a lithium level of 1.8 mEq/L.
4. The patient signed the rights acknowledgment.

Answer: 3. Hold the lithium, notify the provider, and report the assembled picture. No single row makes the case; the tabs do.

Watch outfluid loss plus a falling sodium raises the lithium level. Margin note: read the labs against the notes, not alone. Commitment criteria and hold durations are state-specific, and the state Nurse Practice Act supersedes any general rule printed here. → BOOK 14 · P8

Takeawaythe chart tells one story across tabs, and lithium toxicity here is assembled from the vomiting, the sodium, the level, and the tremor together.