Crisis Intervention (90899)
When documenting a crisis intervention, you just need to explain in "G" why you felt it was necessary to take immediate action. You don't need to make reference anything in the treatment plan, although including some information about a member's history (e.g., hospitalizations, cutting, suicide attempts, gun ownership, assaultive behavior) can help you make a stronger case.
Danger to Self
Note 1 (90899):
G: Jean is a 34 y/o single Caucasian female. Jean was at TAO today for a doctor's appointment. I was notified by another staff member that she was sitting outside on the curb cutting herself. Jean has a history of self-mutilation and has cut herself so deeply in the past that her wounds required sutures.* I intervened to ensure her safety and assessed her for 5150 criteria (DTS).
I: As I approached Jean she was cutting the underside of her left forearm with a metal paper binder. She had broken the skin and was bleeding. I spoke reassuringly to Jean and asked her to give me all of the sharp objects she had, which she did. I determined she met criteria for DTS based on my observations and her past history of deep cutting. Provided detainment advisement and informed her that she was being placed on a 72-hour hold for evaluation and treatment in an inpatient psychiatric facility. Because Jean was threatening to leave TAO, I called police for assistance. I remained with Jean and tried to help her stay calm and ensure that she did not hurt herself while the ambulance and police were on their way. Crisis intervention services ended when police and ambulance arrived at the clinic.
R: Jean was upset about being placed on a hold and had to be warned by police that she would be restrained if she tried to hurt herself or run away. Jean calmed down and did not resist being placed in the ambulance.
P: Will accompany Jean to the ER and relay relevant information to hospital staff to facilitate treatment.
Note 2 (90899-5):
Jean is a 34 y/o single Caucasian female. I placed Jean on a 5150 hold today as a result of self-inflicted injuries (see separate note). This note is to account for time I spent driving to the ER immediately afterwards, speaking with hospital staff, waiting for Jean to be medically cleared, then returning to TAO.
*Asking people if their wounds have ever required sutures (stitches) can be a better question to ask in this situation than whether their wounds ever required treatment in an ER, or led to hospitalization, since even superficial scratches will have been treated in an ER if the member decided to go there, or was taken there on a hold, and hospitalizations are often for psychiatric rather than medical reasons.
Danger to Others
G: Ian is a 27 y/o single African American male. Due to A/H, delusions, and poor impulse control, Ian becomes convinced that housemates are plotting against him or trying to harm him in some way. He then becomes aggressive and in some cases physically assaultive. I received a call today from his R&B manager who said Ian had threatened to kill housemates when they returned to the home because he believed they had stolen his food. I directed the R&B manager to call 911 because of Ian's history of violence, then went to the R&B to assess Ian for DTO.
I: Met with Ian at his R&B. I asked if he was serious about the threat he had made to kill housemates he believed had stolen his food from the refrigerator. I also asked if he had any knives or other weapons. Ian's thinking was disorganized and he had difficulty answering questions in a coherent way. I noted he was agitated and continued pacing and looking out the window for his housemates to return. I asked him several times if he was willing to contract not to harm anyone but he refused to do so. He said "I know what I have to do" and continued pacing while responding to internal stimuli. At this point police arrived and I placed Ian on a 5150 hold for DTO. Provided detainment advisement and informed him he was being placed on a 72-hour hold for evaluation and treatment in an inpatient psychiatric facility. Called ETS and arranged ambulance services. Remained with Ian to help him stay calm and assist in ensuring the safety of others until the ambulance arrived. Crisis intervention services ended at this time.
Danger to Self & Danger to Others
G: Jason is a 31 y/o single Caucasian male. While meeting with his psychiatrist today, Jason complained about the behavior of other tenants at his apartment complex and said "I'm gonna blow the place up. I'm gonna take them all with me." When asked what he meant, he said "You heard me." He refused to answer further questions and eventually walked out of the session. This was brought to my attention by the psychiatrist and I assessed Jason for 5150 criteria before he left the premises.
I: Met with Jason outside the building. He reiterated his intention to blow up his apartment building, killing himself and the occupants of adjacent apartments. Although he was unable to describe how he would kill himself or blow up his apartment, he attempted suicide in November 2015 by jumping off an overpass, sustaining severe injuries and requiring both medical and psychiatric hospitalization. He told the nurse he would "use things at the hardware store" to make an explosive and that he had a book that "shows how to do it". Jason refused voluntary hospitalization. For these reasons I determined he met criteria for DTS/DTO and placed him on a 5150 hold. Informed him he was being placed on a 72-hour hold for evaluation and treatment in an inpatient psychiatric facility. I remained outside with Jason while another staff member called police, ETS, and ambulance. I stayed with Jason and continued attempts to de-escalate him until police and ambulance arrived. Crisis intervention services ended at this time.
G: Rebecca is a 45 y/o single Caucasian female diagnosed with paranoid schizophrenia who has been living with her elderly parents for the last 3 years. She stopped taking her meds 11 months ago and has become highly symptomatic. She rarely goes outside, doesn't bathe or shower, responds to internal stimuli all day, and refuses to do anything her parents ask her to do. She behaves aggressively towards them when they try to approach her but has never met criteria for DTO. Her parents fear for their safety and want Rebecca to get treatment, so they filed a restraining order that will result in Rebecca being exited from their home. Sheriffs will be serving the order today and it is likely Rebecca will meet criteria for GD as soon as she is outside her parents' home. I agreed to be present to make the assessment.
I: When deputies escorted Rebecca out of the house she was wearing pajamas and bath slippers and declined offers of more appropriate clothing. She was walking in circles and responding to internal stimuli. She was unable to verbalize any type of plan for obtaining food and shelter, saying only that she would "go live in a tree in the forest". She refused to go to the hospital voluntarily. I determined she met criteria for GD due to her inability to provide for her basic personal needs as a result of her mental illness. Informed her that she was being placed on a 72-hour hold for evaluation and treatment in an inpatient psychiatric facility. Located an available bed and contacted ambulance provider. Remained with Rebecca to help her stay calm until ambulance arrived.
Sometimes we don't need to write a hold.
G: Lucia is 31 y/o single Hispanic female. Lucia's R&B manager called to report that Lucia was upset over a breakup with her boyfriend and had told other residents she wanted to die the prior evening. For this reason I went to her R&B to meet with her and evaluate her for DTS.
I: Lucia denied having active S/I, intent, or plan. Statements she made during the course of our conversation, such as "I just want to go to sleep and not wake up," were passive in nature. She made references to several tasks and goals she had in the future. She said she planned to discuss a med adjustment with her psychiatrist later this week, and that she was looking forward to celebrating Christmas with her family next month. She also talked about returning to school and graduating with her cosmetology license. Lucia has no prior S/A and a strong family support system. For these reasons I determined she did not meet criteria for a hold.
R: Lucia agreed to contact her PSC and/or the after-hours crisis line if suicidal thoughts became more active. She also agreed to come to the clinic tomorrow to meet with her doctor.
P: Will brief the other members of Lucia's treatment team as well as notifying on-call staff.
Other times we decide the member doesn't meet criteria and switch over to providing a rehab service.
Note 1 (90899)
G: Joe is a 35 y/o single Hispanic male who is currently experiencing paranoia and delusional thoughts as a result of being off his medications. During a meeting with his psychiatrist today, he became extremely agitated and accused her of prescribing meds to make him sick. He stood up, raised his voice, and assumed a threatening posture in her office. Because Joe has a history of assaultive behavior I intervened to help de-escalate him and determine whether he met criteria for DTO.
I: Escorted Joe out of the clinic and talked to him in an area away from his psychiatrist and other members. Helped him de-escalate by taking him through a series of relaxation exercises. Once he became calmer, he informed me that although he was upset he had no intention of harming his psychiatrist today. Based on his statements and my observations of his affect and posture, I determined that he did not meet criteria for DTO. Crisis intervention services ended at this time. The remainder of today’s service is accounted for in a separate note.
R: Joe remained agitated throughout this meeting but did not appear to present a threat to his doctor.
P: Will provide rehab services immediately following this assessment.
Note 2 (90899-17)
G: Joe is a 35 y/o single Hispanic male who is currently experiencing paranoia and delusional thoughts as a result of being off his medications. During a meeting with his psychiatrist today, he became extremely agitated and made threatening gestures. After determining he did not meet criteria for DTO (see separate note) I continued working with Joe to help him de-escalate and learn better ways of managing his anger in the future.
I: Discussed situations that trigger Joe's anger and helped him identify early warning signs that he is about to lose his temper. Encouraged him to use relaxation techniques such as deep breathing as soon as he recognizes one of these signs. Discussed the pros and cons of making threats. Was able to show that while there were multiple risks involved there were few if any benefits for Joe. Collaborated with him to identify other solutions, including being more up-front with his doctor about his symptoms and his concern about his weight, staying on his meds while he and his doctor try to find something that works better for him, and asking to take a break if he begins feeling upset.
R: Joe became calmer as the meeting progressed. He stopped pacing and lowered his tone of voice. He said he was upset because "the medicine isn't working and it's making me fat". He was receptive to my suggestions about changes he could make in his behavior, and agreed to go home and relax. He asked me to tell his psychiatrist he was sorry about how he acted.
P: Will brief Joe's PSC and psychiatrist on what happened during my meetings with him.