A. Admission Standing Orders

1. Laboratory – Obtain U/A, General Health Panel (GHP contains CBC, Comprehensive Metabolic Panel, TSH), Hepatitis C AB, Hepatitis B AB, Hepatitis B Surface Antigen, Lipid Panel, Lead Level if < than 10 y.o. and none documented in chart, RPR, U/A for HCG if have had menarche, medication levels if indicated, varicella titer if exposure history is unknown. If on atypical antipsychotics get Prolactin Level, Glucose and Insulin levels on admission, at six months, and then annually. Other labs as ordered by M.D. Some labs may be omitted if testing within 6 months or less is provided at intake. 2. PPD Testing – On admission if not done within the previous 60 days, then annually. 3. Routine Height/Weight/Blood Pressure/Pulse Monitoring – a) Heights – every 6 months, please plot with corresponding weight b)Weights 1) Once a month for all students- more frequently on students with BMI <19 or as orders by physician 2) Notify nutritionist of any changes (up or down) of greater than 10 pounds in < than 8 weeks OR if BMI < 19. b) Blood Pressure and Pulse 1) Every month for all students a. B/P & P q week As directed by physician. 4. EKG – Baseline EKG for all students. If EKG done prior to admission is available, review with M.D. prior to scheduling. B. Routine Lab Orders 1. Annual Labs – CBC, U/A, Medication levels if indicated. Other labs as ordered by physician or psychiatrist. Previously drawn labs are acceptable if dated in the past 60 days. 2. Other Orders Related to Medications Atypical Antipsychotics – Prolactin levels at baseline and every 6 months. Glucose and Insulin levels at baseline 3 months later then annually, per MD if results are abnormal. Fasting Lipid Profile annually. Trileptal – Sodium level at 4 weeks and 12 weeks Tegretol – Tegretol level, CBC, LFT’s q 6 months Lithium – Lithium level, TSH, BUN, Creatinine, U/A q 3 months. Depakote – Depakote level, CBC, LFT’s, q 3 months. Dilantin – Dilantin level, CBC, LFT’s q 3 months. . Clonidine, Tenex Risperidone(Risperdal), Ziprasidone(Geodon), B-Blockers, Tryciclics, Venlafaxine(Effexor ) and any other medication known to induce arrhythmia. Review with MD re: future EKG monitoring. Clozapine - weekly WBC done and entered into the national database. AIMS testing q 6 months if on neuroleptics, including atypical antipsychotics. 3. Hepatitis C Exposure Protocol for Students – In the event of a student having a possible exposure to Hepatitis C, the following blood work should be obtained: Time after Exposure Blood Work 2 Weeks or less Baseline Liver Function Tests 4 Weeks Qualitative Hep C V PCR TMA 6 Weeks Hep C Antibody, Liver Function Tests 3 Months If Hep C PCR TMA is positive repeat, Hep C antibody, Liver Function Tests 6 Months Hep C antibody, Liver Function Tests In addition, every effort must be made to maintain the highest level of confidentiality possible. Guidelines include but are not limited to the following: a) Source of Exposure should NEVER be explicitly identified in a Hillcrest chart. b) All health referrals for staff made to Occupational Health for counseling need to be made in as confidential a manner as possible. c) If exposed student is a minor, his / her legal guardian needs to be contacted and advised of the possible exposure to Hepatitis C. They also need to be notified of our wish to follow the patient closely with the above mentioned lab work. Hepatitis C is a treatable illness especially when detected in its earliest stages. d) If student had baseline liver function tests within one (1) month prior to exposure, additional liver function tests do not need to be done. C. IDENTIFYING AND COMMUNICATING CRITICAL VALUES AND INTERPRETATIONS OF MEDICAL TESTING RESULTS Purpose: To describe the process of reporting abnormal values and interpretations from laboratory, cardiology and radiology to HEC medical providers. Laboratory results: Critical tests are those tests that always require rapid communication of the results, even if normal Critical tests are ordered specifically by the physician. The physician also indicates the timeframe of the reported results at the time of the written or verbal order. However, results should be obtained and reported to the ordering physician within 8 hours of the test having been performed. Critical results, also known as “critical values,” are test results that fall significantly outside the normal range and may represent life-threatening values even if from routine tests. As per the policy of Berkshire Medical Center, the time period for notification to the Licensed Caregiver must be immediate, occurring within 30 minutes from receipt of the result. This communication will occur directly to the ordering physician. If the physician cannot be notified in their office, the RN or LPN for the physician will be notified with the understanding of the urgent need to report the result immediately to the physician. The following are suggested critical values of routine lab testing and should be reported directly and immediately to the ordering physician: Liver Enzymes: SGOT- greater than 150 SGPT- greater than 150 AST- greater than 3 times normal ALT- greater than 3 times normal Bilirubin- greater than 3 Complete Blood Count: HCT –less than 20 WBC- less than 3,000 or greater than 20,000 Platlets- less than 60,000 ANC- less than 1.5 Glucose- greater than 200 Creatinine- greater than 2.0 Prolactin- greater than 100 Amonia- Any elevation above normal level Urine: Positive for STD Positive for beta HCG Positive for blood or bacteria RPR- any positive result Anti- HIV AB- any positive result Blood culture- any positive result Drug Levels: Lithium- greater than 1.3 Depakote (valproate)- greater than 100 Carbamezapine- greater than 12 Cardiology results: Critical interpretations are those that indicate the patient may be in imminent danger of death or serious adverse consequences unless treatment is initiated immediately. These interpretations will be reported, by the cardiologist, immediately (within 30 minutes) to the ordering physician. Other urgent or significant interpretations that are not considered life threatening but may need medical intervention will be reported by the cardiologist to the ordering physician within 48 hours. Radiology results: Critical interpretations are those that indicate the patient may be in imminent danger of death or serious adverse consequences unless treatment is initiated immediately. These interpretations will be reported, by the radiologist, immediately (within 30 minutes) to the ordering physician. Other urgent or significant interpretations that are not considered life threatening but may need medical intervention will be reported by the radiologist to the ordering physician within 48 hours.