Ricky Medical File

Westborough Behavioral Health Hospital

Ht: 72.00cm Wt: 0.00kg BMI: BSA: 0.00 Regular Pharmacy: CVS/pharmacy #1291, 01291

Patient Name: Stebbins Jr., Richard L DOB: 10/08/1978 Room-Bed: 2112a Admit Date/Time: 7/19/25 13:57

0.00

Allergies: NKDA - NO KNOWN DRUG ALLERGIES

Medications to take after Discharge

Medication Dose Route Freq Morning Noon Evening Bedtime

HORMONES/HORMONE MODIFIERS

methIMAzole 5 mg TAB (Tapazole)

2.5 mg Oral ONCE A DAY ü

Indication: Hyperthyroidism.

Last Dose:

MISCELLANEOUS AGENTS

2 mg Oral

Transmucos

EVERY 2 HOURS

AS NEEDED

nicotine 2 mg GUM (Nicorette)

Indication: craving

Last Dose: 7/30/25 6:49 am

UNKNOWN

40 mg Oral THREE TIMES A

DAY

propranolol 40 mg TAB (Inderal) ü ü ü

Indication: Anxiety

Last Dose:

Keep a list of your Medications and update with any changes including non prescription products. Tell all of your physicians

about changes at each visit and carry a copy with you at all times in case of an emergency situations. Always take medications

according to your physicians instructions. Discard Medications that have expired.

Physician: Rathore, Perveen

ACCT #: 2501656

SEX: M

MR #: 109912

DOB: 10/08/1978 AGE: 47 years

Admit Date: 7/19/25 13:57

Stebbins Jr., Richard L

Do NOT Scan to Pharmacy

Page 1 of 3

printed 3/9/26 07:32

Transition Record - Part 3

DISCHARGE MEDICATION SUMMARY FOR PATIENT

Patient Name: Stebbins Jr., Richard L

Westborough Behavioral Health Hospital

Medication Dose Route Frequency

DO NOT CONTINUE THESE MEDICATIONS AT HOME

Physician: Rathore, Perveen

ACCT #: 2501656

SEX: M

MR #: 109912

DOB: 10/08/1978 AGE: 47 years

Admit Date: 7/19/25 13:57

Stebbins Jr., Richard L

Do NOT Scan to Pharmacy

Page 2 of 3

printed 3/9/26 07:32

Transition Record - Part 3

DISCHARGE MEDICATION SUMMARY FOR PATIENT

Patient Name: Stebbins Jr., Richard L

Westborough Behavioral Health Hospital

THESE DISCHARGE PRESCRIPTIONS e-PRESCRIBED TO:

CVS/pharmacy #1291, 01291

770 BOSTON RD

SPRINGFIELD, MA 01119

Phone Number: 4137830125

03/09/2026 7:32 am

Take this form to your pharmacy to pick up your medications.

All these medications are listed on the front sheet under Medications to take after Discharge.

Medication Dose Route Frequency Quantity Refills

propranolol 40 mg Oral THREE TIMES A DAY 42 0

Inderal

methIMAzole 2.5 mg Oral ONCE A DAY 7 0

Tapazole

_______________________________________________ ____________________________________________________

Patient/Guardian Signature Date/Time Nurse Signature Date/Time

Physician: Rathore, Perveen

ACCT #: 2501656

SEX: M

MR #: 109912

DOB: 10/08/1978 AGE: 47 years

Admit Date: 7/19/25 13:57

Stebbins Jr., Richard L

Do NOT Scan to Pharmacy

Page 3 of 3

printed 3/9/26 07:32

Transition Record - Part 3

Clinical Progress Note

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Westborough Behavioral Health Hospital

PCU: Adult B

Observation Date/Time: 7/23/25 16:27

Date/Time 7/21/2025 16:27

Treatments

- Richard will implement behavioral activation; being part of the routine/schedule,

structure of the hospital, daily hygiene and pleasurable activities such as yoga, music

therapy, and CBT, ACT, DBT groups while at WBHH. (Objective)

Summary Clinician met with patient to complete PSA. Patient presented as paranoid and

labile.

Staff Signature e-Signed by Johnson, Amanda at 07/23/2025 16:27

Observation Date/Time: 7/23/25 16:27

Date/Time 7/23/2025 16:27

Treatments

- Therapy will assist Richard in identifying desired/helpful leisure activities

(Intervention)

Summary Clinician met with patient to check in. Patient reported frustrations around provider

filing on him. Validated feelings and explained filing process.

Staff Signature e-Signed by Johnson, Amanda at 07/23/2025 16:28

Observation Date/Time: 7/29/25 13:34

Date/Time 7/29/2025 13:34

Treatments

Printed On: 03/09/2026 @ 7:32 Page 1 of 2

Clinical Progress Note

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Westborough Behavioral Health Hospital

PCU: Adult B

Problem: Danger to Self r/t SI (SI with plan to hang self)

Summary Clinician checked in with patient on 7/28 for introductions. Patient was well

groomed, calm, cooperative, and continues to present with an accusatory, paranoid

thought process. Patient has poor insight and continues to refuse pharmacological

intervention. Patient is schedule do discharge on 7/30.

Staff Signature e-Signed by Gaynor, Shaliva, MA at 07/29/2025 13:53

Observation Date/Time: 7/29/25 14:35

Date/Time 7/29/2025 14:35

Treatments

Problem: Danger to Self r/t SI (SI with plan to hang self)

Summary Patient signed ROI to contact outpatient providers.

Staff Signature e-Signed by Gaynor, Shaliva, MA at 07/29/2025 14:36

Observation Date/Time: 7/30/25 11:21

Date/Time 7/30/2025 11:21

Treatments

Problem: Danger to Self r/t SI (SI with plan to hang self)

Summary Patient reported feeling safe and ready to discharge today. Patient refused to

complete in a safety assessment.

Staff Signature e-Signed by Gaynor, Shaliva, MA at 07/30/2025 11:22

Printed On: 03/09/2026 @ 7:32 Page 2 of 2

Discharge Aftercare Plan

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/29/2025 10:28:38AM

Name of person receiving

instructions

Richard Stebbins

Relationship Patient

Discharge status Pt Initiated Prior to Recommended Date

Will be returning to work/school N/A

Substance Abuse ot Tobacco

Cessation Treatment Offered

N/A

Does patient have Advanced

Directive?

N/A

Other Instructions Patient will discharge home on 07/30/2025 @ 11:00 AM via Lyft.

Address: 54 Hope St, Springfield, MA 01119.

Missing Appointments:

If you are unable to keep your appointment, please call the appointment location at least 24 hours in advance, if possible, so you

can reschedule. It is important that you maintain contact with your physician(s) and/or therapist after discharge.

* If discharged to a home health agency (HHA), skilled nursing facility (SNF), inpatient rehab facility (IRF), or long-term care

hospital (LTCH), the patient was provided Key Performance Data, including Quality Metrics to assist with discharge planning

process.

Staff Initials FS

CRISIS EMERGENCY CONTACT INFORMATION:

The following are Emergency Numbers I can call if I need help.

911

Suicide Hotline 988

Westborough Behavioral HealthCare Hospital 508-329-6300

Discharge Meds:

None

Medication Orders:

Description Brand Dose Route Frequency PRN

Indication

----------- ----- ---- ----- --------- ---

----------

methIMAzole 5 mg TAB Tapazole 2.5 mg PO DAILY

Hyperthyroidism.

Notes:Give half of 5mg tab PT CASSETTE

nicotine Oral Transmucosal 2 mg Nicorette 2 mg OM Q2H P

craving

GUM

propranolol 20 mg TAB Inderal 40 mg PO TID

Anxiety

Printed On: 03/09/2026 @ 7:32 Page 1 of 3

Discharge Aftercare Plan

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time:

MEDICATION REMINDERS

DO NOT TAKE ALCOHOLIC BEVERAGES OR STREET DRUGS OF ANY KIND WHILE ON MEDICATIONS

Take Medications as they are prescribed at discharge. Do not change the dosed or time, unless directed by your physician

For adolescents, medication should be kept out of reach and in a secure place.

Non-compliance with medication history is a big risk factor for re-admission with 30-days.

Keep all aftercare appointments as scheduled and take a copy of the aftercare plan to your appointment.

Allergy Type Reaction Severity Date Code

System Comments

------- ---- -------- -------- ---- ----

------ --------

NKDA - NO KNOWN DRUG ALLERGIES Drug Allergy

7708584 RB Alg ID

Continuity of Lab / X-rays / Tests

Results and Contact Information

There were no lab/test results pending at the time of discharge

Labs pending at the time of

discharge

In case of a medical emergency, information will be provided to medical professionals by calling 508-329-6300 and asking for

the Nursing Supervisor.

I do not have access to any

prescription medications, drugs,

alcohol or drug paraphernalia, guns,

sharp utensils or any other weapons /

items that I would use with lethal

intent or intent to harm self or others.

Yes

I have received a copy of my

Aftercare Discharge Instructions and

Individual Wellness Recovery Plan

and I understand the instructions

provided and all my questions have

been answered.

Yes

I authorize the release of this

Aftercare Discharge Instructions to

the providers listed on the first page,

to assist in continuity of care.

Yes

Printed On: 03/09/2026 @ 7:32 Page 2 of 3

Discharge Aftercare Plan

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time:

I understand these records may include drug/alcohol/mental health/communicable disease-related information. I understand that

information released could contain reference to results of HIV antibody testing. A photocopy of this authorization should be

considered as valid as the original.

This consent is subject to revocation by the undersigned at any time, except to the extent that action has been taken in reliance

hereon and in any event shall expire within ninety (90) days from the date of signature below.

The information being authorized to release is being disclosed to you from records protected by the Federal Confidentiality Rules

(42CFR Part 2). A general authorization for the release of medical or other information is not sufficient for this purpose .

The information to be released is PRIVILEGED and CONFIDENTIAL and is intended ONLY for the use of the recipient(s) named

above.

Status at Discharge Verbalized ready for discharge and Ambulatory

Mode of transport Lyft

Accompanied by Self

Accompanied by Name Richard Stebbins

Signatures

The discharge instructions (pages 1 and 2) have been explained to me and my questions have been answered. I understand

and agree with the instructions.

Patient Signature Verbal Consent obtained from Stebbins Jr., Richard L at 07/30/2025 09:52

Case Manager Signature e-Signed by Syll, Fatma at 07/30/2025 09:53

Nurse Signature e-Signed by Nakityo, Jane, RN at 07/30/2025 10:12

Row Resource/Fac Provider Appointment Address Telephone/Fax/Em Reason

ility Name Date/Time ail

Follow-Up Care/Referrals

1 Trinity DR. Mark 08/01/2025 @ 305 Phone: 413-733- PCP Aftercare

Health Skalski 10:30 AM Bicentennial 4101 Ext2,1,1 Appointment

Hwy 2nd FL, Fax: 413- (DC Summary to

Springfield, 783-9544 Be Faxed)

MA 01118

2 Griswold Dr. 08/11/2025 @ 42 Wright Phone: 413-370- Psychiatric

Center Toussaint 12:00 PM in St, Palmer, 5285 Aftercare

covering for person MA 01069 Fax: 413- Appointment

Dr. Kristen 370-8575

Briody

Printed On: 03/09/2026 @ 7:32 Page 3 of 3

Discharge Summary

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/30/2025 10:21:00AM

Initial

Date/Time: 7/30/2025 00:00

Diagnosis Class Type Priority Date

Code System

--------- ----- ---- -------- ----

---- ------

Initial

Bipolar disorder, unspecified Psychiatric Provisiona Primary Diagnosis

F31.9 ICD-10

Attention-deficit Psychiatric Working Secondary Diagnosis

F90.9 ICD-10

hyperactivity disorder,

unspecified type

Essential (primary) Medical Working Secondary Diagnosis

I10 ICD-10

hypertension

Bipolar disorder, unspecified Medical Working

F31.9 ICD-10

Reason for Admission Acute manic episode w/physical aggression, grandiose, persecutory and paranoid

delusions. Hyperverbal tangential, with flight of ideas.

Chief Complaint (In patient's own

words)

" The CCA is defrauding me."

CC: " I will file law suit on the hospital " conversation need to be recorded will file

retaliation”

Printed On: 03/09/2026 @ 7:32 Page 1 of 7

Discharge Summary

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/30/2025 10:21:00AM

Course of Treatment Reason for Admission:

Presented to the emergency department following severe behavioral dysregulation,

paranoia, and agitation, with subsequent transfer to Baystate Medical Center. The

patient exhibited acute manic symptoms with psychosis.

History of Present Illness:

The patient has a psychiatric history of Major Depressive Disorder (MDD) with

psychotic features, ADHD, anxiety, and suspected bipolar disorder, currently in a

manic episode with psychotic features. He reports a medical history of thyroid

issues. The patient has had multiple suicide attempts (2004, 2005, 2015, 2016),

longstanding medication nonadherence, and recent discontinuation of psychiatric

medications.

On presentation, he was agitated, paranoid, and exhibiting persecutory delusions,

notably believing that the CCA was trying to defraud him. He was

non-communicative and required physical and chemical restraints, receiving IM

Versed 5 mg and Droperidol 10 mg for agitation control.

Hospital Course:

Upon arrival at WBHH, the psychiatric team discussed the need for medication to

improve prognosis. The patient refused medication, and his psychotic symptoms

persisted, primarily delusional in nature. Dr. Rathore took over his care, advocating

for inpatient commitment due to safety concerns. Despite efforts to encourage

medication adherence and safety planning, the patient remained noncooperative

and refused treatment.

Throughout hospitalization, the patient demonstrated ongoing delusional thinking,

tangential speech, and an irritable mood. He was non-violent, with no aggression

toward others noted for over 48 hours before his court hearing. His disorganization

made discharge planning challenging; however, he eventually signed releases for

outpatient services.

Discharge Plan:

The patient was discharged in a stable condition with no active SI or HI.

Encouraged to follow up with outpatient psychiatric services immediately.

Advised on medication adherence and safety planning.

Instructed to seek urgent care if symptoms worsen or if he experiences any suicidal

or homicidal thoughts.

Follow-Up:

Outpatient psychiatric appointment scheduled for [date], with community mental

health providers.

Summary:

This patient experienced an acute manic episode with psychotic features, requiring

inpatient stabilization. While medication refusal persisted, safety was maintained,

and the patient was discharged to outpatient services with encouragement for

continued treatment and monitoring.

Functional/ADL/Type

Printed On: 03/09/2026 @ 7:32 Page 2 of 7

Discharge Summary

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/30/2025 10:21:00AM

Check one of the following None or less than two antipsychotic medication prescribed at discharge

Physical/Baseline Functional Status

Physical condition is stable Yes

Ambulation Normal

Activities of Daily Living (Grooming

and Hygeine)

Able to Perform

Social functioning within normal

limits/baseline

Yes

Condition at the Time of Discharge

Include patient's strengths and risk factors, adjustment, ability to function upon discharge, including assessement of

suicidal/homicidal ideation.

Discharge Type at pt request

Status on day of discharge No aggression

Anticipated Problems after discharge

and suggested means for

intervention

encouraged to seek help for mental health

MSE

Appearance Appropriate

Behavior Guarded

Eye Contact Appropriate

Speech Appropriate

Orientation Time and Place

Attention Fair

Motor Appropriate

Thought Process Loose Associations and Disorganized

Thought Content delusions

Printed On: 03/09/2026 @ 7:32 Page 3 of 7

Discharge Summary

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/30/2025 10:21:00AM

Mood Euthymic

Affect Congruent

Insight Limited

How Tested/Assessed Inability to understand

Describe Inability to understand Nature of illness and Need for treatment

Judgement Limited

How Tested/Assessed Difficulty predicting results of choices

Recent Memory Not Impaired

Direct Questioning Name

Remote Memory Not Impaired

Direct Questioning Name of childhood town

Therapeutic Services

Columbia-Suicide Severity Rating Scale-Discharge

1. Have you wished you were dead or

wished you could go to sleep and not

wake up?

2. Have you actually had thoughts

about killing yourself?

If YES to 2, ask questions 3, 4, 5, and 6. If NO to 2, go directly to question 6

6. Have you done anything, started to

do anything, or prepared to do

anything to end your life?

Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn't swallow any,

held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn't jump;

or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.

Risk Level Low Suicide Risk

Printed On: 03/09/2026 @ 7:32 Page 4 of 7

Discharge Summary

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/30/2025 10:21:00AM

Violence or Harm to others

1. Are you having any thoughts of

harming others?

Outcome/justification for discharge no Aggression

Protective Factors: (Identify protective factors offsetting/mitigating identified risks)

Describes reasons for living and "Absence of plan, intent or means"

Therapeutic Services

Aftercare Plans (Document the following)

Patient is discharged to Home

Document the address and phone number to where patient is discharging to

Address na

Phone Number na

Transportation from Hospital Cab/Uber/etc

Post-Discharge Goal(s) (in patients’

own words)

" to stay safe"

Outpatient Tobacco Cessation

Counseling Treatment Provided

Refused

Row Resource/Fac Provider Appointment Address Telephone/Fax/Em Reason

ility Name Date/Time ail

Follow-Up Care/Referrals

1 Trinity DR. Mark 08/01/2025 @ 305 Phone: 413-733- PCP Aftercare

Health Skalski 10:30 AM Bicentennial 4101 Ext2,1,1 Appointment

Hwy 2nd FL, Fax: 413- (DC Summary to

Springfield, 783-9544 Be Faxed)

MA 01118

2 Griswold Dr. 08/11/2025 @ 42 Wright Phone: 413-370- Psychiatric

Center Toussaint 12:00 PM in St, Palmer, 5285 Aftercare

covering for person MA 01069 Fax: 413- Appointment

Dr. Kristen 370-8575

Briody

Printed On: 03/09/2026 @ 7:32 Page 5 of 7

Discharge Summary

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/30/2025 10:21:00AM

Nursing

Test and Procedures

Laboratory Results Copies provided

X-Ray Results N/A

EKG Results N/A

Other Results? No

Results Pending at Discharge N/A

Patient/Family Instructions completed

Medications Education

Diet N/A

Activity No Restrictions

Summary

Ability to return to work or school does not work

Description Brand Dose Route Frequency PRN

Indication

----------- ----- ---- ----- --------- ---

----------

Summary

methIMAzole 5 mg TAB Tapazole 2.5 mg PO DAILY

Hyperthyroidism.

nicotine Oral Transmucosal 2 mg Nicorette 2 mg OM Q2H P

craving

GUM

propranolol 40 mg TAB Inderal 40 mg PO TID

Anxiety

Is it appropriate to bill for this

documentation?

Yes

Printed On: 03/09/2026 @ 7:32 Page 6 of 7

Discharge Summary

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/30/2025 10:21:00AM

99238 - Discharge < 30 Minutes Yes

I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any

falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.

Provider Signature e-Signed by Okorafor, Ayodeji E, DNP at 07/30/2025 12:20

Printed On: 03/09/2026 @ 7:32 Page 7 of 7

General Note

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Westborough Behavioral Health Hospital

PCU: Adult B

Observation Date/Time: 7/19/25 15:31

Note After giving pt education about why a skin check is done, patient accepted. Skin

had no issues. Dr. Marks, was called and patient was removed off one to one.

Patient was put on 15 minutes checks.

Staff Signature e-Signed by Sebanenya, Isaac, RN at 07/19/2025 15:31

Observation Date/Time: 7/30/25 11:52

Note Pt discharged today 7-30-25 to home via Lyft. Pt refused to sign discharge

paperwork. Pt left unit in pleasant mood, ready for discharged.

Staff Signature e-Signed by Grampetro, Michael, RN at 07/30/2025 11:55

Printed On: 03/09/2026 @ 7:32 Page 1 of 1

History and Physical Exam

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/19/2025 8:41:47PM

Assessment

Date of Service: 7/19/2025 00:00

Chief Complaint (In patient's own

words)

" The CCA is defrauding me."

History of Present Illness 46 y.o. male with a history of bipolar disorder, ADHD, Hypertension admitted for SI

and plan to hang self.

Allergy Type Reaction Severity Date Code

System Comments

------- ---- -------- -------- ---- ----

------ --------

Assessment

NKDA - NO KNOWN DRUG ALLERGIES Drug Allergy

7708584 RB Alg ID

Medications

Home Meds:

Description Brand Dose Route Frequency PRN

Indication

----------- ----- ---- ----- --------- ---

----------

Medications

lisdexamfetamine Oral 20 mg CAP 1 Vyvanse 20 mg PO DAILY

Attention-deficit

hyperactivity disorder,

unspecified type

methIMAzole 5 mg TAB Tapazole

propranolol Oral 10 mg TAB Inderal

propranolol 40 mg TAB Inderal

propranolol 40 mg TAB Inderal 40 mg PO TID

Anxiety

Admission Meds:

Description Brand Dose Route Frequency PRN

Indication

----------- ----- ---- ----- --------- ---

----------

propranolol 40 mg TAB Inderal 40 mg PO TID

Anxiety

Printed On: 03/09/2026 @ 7:32 Page 1 of 8

History and Physical Exam

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/19/2025 8:41:47PM

Past, Family, and Social History (PFSH)

Surgical History Patient denies

Past Medical History Bipolar and HTN - Hypertension

Family History Denies history of problems

Martial Status Single

Living Situation Family/Sig. Other

Have you used tobacco within

previous 30 days?

Row Used in Age of 1st Current Current Current Date of Route of

last 30 Use Amount Frequency Duration Last Usage (IV,

Days Use/Amt Smoking,

etc.)

Social History

1 Cannabis unk pt unk unk unk unk unk

refusing to

sit down

and be

assessed by

clinician

without

lawyer and

without

recording

it but tox

screen

ppositive

for THC

Past, Family, and Social History (PFSH)

History of STD No

Exam

Review of Systems

Constitutional No Complaints

Printed On: 03/09/2026 @ 7:32 Page 2 of 8

History and Physical Exam

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/19/2025 8:41:47PM

Eyes No Complaints

ENMT No Complaints

Cardiovascular No Complaints

Respiratory No Complaints

Gastrointestinal No Complaints

Genitourinary No Complaints

Musculoskeletal No Complaints

Integumentary/Breast No Complaints

Neurological No Complaints

Psychiatric Anxiety

Endocrine No Complaints

Hematologic/Lymphatic No Complaints

Allergic/Immunologic No Complaints

Vital Signs

Systolic Blood Pressure 117 mmHg

Diastolic Blood Pressure 70 mmHg

Blood Pressure 117 / 70

Heart Rate 87 beats/min

Temperature 98.2 ºF

Respirations 18 brth/min

Height 72 in

Weight 190 lb

Printed On: 03/09/2026 @ 7:32 Page 3 of 8

History and Physical Exam

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/19/2025 8:41:47PM

SPO2 98 %

Physical Exam

General Apperance Cooperative

Orientation Person, Place and Time

Hallucination Denies

HEENMT WNL: Normocephalic, atraumatic. Pupils equal, round and reactive to light

symmetrically. EOM intact. Anicteric sclera. TM intact bilaterally. Nares clear.

Oropharynx is clear. No erythema or exudates noted. No acute dental problems

noted. Oral mucosa is moist.

Neck WNL: Supple. No lymphadenopathy, thyromegaly, or masses. No carotid bruit. No

JVD.

Respiratory WNL: clear to auscultation bilaterally. No wheezing or crackles heard. No deformity

or tenderness noted.

Cardiovascular WNL: Regular rate and rhythm. No murmur, gallop, or rub noted. No S3 or S4 heard.

PMI non displaced.

Chest/(Breasts) WNL: Clear to auscultation bilaterally. No wheezing or crackles heard. No deformity,

or tenderness noted.

Gastrointestinal (Abdomen) WNL: soft, normoactive bowel sounds, nondistended, nontender. No guarding or

rebound. No organomegaly.

Genitourinary (Male/Female) WNL: no complaints or concerns

Lymphatic WNL (without tenderness)

Musculoskeletal WNL (No clubbing, cyanosis, or edema. Pulses are present and equal bilaterally. No

scoliosis, kyphosis, or abnormal lordosis. NO CVA tenderness)

Skin WNL: Skin is warm and dry. No rashes or lesions noted

Psychiatric Abnormal

admitted for behavioral health care

Neurological Exam

(CN I) Olfactory Normal

How Tested Identification of cinnamon sample

(CN II) Optic Nerve Normal

Printed On: 03/09/2026 @ 7:32 Page 4 of 8

History and Physical Exam

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/19/2025 8:41:47PM

How Tested Distinguishes number of fingers in central field

(CN III) Oculomotor Normal

How Tested Able to move eyes upward and outward

(CN IV) Trochlear Normal

How Tested Able to move eyes medially (downward at nose)

(CN V) Trigeminal Normal

How Tested Able to clench teeth and feels touch on front of head

(CN VI) Abducens Normal

How Tested Able to move eyes to either side

(CN VII) Facial Normal

How Tested Able to lift both eyebrows

CN VIII – Vestibulocochlear Normal

How Tested Able to hear finger rubs in both ears

(CN IX) Glossopharyngeal Normal

How Tested Swallow intact

(CN X) Vagus Normal

How Tested Able to lift palate when saying “Ah”

(CN XI) Accessory Normal

How Tested Able to shrug shoulders equally

CN XII – Hypoglossal Normal

How Tested Able to stick tongue out straight without tremors or fasciculation

Motor/Sensory Functions

Printed On: 03/09/2026 @ 7:32 Page 5 of 8

History and Physical Exam

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/19/2025 8:41:47PM

Gait and station Normal

Romberg test Normal

Muscle tone Normal

No signs of limb weakness, atrophy

and fasciculation

Normal

Deep tendon reflexes are 2+ and

symmetrical

Normal

Plantar responses are down going Normal

Finger- to- nose Normal

Heel-to-shin Normal

Sensory -

pain/touch/vibration/position

Normal

Lab Results/Consultation/Record

Review

per medical clearance

Medical Diagnosis

Diagnosis Class Type Priority Date

Code System

--------- ----- ---- -------- ----

---- ------

Exam

Essential (primary) Medical Working Secondary Diagnosis

I10 ICD-10

hypertension

Bipolar disorder, unspecified Medical Working

F31.9 ICD-10

ATTESTATION

DeMertine, Marcel

have reviewed and updated the above diagnoses as appropriate

Yes

INITIAL CERTIFICATION

Printed On: 03/09/2026 @ 7:32 Page 6 of 8

History and Physical Exam

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/19/2025 8:41:47PM

I certify that inpatient psychiatric

hospital services furnished are

necessary for either: (1) treatment

which could reasonably be expected

to improve the patient's condition, or

(2) diagnostic study.

Yes

I also certify that the patient

continues to need, on a daily basis,

active treatment furnished directly by

or requiring the supervision of

inpatient psychiatric facility

personnel.

Yes

Treatment Plan and Recomendations

Problem: Danger to Self r/t SI (SI with plan to hang self)

- On a scale of 1-10 (where 1=manageable and 10=unmanageable) patient will report

diminished suicidal ideation and/or danger to self-behaviors from a 7 to a 4 (Goal)

- Patient will, prompted or independently, use a self-identified regulation skill to safely

manage suicidal ideation and/or danger to self. (Objective)

- .Staff will work with Richard to identify triggers and coping skills (Intervention)

Problem: Altered Cardiac Output – Hypertension/Hypotension r/t htn (Medication regimen)

- Blood Pressure will remain between and between for 4 days prior to discharge (Goal)

- Richard will take medications as ordered (Objective)

- .Staff will monitor patient as ordered by physician (Intervention)

Treatment Plan and Recomendations

Printed On: 03/09/2026 @ 7:32 Page 7 of 8

History and Physical Exam

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/19/2025 8:41:47PM

Medication Orders:

Description Brand Dose Route Frequency PRN

Indication

----------- ----- ---- ----- --------- ---

----------

propranolol 20 mg TAB Inderal 40 mg PO TID

Anxiety

Ancillary Orders:

Description Frequency PRN

----------- --------- ---

-Adult_Admit to: Involuntary Adult

-Assault/Aggression Precautions

- HIGH Suicide Precaution

-Certification of Admission

Notes:I certify that this patient's inpatient psychiatric hospital admission is medically

necessary for treatment which can reasonably be expected to improve the patient's condition

and/ or diagnostic study

-Community Meeting

-Therapeutic Recreation/Activity Therapy

-Psycho-educational Groups

-Psychotherapy Process Groups

-*Regular Diet

-History and Physical Exam

-Weight on admission and Weekly WEEKLY

-Vital Signs VS_BID_Ad

ult

-Review Precaution and Observation Orders ObsPre

Notes:Nurse to review and confirm patient's precautions and observations and document in

nursing notes

-Medical Diagnosis:

-Psychiatric Diagnosis:

-Urine Drug Screen - IN HOUSE Q4H-UC

-Every 15 Minutes Observation

Recommendations for Treatment

and/or Follow-up

review medications and resume as needed

Is it appropriate to bill for this

documentation?

Yes

99223 - Initial Hospital Care - High

Complexity

Yes

I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any

falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.

Signatures

Staff Signature e-Signed by DeMertine, Marcel at 07/19/2025 20:45

Printed On: 03/09/2026 @ 7:32 Page 8 of 8

Inpatient Nursing Admission Assessment

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/19/2025 3:14:49PM

Initial

Date/Time 7/19/2025 13:14

Chief Complaint (patient's own

words)

" The CCA is defrauding me."

Reason for Admission Acute manic episode w/physical aggression, grandiose, persecutory and paranoid

delusions. Hyperverbal tangential, with flight of ideas.

Preferred Language English

Preferred Name Richard

Preferred Pronoun He/Him/His

Sexual Orientation

What was your assigned sex at birth? Male

How do you currently describe

yourself?

Male

Which of the following best

represents how you think of your

sexual orientation?

Sexual or Heterosexual

Initial

Learning Assessment

Patient prefers Unable to assess pt refusing assessment unles its recorded

Cultural or Religious Preferences NA

Motivation to learn (rate) 1

Emotional Barriers to Learning Labile mood

Physical/Cognitive Limitations Active psychosis

Communication Barriers Tangential-difficulty staying on topic

Printed On: 03/09/2026 @ 7:32 Page 1 of 9

Inpatient Nursing Admission Assessment

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/19/2025 3:14:49PM

Allergy Type Reaction Severity Date Code

System Comments

------- ---- -------- -------- ---- ----

------ --------

Initial

NKDA - NO KNOWN DRUG ALLERGIES Drug Allergy

7708584 RB Alg ID

General Appearance pt neat and clean dressed in hospital scrubs, appears lean, nourished and hydrated

without any limits to mobility

Tobacco Use

Have you used tobacco within

previous 30 days

The Alcohol Use Disorders Identification Test (AUDIT-C)

How often do you have a drink

containing alcohol?

Never

How many drinks containing alcohol

do you have on a typical day when

you are drinking?

Never

How often do you have six or more

drinks if female, or 8 or more drinks if

male, on one occasion?

Never

Audit-C Score 0

Score is Less than 5

Scores between 0 and 7 - Lower Risk - No Intervention Required

Physical Status

Systolic Blood Pressure 156 mmHg

Diastolic Blood Pressure 91 mmHg

Printed On: 03/09/2026 @ 7:32 Page 2 of 9

Inpatient Nursing Admission Assessment

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/19/2025 3:14:49PM

Blood Pressure 156 / 91

Heart Rate 85 beats/min

Temperature 98.0 ºF

Respirations 18 brth/min

Height 72 in

Weight 190 lb

SPO2 98 % Room Air

Brief Psychiatric Rating Scale

Somatic Concern (0) Not Present

Guilty Feelings (0) Not Present

Emotional Withdrawal (5) Severe

Conceptual Disorganization (5) Severe

Tension (4) Moderately Severe

Mannerisms and Posturing (4) Moderately Severe

Grandiosity (5) Severe

Depressive Mood (0) Not Present

Hostility (0) Not Present

Suspiciousness (4) Moderately Severe

Hallucinatory Behavior (0) Not Present

Motor Retardation (0) Not Present

Blunted Affect (0) Not Present

Uncooperativeness (5) Severe

Printed On: 03/09/2026 @ 7:32 Page 3 of 9

Inpatient Nursing Admission Assessment

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/19/2025 3:14:49PM

Unusual Thought Content (5) Severe

Anxiety (5) Severe

Excitement (0) Not Present

Disorientation (2) Mild

Brief Psychiatric Rating Scale Total 44

Sleep/Vision/Hearing/Speech

Sleep, Vision, Hearing, Speech

Average hours of sleep per day unable to assess

Hours

Sleep - Check all that apply Problems Denied

Vision - Check all that apply Problems Denied

Hearing - Check all that apply Problems Denied

Immunization History/Flu Screening

Immunization History

Patient attends a school for which

enrollment is dependent upon current

immunizations

Immunizations believed to be current No

Have you had a Covid Vaccine? Unknown

Is it Flu season October-March? No

Check all that apply: (1 – 4 Permanent Contra-Indications for taking the influenza vaccine)

*Reminder to address form INFORMED CONSENT/DECLINATION FOR PATIENT INFLUENZA VACCINE with Patient

Printed On: 03/09/2026 @ 7:32 Page 4 of 9

Inpatient Nursing Admission Assessment

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time:

Nutritional

Nutritional Assessment

BMI 25.8

Total Score 0

Hydration Assessment

Approximate Daily Fluid Intake:

(other than ETOH)

3 – 6 glasses/day

If 0 – 2 glasses/day is selected, Patient may be dehydrated CALL PHYSICIAN to assess hydration status

Physical

Skin/Skin Integrity

Skin Check

Image

Per Patient Report: No Skin Issues Reported

Please explain any reported skin

integrity problems below

pt refused skin assesment in intake went up on 1 to 1

Staff Witness Grant, Elijah Walker, RN

Physical

Pain

Do you have pain now? No

Wong-Baker FACES

Printed On: 03/09/2026 @ 7:32 Page 5 of 9

Inpatient Nursing Admission Assessment

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time:

Humpty Dumpty

Humpty Dumpty Fall Assessment

Total Humpty Dumpty score: 0

Low Risk Humpty Dumpty score = 7-11

High Risk Humpty Dumpty score = 12 or above

Edmonson Psychiatric Fall Risk Assessment

Sleep Disturbance 12= Report of Sleep Disturbance by patient, family or staff

History of Falls 8=No history of falls

Mental Status 12=Agitation/Anxiety

Diagnosis 10=Bipolar/ Schizoaffective Disorder

Elimination 8=Independent with control of bowel/bladder

Medication 8= Psychotropic Medications (Including benzodiazepines and

Ambulation/Balance 7= Independent/Steady gait/Immobile

Nutrition 0=No apparent abnormalities with appetite

Age 8 = Less than 50

Total Score 73

Strengths and Liabilities

Inventory of Strengths and Liabilities

Patient's Strengths Supportive Family/Friends and Hx of Psychiatric Stability or Sobriety

Patient's Limitations Unemployed and Frequent Inpatient Admissions

Patient & Family Educational Needs Community Resources, Outpatient Programs and Substance Abuse

Printed On: 03/09/2026 @ 7:32 Page 6 of 9

Inpatient Nursing Admission Assessment

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/19/2025 3:14:49PM

Substance Abuse cannabis

Review Of Systems

Past Medical History per Intake Bipolar

Surgical History Patient denies

Review of Systems (Check all that apply)

Physical Problems denied

Occupational (Check areas requiring

assistance)

Problems denied

Swallowing Problems denied

ENMT No Complaints

Cardiovascular No Complaints

Respiratory No Complaints

Central Nervous System No Complaints

Gastrointestinal No Complaints

Genitourinary No Complaints

Musculoskeletal No Complaints

Integumentary/Breast No Complaints

Printed On: 03/09/2026 @ 7:32 Page 7 of 9

Inpatient Nursing Admission Assessment

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/19/2025 3:14:49PM

RN Narrative and Conclusions Patient is a 46-year-old male with psychiatric hx of MDD with psychotic features,

ADHD, anxiety, and r/o bipolar disorder. Pt reports medical hx of “thyroid issues.”

Patient has NKDA or allergies to food. Pt was brought to Baystate Medical Center

after exhibiting severe behavioral dysregulation and paranoia at court. Pt presented

with acute mania (elevated mood, pressured speech, grandiosity, persecutory

delusions and agitation.” Pt explained that CCA is trying to defraud him. Patient

arrived to the ED agitated, non-directable requiring physical and chemical

restraints, pt received IM Versed 5mg and Droperidol 10 mg. Patient has hx of

multiple suicide attempts (2004, 2005, 2015, and 2016), longstanding tx

nonadherence and recently off psychiatric medications. Per chart review in January

2016 while admitted inpatient pt Parker North barricaded himself in his room and

attempted to hang himself. Pt has hx of chronic self-injurious behaviors and

ongoing paranoid ideation. Pt lives with his younger sister.

Upon arrival to intake pt was agitated, noncompliant w/assessment, refusing to

sign anything, requesting to contact lawyer. Pt given phone and he left a message

for his “personal lawyer” about the unit he was on and the situation he is in. He

continues to endorse that CCA is conspiring against mental health professionals

and pts and that he is going to sue them and in doing this he is going to fix all the

problems with the current mental health system in America. He is hyperverbal,

tangential w/flight of ideas , paranoid and grandiose delusions

Pt admitted to adult B on 1:1 as he refused skin check in intake, AA, self-harm and

high suicide precautions.

Review Of Systems

Psychiatric

Problem - Danger to Self r/t SI (SI with plan to hang self) - Acute Care

07/19/2025

Goal - On a scale of 1-10 (where 1=manageable and 10=unmanageable) patient will report

diminished suicidal ideation and/or danger to self-behaviors from a 7 to a 4

07/19/2025 07/26/2025

Objective - Patient will, prompted or independently, use a self-identified regulation

skill to safely manage suicidal ideation and/or danger to self. 07/19/2025

07/26/2025

Intervention - .Staff will work with Richard to identify triggers and coping skills

TWICE A DAY 07/19/2025 Grant, Elijah Walker, RN

Medical

Problem - Altered Cardiac Output – Hypertension/Hypotension r/t htn (Medication regimen) -

Outpatient 07/19/2025

Goal - Blood Pressure will remain between and between for 4 days prior to

discharge 07/19/2025 07/26/2025

Objective - Richard will take medications as ordered 07/19/2025 07/26/2025

Intervention - .Staff will monitor patient as ordered by physician TWICE A DAY

07/19/2025 Grant, Elijah Walker, RN

Printed On: 03/09/2026 @ 7:32 Page 8 of 9

Inpatient Nursing Admission Assessment

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Observation Date/Time: 7/19/2025 3:14:49PM

Nursing Signature e-Signed by Guenette, Kara at 07/19/2025 15:26

Printed On: 03/09/2026 @ 7:32 Page 9 of 9

Inpatient Psychiatric Progress Note

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Westborough Behavioral Health Hospital

PCU: Adult B

Observation Date/Time: 7/22/25 11:23

Date of Service: 7/22/2025 00:00

Chief Complaint "in patient's own

words"

" The CCA is defrauding me."

Printed On: 03/09/2026 @ 7:32 Page 1 of 34

Inpatient Psychiatric Progress Note

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Westborough Behavioral Health Hospital

PCU: Adult B

Current or Interval Psychiatric history The service provided by the MD and 1:1 meeting with the patient.

reviewed chart, discussed patient in the Team meeting and w/ staff, met w/ pt..

EVENTS/Sx:

Patient presented alert and oriented to surroundings, irritable, reported sleeping

"okay". Patient denied pain or any discomfort, denied SI/HI/AVH. Patient was

disorganized, labile, loud. Refused scheduled medication. Patient did not utilize any

PRNs. Patient had meals off the unit in the cafeteria safely. No aggression.

Patient is a 46-year-old male with psychiatric hx of MDD with psychotic features,

ADHD, anxiety, and r/o bipolar disorder. Pt reports medical hx of “thyroid issues.”

Patient has NKDA or allergies to food. Pt was brought to Baystate Medical Center

after exhibiting severe behavioral dysregulation and paranoia at court. Per pt was in

Court for harassment complaint against the insurance company.

Pt presented with acute mania (elevated mood, pressured speech, grandiosity,

persecutory delusions and agitation.” Pt explained that CCA is trying to defraud

him. Patient arrived to the ED agitated, non-directable requiring physical and

chemical restraints, pt received IM Versed 5mg and Droperidol 10 mg.

Patient has hx of multiple suicide attempts (2004, 2005, 2015, and 2016),

longstanding tx nonadherence and recently off psychiatric medications. Per chart

review in January 2016 while admitted inpatient pt Parker North barricaded himself

in his room and attempted to hang himself. Pt has hx of chronic self-injurious

behaviors and ongoing paranoid ideation. ( it happened in the past” 2004-2005 tried

to kill myself. Pt lives with his younger sister.

At the intake at WBHH pt was agitated, noncompliant w/assessment, refusing to

sign anything, requesting to contact lawyer. Pt given phone and he left a message

for his “personal lawyer” about the unit he was on and the situation he is in. He

continues to endorse that CCA is conspiring against mental health professionals

and pts and that he is going to sue them and in doing this he is going to fix all the

problems with the current mental health system in America. He is hyperverbal,

tangential w/flight of ideas , paranoid and grandiose delusions

Propranolol: 40 mg TID for anxiety.

CC: " I will file law suit on the hospital "

Pt alert, verbal, attentive, Speech and eye contact wnl.

Per Report: They sent me to teach a lesson as he was filing charges. This hospital

is not Tx me.

If you are not going to release me I will file charges.

Pt live with his sister and nephew and My dog. I have not seen anyone not get my

tel.no

the therapist got upset with me and sent me here.

Mood is” I was kidnapped and wait to charge you

Pt very disorganized, hostile and not engaging in Tx Pt sign a 3 day which expires

tomorrow. Will File in Court for Commitment and 7&8

Pt sleep is no issues reported

Appetite is with in normal limits.

SI/self-harm - Pt denies any current suicidal thoughts or thoughts of self-harm.

Relevant MSE: MSE as above.

Tx Plan: Treatment plan reviewed and understood by patient

MEDS/sfx: Taking medication as prescribed. Medication education done and

discussed.

risk, benefits, and alternatives discussed including metabolic issues with

neuroleptic, ( if applicable) and patient understood and agreed.

Discussed the rationale for inpatient hospitalization, current clinical symptoms and

status, treatment planning including monitoring for stabilization and clinical

Printed On: 03/09/2026 @ 7:32 Page 2 of 34

Inpatient Psychiatric Progress Note

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Westborough Behavioral Health Hospital

PCU: Adult B

improvement, medications education and psychotherapy and other therapeutic

activities. Informed about the diagnostic impression and differential diagnosis.

Target symptoms discussed. Individualized treatment plan discussed including

goal, objectives, and intervention. Individualized crisis prevention plan and safety

plan reviewed. Patient was educated about medications options. Discussed

indications, CI, benefits, risks and side-effects and alternative options w

medications. Discussed FDA indications and warnings and cautions. Patient has

been tolerating treatment and medications well without any side effects, adverse

reactions or allergic reactions. Pt verbalized understanding and consented for

medications.

PLAN:

Patient requires continued hospitalization, for ongoing stabilization and possible

medications adjustment; and coping skills and milieu to manage stability.

Continue with individual and group therapy.

Medication side effects No

Compliance with treatment No

Describe will not take any meds for mania

Suicidal Ideation No

Homicidal Ideation No

Mental Status Exam

Appearance "Neat and Clean"

Behavior Guarded

Orientation Person

Concentration Inattentive

Speech Pressured

Insight Poor

Memory Poor

Printed On: 03/09/2026 @ 7:32 Page 3 of 34

Inpatient Psychiatric Progress Note

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Westborough Behavioral Health Hospital

PCU: Adult B

Judgement Poor

Affect hostile

Mood Irritable

Hallucinations Denies

Delusions Positive*

paranoia

Significant Labs & Dates none

Assessment Unchanged

Rationale for continued in-patient

care

Stabilization

MEDICATION / ANCILLARY

ORDERS

Medication Orders:

Printed On: 03/09/2026 @ 7:32 Page 4 of 34

Inpatient Psychiatric Progress Note

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Westborough Behavioral Health Hospital

PCU: Adult B

methIMAzole 5 mg TAB Tapazole 2.5 mg PO DAILY

Hyperthyroidism.

Notes:Give half of 5mg tab PT CASSETTE

propranolol 20 mg TAB Inderal 40 mg PO TID Anxiety

Ancillary Orders:

Description Frequency PRN

----------- --------- ---

-Adult_Admit to: Involuntary Adult

-Assault/Aggression Precautions

- HIGH Suicide Precaution

-Certification of Admission

Notes:I certify that this patient's inpatient psychiatric hospital admission is medically

necessary for treatment which can reasonably be expected to improve the patient's condition

and/ or diagnostic study

-Community Meeting

-Therapeutic Recreation/Activity Therapy

-Psycho-educational Groups

-Psychotherapy Process Groups

-*Regular Diet

-History and Physical Exam

-Weight on admission and Weekly WEEKLY

-Vital Signs VS_BID_Ad

ult

-Review Precaution and Observation Orders ObsPre

Notes:Nurse to review and confirm patient's precautions and observations and document in

nursing notes

-Medical Diagnosis:

-Psychiatric Diagnosis:

-Urine Drug Screen - IN HOUSE Q4H-UC

-Every 15 Minutes Observation

Treatments

Problem: Danger to Self r/t SI (SI with plan to hang self)

- On a scale of 1-10 (where 1=manageable and 10=unmanageable) patient will report diminished

suicidal ideation and/or danger to self-behaviors from a 7 to a 4 (Goal)

- Patient will, prompted or independently, use a self-identified regulation skill to safely

manage suicidal ideation and/or danger to self. (Objective)

- .Staff will work with Richard to identify triggers and coping skills (Intervention)

- Richard will implement behavioral activation; being part of the routine/schedule,

structure of the hospital, daily hygiene and pleasurable activities such as yoga, music

therapy, and CBT, ACT, DBT groups while at WBHH. (Objective)

- Therapy will assist Richard in identifying desired/helpful leisure activities

(Intervention)

- Attending Psychiatrist will conduct daily assessment of mood and mental status

(Intervention)

Change in psychiatric

Diagnosis/Treatment

Change in medical

Diagnosis/Treatment

Printed On: 03/09/2026 @ 7:32 Page 5 of 34

Inpatient Psychiatric Progress Note

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Westborough Behavioral Health Hospital

PCU: Adult B

Diagnosis Class Type Priority Date Code SyBipolar disorder, unspecified Psychiatric Provisiona Primary Diagnosis

F31.9 ICD-10

Attention-deficit Psychiatric Working Secondary Diagnosis

F90.9 ICD-10

hyperactivity disorder,

unspecified type

Essential (primary) Medical Working Secondary Diagnosis

I10 ICD-10

hypertension

Bipolar disorder, unspecified Medical Working

F31.9 ICD-10

Additional Information Mood is” I was kidnapped and wait to charge you

Pt very disorganized, hostile and not engaging in Tx Pt sign a 3 day which expires

tomorrow. Will File in Court for Commitment and 7&8

Is it appropriate to bill for this

documentation?

Yes

99233 - Subsequent Hospital High Yes

I do hereby attest that this

information is true, accurate and

complete to the best of my

knowledge and I understand that any

falsification, omission, or

concealment of material fact may

subject me to administrative, civil, or

criminal liability.

Provider Signature e-Signed by Rathore, Perveen, MD at 07/22/2025 23:01

Observation Date/Time: 7/23/25 16:48

Date of Service: 7/23/2025 00:00

Chief Complaint "in patient's own

words"

" The CCA is defrauding me."

CC: " I will file law suit on the hospital " conversation need to be recorded will file

retaliation”

Printed On: 03/09/2026 @ 7:32 Page 6 of 34

Inpatient Psychiatric Progress Note

Admit Date: 07/19/2025

DOB: 10/08/1978

Hosp #: 2501656

MR#: 109912

Stebbins Jr., Richard L

Westborough Behavioral Health Hospital

PCU: Adult B

Current or Interval Psychiatric history LAMB warning given and patient expressed understanding of the limits of

confidentiality

The service provided by the MD and 1:1 meeting with the patient.

reviewed chart, discussed patient in the Team meeting and w/ staff, met w/ pt..

Pleasantly psychotic paranoid visible hyperverbal grandiose and paranoia today.

Groups social, file for commitment if patient will not retract the three-day

EVENTS/Sx:

patient presenting as irritable, reported sleeping "okay". Patient denied pain or any

discomfort, denied SI/HI/AVH. Patient was disorganized, labile, loud. Refused

scheduled medication. Patient did not utilize any PRNs. Patient had meals off the

unit in the cafeteria safely. No aggression. Patient was educated about safety on the

unit with good understanding. Q 15 minute checks maintained for safety