2025-07-25-Dallas-Flaherty-Westborough

Westborough Behavioral Health Hospital

Ht: 70.00cm Wt: 0.00kg BMI: BSA: 0.00 Regular Pharmacy: WALGREENS DRUG STORE #05755

Patient Name: Flaherty, Dallas G DOB: 11/03/1994 Room-Bed: 2210b Admit Date/Time: 7/22/25 17:35

 0.00

Allergies: metoclopramide, NO FOOD ALLERGIES

Medications to take after Discharge

Medication Dose Route Freq Morning Noon Evening Bedtime

CARDIOVASCULAR AGENTS

amLODIPine 10 mg TAB (Norvasc) 10 mg Oral ONCE A DAY ü

Indication: Essential (primary) hypertension

Last Dose: 7/29/25 8:21 am

hydroCHLOROthiazide 25 mg TAB (Oretic) 25 mg Oral ONCE A DAY ü

Indication: Essential (primary) hypertension

Last Dose: 7/29/25 8:21 am

CENTRAL NERVOUS SYSTEM AGENTS

busPIRone 10 mg TAB (BuSpar) 10 mg Oral TWICE A DAY ü ü

Indication: Generalized anxiety disorder

Last Dose: 7/29/25 8:21 am

divalproex sodium ERT 500 mg ERT 1,000 mg Oral ONCE A DAY

(Depakote ER)

ü

Indication: Epilepsy,unspecified,not

intractable,without status epilepticus

Last Dose: 7/29/25 8:21 am

650 mg Oral EVERY 6 HOURS

AS NEEDED

acetaminophen 325 mg TAB (Tylenol)

Indication: pain

Last Dose:

GASTROINTESTINAL AGENTS

omeprazole 20 mg DRC (PriLOSEC) 20 mg Oral ONCE A DAY ü

Patient Note: SALAD

Indication: GERD

Physician: Okorafor, Ayodeji E, DNP

ACCT #: 2501689

SEX: M

MR #: 109931

DOB: 11/03/1994 AGE: 31 years

Admit Date: 7/22/25 17:35

Flaherty, Dallas G

Do NOT Scan to Pharmacy

Page 1 of 4

printed 3/31/26 11:12

Transition Record - Part 3

DISCHARGE MEDICATION SUMMARY FOR PATIENT

Patient Name: Flaherty, Dallas G

Westborough Behavioral Health Hospital

Medication Dose Route Freq Morning Noon Evening Bedtime

Last Dose: 7/29/25 8:21 am

MISCELLANEOUS AGENTS

4 mg Oral

Transmucos

al

EVERY 2 HOURS

AS NEEDED

nicotine 2 mg GUM (Nicorette)

Indication: Smoking Cessation

Last Dose: 7/28/25 6:06 pm

1 PATCH Transdermal ONCE A DAY AS

NEEDED

nicotine 21 mg/24 hr 21 mg/24 hr TERF

(nicotine patch 21mg)

Indication: Nicotine Dependence

Last Dose:

PSYCHOTHERAPEUTIC AGENTS

FLUoxetine 20 mg CAP (PROzac) 20 mg Oral ONCE A DAY ü

Indication: Anxiety,current episode manic without

psychotic features,severe

Last Dose: 7/29/25 8:21 am

UNKNOWN

0.5 mg Oral TWICE A DAY AS

NEEDED

LORazepam 0.5 mg TAB (Ativan)

Patient Note: SALAD

Indication: Generalized anxiety disorder

Last Dose: 7/29/25 10:13 am

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: Okorafor, Ayodeji E, DNP

ACCT #: 2501689

SEX: M

MR #: 109931

DOB: 11/03/1994 AGE: 31 years

Admit Date: 7/22/25 17:35

Flaherty, Dallas G

Do NOT Scan to Pharmacy

Page 2 of 4

printed 3/31/26 11:12

Transition Record - Part 3

DISCHARGE MEDICATION SUMMARY FOR PATIENT

Patient Name: Flaherty, Dallas G

Westborough Behavioral Health Hospital

Medication Dose Route Frequency

DO NOT CONTINUE THESE MEDICATIONS AT HOME

FLUoxetine 40 mg CAP ONCE A DAY

PROzac

40 mg Oral

divalproex sodium ERT 500 mg ERT ONCE A DAY

Depakote ER

500 mg Oral

Notes:Once-Daily

Physician: Okorafor, Ayodeji E, DNP

ACCT #: 2501689

SEX: M

MR #: 109931

DOB: 11/03/1994 AGE: 31 years

Admit Date: 7/22/25 17:35

Flaherty, Dallas G

Do NOT Scan to Pharmacy

Page 3 of 4

printed 3/31/26 11:12

Transition Record - Part 3

DISCHARGE MEDICATION SUMMARY FOR PATIENT

Patient Name: Flaherty, Dallas G

Westborough Behavioral Health Hospital

THESE DISCHARGE PRESCRIPTIONS e-PRESCRIBED TO:

WALGREENS DRUG STORE #05755

413 WASHINGTON ST

STOUGHTON, MA 020724210

Phone Number: 7813445600

03/31/2026 11:12 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

busPIRone 10 mg Oral TWICE A DAY 14 0

BuSpar

amLODIPine 10 mg Oral ONCE A DAY 7 0

Norvasc

hydroCHLOROthiazide 25 mg Oral ONCE A DAY 7 0

Oretic

omeprazole 20 mg Oral ONCE A DAY 7 0

PriLOSEC

FLUoxetine 20 mg Oral ONCE A DAY 7 0

PROzac

divalproex sodium ERT 1,000 mg Oral ONCE A DAY 14 0

Depakote ER

_______________________________________________ ____________________________________________________

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

Physician: Okorafor, Ayodeji E, DNP

ACCT #: 2501689

SEX: M

MR #: 109931

DOB: 11/03/1994 AGE: 31 years

Admit Date: 7/22/25 17:35

Flaherty, Dallas G

Do NOT Scan to Pharmacy

Page 4 of 4

printed 3/31/26 11:12

Transition Record - Part 3

Clinical Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/26/2025 9:21:00AM

Date/Time 7/26/2025 09:21

Treatments

Problem: Danger To Others r/t Physicial Aggression, Homicidal (HI statements towards parents,

property destruction,)

Problem: Danger to Self (drinking -intoxication, punching objects)

Problem: Altered Cardiac Output – Hypertension/Hypotension (Medication regimen, Verbal report

of history of Hypertension)

Problem: Nicotine Replacement/Smoking Cessation (Use of nicotine patch or gum per facility

protocol, History of excessive nicotine use)

Problem: Seizures (Alteration In Neurologic Homeostasis) (History of seizures. Last seizure

in 2002 per pt. Pt noncompliant with medications, including seizure prevention meds.)

Summary patient observed on the milieu in behavioral control , participating in groups but

observed to become easily agitated on the phone conversation- mood labile at

times. continue to monitor for any HI or aggression.

Staff Signature e-Signed by Campbell, Deanna at 07/26/2025 09:22

Printed On: 03/31/2026 @ 11:12 Page 1 of 1

Discharge Aftercare Plan

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/28/2025 2:01:02PM

Name of Person Receiving

Instructions

Dallas F

Relationship Patient

Discharge Status Completed Treatment Routine

Will be Returning to Work/School N/A

Substance Abuse or Tobacco

Cessation Treatment Offered

N/A

Does Patient Have Advanced

Directive?

N/A

Other Instructions Patient will discharge to mother's home via lyft 61 Drake Ave Stoughton, MA @ 2pm

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 MB

CRISIS EMERGENCY CONTACT INFORMATION:

The Following are Emergency Numbers I Can Call if I Need Help:

911

988 - Suicide Hotline, Call or Text

508-329-6300 - Westborough Behavioral HealthCare Hospital

Printed On: 03/31/2026 @ 11:12 Page 1 of 5

Discharge Aftercare Plan

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/28/2025 2:01:02PM

Discharge Meds:

Description Brand Dose Route Frequency PRN

Indication

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

----------

amLODIPine Oral 10 mg TAB Norvasc 10 mg PO DAILY

Essential (primary)

hypertension

busPIRone Oral 10 mg TAB BuSpar 10 mg PO BID

Generalized anxiety

disorder

divalproex sodium Oral 500 mg ERT Depakote 1,000 PO DAILY

Epilepsy,unspecified,not

(Once-Daily) ER mg

intractable,without status

epilepticus

FLUoxetine Oral 20 mg CAP PROzac 20 mg PO DAILY

Anxiety,current episode

 manic

without psychotic

features,severe

hydroCHLOROthiazide Oral 25 mg TAB Oretic 25 mg PO DAILY

Essential (primary)

hypertension

LORazepam Oral 0.5 mg TAB Ativan 0.5 mg PO BID P

Generalized anxiety

disorder

 Notes:SALAD

nicotine Oral Transmucosal 2 mg Nicorette 4 mg OM Q2H P

Smoking Cessation

GUM

nicotine 21 mg/24 hr Transdermal *nicotine 1 TD DAILY P

Nicotine Dependence

TERF patch PATCH

 21mg

omeprazole Oral 20 mg DRC PriLOSEC 20 mg PO DAILY GERD

 Notes:SALAD

acetaminophen Oral 325 mg TAB *Tylenol 650 mg PO Q6H P pain

Medication Orders:

Description Brand Dose Route Frequency PRN

Indication

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

----------

amLODIPine Oral 10 mg TAB Norvasc 10 mg PO DAILY

Essential (primary)

hypertension

busPIRone Oral 10 mg TAB BuSpar 10 mg PO BID

Generalized anxiety

disorder

cloNIDine (Catapres) Oral 0.1 mg Catapres 0.1 mg PO TID P

Printed On: 03/31/2026 @ 11:12 Page 2 of 5

Discharge Aftercare Plan

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/28/2025 2:01:02PM

Elevated BP above 140/90.

 Notes:Hold if HR<60 OR BP<90/60 or if symptomatic

SALAD

TAB

divalproex sodium Oral 500 mg ERT Depakote 1,000 PO DAILY

Epilepsy,unspecified,not

(Once-Daily) ER mg

intractable,without status

epilepticus

 Notes:Once-Daily

FLUoxetine Oral 20 mg CAP PROzac 20 mg PO DAILY

Anxiety,current episode

 manic

without psychotic

features,severe

hydroCHLOROthiazide Oral 25 mg TAB Oretic 25 mg PO DAILY

Essential (primary)

hypertension

LORazepam Oral 0.5 mg TAB Ativan 0.5 mg PO BID P

Generalized anxiety

disorder

 Notes:SALAD

nicotine Oral Transmucosal 2 mg Nicorette 4 mg OM Q2H P

Smoking Cessation

GUM

nicotine 21 mg/24 hr Transdermal *nicotine 1 TD DAILY P

Nicotine Dependence

TERF patch PATCH

 21mg

omeprazole Oral 20 mg DRC PriLOSEC 20 mg PO DAILY GERD

 Notes:SALAD

acetaminophen Oral 325 mg TAB *Tylenol 650 mg PO Q6H P pain

 Notes:NTE 3000 mg/day

MEDICATION REMINDERS

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

MEDICATIONS!

Take Medications as they are prescribed at discharge. Do not change the dosage 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.

Printed On: 03/31/2026 @ 11:12 Page 3 of 5

Discharge Aftercare Plan

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time:

Allergy Type Reaction Severity Date Code System

Comments

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

--------

metoclopramide Drug Allergy d00298 MULTUM

DRUGID

NO FOOD ALLERGIES Drug Allergy

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

No

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 these

Aftercare Discharge Instructions to

the providers listed on the first page,

to assist in continuity of care.

Yes

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

Mode of transport Lyft

Accompanied by Self

Printed On: 03/31/2026 @ 11:12 Page 4 of 5

Discharge Aftercare Plan

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/28/2025 2:01:02PM

Accompanied by Name self

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 Flaherty, Dallas G at 07/29/2025 12:29

Case Manager Signature e-Signed by Bard, Meghan, COTA/L at 07/29/2025 12:30

Nurse Signature e-Signed by Nalunkuma, Faridah, RN at 07/29/2025 13:36

Row Resource/Fac Provider Appointment Address Contact Reason

 ility Name Date/Time Number/Fax/Email

Follow-Up Care/Referrals

1 Cape *referral tbd 340 Gifford Therapy

 Behavioral initiated* St Falmouth,

 Health MA 02540

 Center

 (North East)

2 Cape Alanya 8/1 @ 2pm 340 Gifford Psychiatry

 Behavioral Bouchard TELEHEALTH St Falmouth,

 Health MA 02540

 Center

 (North East)

Printed On: 03/31/2026 @ 11:12 Page 5 of 5

Discharge Summary

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/29/2025 10:24:14AM

Initial

Date/Time: 7/29/2025 00:00

Diagnosis Class Type Priority Date

Code System

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

---- ------

Initial

Bipolar disorder, current Psychiatric Provisiona Primary Diagnosis

F31.13 ICD-10

episode manic without l

psychotic features, severe

Autistic disorder Psychiatric Working

F84.0 ICD-10

Generalized anxiety disorder Psychiatric Working

F41.1 ICD-10

Personal history of traumatic Medical Working

Z87.820 ICD-10

brain injury

Alcohol abuse, uncomplicated Working

F10.10 ICD-10

Attention-deficit Working

F90.9 ICD-10

hyperactivity disorder,

unspecified type

Cannabis abuse, uncomplicated Working

F12.10 ICD-10

Epilepsy, unspecified, not Working

G40.909 ICD-10

intractable, without status

epilepticus

Essential (primary) Working

I10 ICD-10

hypertension

Nicotine dependence, Working

F17.200 ICD-10

unspecified, uncomplicated

Pervasive developmental Working

F84.9 ICD-10

disorder, unspecified

Presence of other specified Working

Z97.8 ICD-10

devices

Printed On: 03/31/2026 @ 11:12 Page 1 of 7

Discharge Summary

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/29/2025 10:24:14AM

Reason for Admission Dallas is a 30 y.o. male presenting to WBHH from Good Samaritan. Pt was

sectioned by police, for HI (stating he was going to kill parents/ hit father) after an

argument with his parents. PPHx of bipolar d/o, ASD, GAD, PDD nos, and ADHD.

PMH of seizure d/o, TBI (brain bleed/ lack of oxygen at birth) and HTN. Allergy to

Reglan. In-house urine tox positive for benzos and thc. Agitated in ED, required IM

medications (Haldol and Ativan) both 7/21 and 7/22. Pt lives with Mom and wanted

to put a restraining order against Mom, though both mom and pt are on the rental

lease.

Pt arrived cooperative but labile, cycling between irritation, crying spells, and

fatigue. Signed CV. VSS. States reason for admission as “It was just a big big

misunderstanding. I talked to my father on the phone and I got pissed with him and

pissed at my mother and I needed to get away.” Pt confirms diagnoses and reports

he had a VP shunt revision 20 years ago. ROI signed for mom (Terry) in order to get

medication information/ appointment information, as pt did not know all of his

meds or doses, stating “they expire so I don’t take them and I didn’t fill them. They

are always expiring”. Mom called for medications list. She states he is

noncompliant and has been off meds for at least “a couple months.” Home

medications include buspirone 10mg bid, amlodipine 10mg, metoprolol (dose

unknown), hydrochlorothiazide 25mg, omeprazole 20mg, fluoxetine 40mg, and

lorazepam 1mg, divalproex 500mg, 0.5 tab PRN for acute anxiety or agitation and 1

tab hs. Daily 1.5 to 2 packs cigarette smoker. Daily 0.5 oz cannabis user. Twice

weekly drinker (6 beers/ 2 shots). Pt has upcoming appt with new therapist on 8/8.

Perseverating on mom being the cause/ reason he is here. Perseverating on

appointment that he thinks he has on Friday, but mom reports his appt isn’t until

8/8. Pt states “There she goes lying again. This is all her fault.”

15-minute checks, low suicide precautions, AA and seizure precautions. Telephone

orders from Dr Marks: Continue medications except metoprolol, decrease PRN

lorazepam to 0.5mg bid. Start nicotine patch and gum PRN.

Chief Complaint (In patient's own

words)

States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Printed On: 03/31/2026 @ 11:12 Page 2 of 7

Discharge Summary

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/29/2025 10:24:14AM

Course of Treatment Reason for Admission:

Patient was admitted to the emergency department under Section 12 following

homicidal statements directed toward his parents. He denies current homicidal

ideation but admits to past threats, including an intent to punch his father. The

patient reports frustration stemming from unresolved family disputes, notably

concerning his uncle's coin collection, which his father is withholding. He

attempted to file a restraining order against his mother but was unable to articulate

specific reasons.

Clinical Course and Treatment:

Upon arrival, the patient presented as anxious, irritable, with a labile mood. His

Depakote dosage was increased to 1000 mg, which resulted in a good therapeutic

effect. His mood gradually improved over the course of hospitalization. A Depakote

level was ordered, but results were unavailable at the time of discharge. The patient

demonstrated good compliance with treatment recommendations and reported

improvement in symptoms of mood and perceived safety.

Throughout hospitalization, the patient did not exhibit any unsafe behaviors,

including aggression, suicidal ideation (SI), or self-harm (SIB). There were no

reports of new medical issues or allergies, and he denied any worsening of

pre-existing medical conditions. His medical status remained stable during his stay.

Assessment and Disposition:

The clinical presentation and progress indicated that the patient had reached

maximum benefit from the inpatient program. Given his stability and lack of

imminent danger to self or others, a decision was made to discharge him. The

patient continues to deny SI, SIB, or homicidal ideation.

Plan and Recommendations:

Continue adherence to prescribed medication regimen, including Depakote.

Follow up with psychiatrist, therapist, and primary care provider for ongoing

stabilization and treatment.

Emphasized the importance of regular outpatient appointments to prevent relapse

and decompensation of both medical and mental health conditions.

Patient was educated on recognizing early warning signs of mood destabilization

and instructed to seek immediate help if symptoms worsen.

Summary:

The patient showed significant clinical improvement, with stabilization of mood and

overall functioning. He is deemed safe for community reintegration with appropriate

outpatient support and medication management.

Discharge Status:

Stable, improved, not an imminent risk to self or others.

Functional/ADL/Type

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

Physical/Baseline Functional Status

Printed On: 03/31/2026 @ 11:12 Page 3 of 7

Discharge Summary

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/29/2025 10:24:14AM

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 Routine

Status on day of discharge Improved mood

Anticipated Problems after discharge

and suggested means for

intervention

encouraged med adherence

MSE

Appearance Appropriate

Behavior Cooperative

Eye Contact Appropriate

Speech Appropriate

Orientation Time and Place

Attention Fair

Motor Appropriate

Thought Process Appropriate

Thought Content Denies

Mood Euthymic

Affect Congruent

Printed On: 03/31/2026 @ 11:12 Page 4 of 7

Discharge Summary

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/29/2025 10:24:14AM

Insight Fair

How Tested/Assessed Understanding severity of illness

Judgement Fair

How Tested/Assessed Able to anticipate outcomes

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?

No

2. Have you actually had thoughts

about killing yourself?

No

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?

No

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

Violence or Harm to others

1. Are you having any thoughts of

harming others?

No

Outcome/justification for discharge improved mood

Printed On: 03/31/2026 @ 11:12 Page 5 of 7

Discharge Summary

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/29/2025 10:24:14AM

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

"Absence of plan, intent or means" and Engages in formulation of treatment plan

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 Contact Reason

 ility Name Date/Time Number/Fax/Email

Follow-Up Care/Referrals

1 Cape *referral tbd 340 Gifford Therapy

 Behavioral initiated* St Falmouth,

 Health MA 02540

 Center

 (North East)

2 Cape Alanya 8/1 @ 2pm 340 Gifford Psychiatry

 Behavioral Bouchard TELEHEALTH St Falmouth,

 Health MA 02540

 Center

 (North East)

Nursing

Test and Procedures

Printed On: 03/31/2026 @ 11:12 Page 6 of 7

Discharge Summary

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/29/2025 10:24:14AM

Laboratory Results Copies provided

X-Ray Results N/A

EKG Results N/A

Other Results? No

Results Pending at Discharge Yes

Explain VPA

Patient/Family Instructions completed

Medications Education

Diet N/A

Activity No Restrictions

Summary

Ability to return to work or school does not work

Summary

None

Is it appropriate to bill for this

documentation?

Yes

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 07/29/2025 10:37

Printed On: 03/31/2026 @ 11:12 Page 7 of 7

General Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/29/2025 2:03:36PM

Note Patient is alert and verbally responsive. Denies having any pain or discomfort. No

SI/SH noticed this shift. Patient verbalized of feeing great and ready to go home.

RN educated patient about his medication and future appointments. Patient

verbalized of understanding and will follow through. Patient went home with his

belongings and used a lyft to go home.

Staff Signature e-Signed by Nalunkuma, Faridah, RN at 07/29/2025 14:07

Printed On: 03/31/2026 @ 11:12 Page 1 of 1

History and Physical Exam

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:13:15AM

Assessment

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

Chief Complaint (In patient's own

words)

States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

History of Present Illness 30 y/o male with hx of Bipolar, ASD, GAD, nicotine dependence, Essential HTN,

Epilepsy, GERD is admitted from Boston medical hospital due to threatening

statements. He denies any medical complaints.

Allergy Type Reaction Severity Date Code System

Comments

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

--------

Assessment

metoclopramide Drug Allergy d00298 MULTUM

DRUGID

NO FOOD ALLERGIES Drug Allergy

Medications

Medications

Medications

Printed On: 03/31/2026 @ 11:12 Page 1 of 11

History and Physical Exam

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:13:15AM

Home Meds:

Description Brand Dose Route Frequency PRN

Indication

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

----------

Although a patient record was

found, no medications were

available.

amLODIPine Oral 10 mg TAB Norvasc 10 mg PO DAILY

Essential (primary)

hypertension

busPIRone Oral 10 mg TAB BuSpar 10 mg PO BID

Generalized anxiety

disorder

divalproex sodium Oral 500 mg ERT Depakote 500 mg PO DAILY

Epilepsy, unspecified, not

(Once-Daily) ER

intractable, without status

epilepticus

 Notes:Once-Daily

FLUoxetine 40 mg CAP PROzac 40 mg PO DAILY

Bipolar disorder, current

episode manic without

psychotic features, severe

hydroCHLOROthiazide Oral 25 mg TAB Oretic 25 mg PO DAILY

Essential (primary)

hypertension

LORazepam Oral 0.5 mg TAB Ativan 0.5 mg PO BID P

Generalized anxiety

disorder

 Notes:SALAD

omeprazole Oral 20 mg DRC PriLOSEC 20 mg PO DAILY GERD

 Notes:SALAD

Admission Meds:

Description Brand Dose Route Frequency PRN

Indication

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

----------

amLODIPine Oral 10 mg TAB Norvasc 10 mg PO DAILY

Essential (primary)

hypertension

busPIRone Oral 10 mg TAB BuSpar 10 mg PO BID

Generalized anxiety

disorder

divalproex sodium Oral 500 mg ERT Depakote 500 mg PO DAILY

Epilepsy, unspecified, not

(Once-Daily) ER

intractable, without status

Printed On: 03/31/2026 @ 11:12 Page 2 of 11

History and Physical Exam

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:13:15AM

epilepticus

 Notes:Once-Daily

FLUoxetine 40 mg CAP PROzac 40 mg PO DAILY

Bipolar disorder, current

episode manic without

psychotic features, severe

hydroCHLOROthiazide Oral 25 mg TAB Oretic 25 mg PO DAILY

Essential (primary)

hypertension

LORazepam Oral 0.5 mg TAB Ativan 0.5 mg PO BID P

Generalized anxiety

disorder

 Notes:SALAD

omeprazole Oral 20 mg DRC PriLOSEC 20 mg PO DAILY GERD

 Notes:SALAD

Past, Family, and Social History (PFSH)

Surgical History VP shunt/ VP revision 20 years ago

Past Medical History Bipolar, Seizures, Suicide attempts and "Bipolar disorder, current episode manic

without psychotic features, severe,Autistic disorder,Generalized anxiety

disorder,Personal history of traumatic brain injury,Alcohol abuse,

uncomplicated,Attention-deficit hyperactivity disorder, unspecified type,Cannabis

abuse, uncomplicated,Epilepsy, unspecified, not intractable, without status

epilepticus,Essential (primary) hypertension,Nicotine dependence, unspecified,

uncomplicated,Pervasive developmental disorder, unspecified,Presence of other

specified devices"

Family History Cardiovascular Disease, Psychiatric Illness, Cancer/Tumors and Diabetes

Martial Status Engaged

Living Situation Family/Sig. Other

Have you used tobacco within

previous 30 days?

Yes

Choose one Greater than ¼ pack / day or daily use of smokeless tobacco, pipe, cigars

Printed On: 03/31/2026 @ 11:12 Page 3 of 11

History and Physical Exam

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:13:15AM

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 Nicotine 18 1.5 to 2 Daily 12 years Prior to ED Inhalation

 packs daily Admittance

2 Cannabis 18 0.5 ounce Daily 12 years Prior to ED Inhalation

 daily Admittance

3 ETOH Unknown Twice Twice Unknown Unknown PO

 weekly: 6 weekly

 beers/ 2

 shots

Past, Family, and Social History (PFSH)

History of STD No

Exam

Review of Systems

Constitutional No Complaints

Eyes No Complaints

ENMT No Complaints

Cardiovascular No Complaints

Respiratory No Complaints

Gastrointestinal No Complaints

Genitourinary No Complaints

Musculoskeletal Pain

Musculoskeletal Comments Back pain

Integumentary/Breast No Complaints

Printed On: 03/31/2026 @ 11:12 Page 4 of 11

History and Physical Exam

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:13:15AM

Neurological No Complaints

Psychiatric No Complaints

Endocrine No Complaints

Hematologic/Lymphatic No Complaints

Allergic/Immunologic No Complaints

Vital Signs

Systolic Blood Pressure 131 mmHg

Diastolic Blood Pressure 91 mmHg

Blood Pressure 131 / 91

Heart Rate 102 beats/min

Temperature 98 ºF

Respirations 18 brth/min

Height 70 in

Weight 201 lb

SPO2 96 %

Physical Exam

General Apperance Cooperative

Orientation Person, Time and Situation

Hallucination Denies

HEENMT Abnormal

Wears glasses

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

JVD.

Printed On: 03/31/2026 @ 11:12 Page 5 of 11

History and Physical Exam

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:13:15AM

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 Abnormal

surgical scar to R head, Hx of head surgery due to head bleed.

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

Psychiatric Abnormal

admitted for psychiatry eval and treatment.

Neurological Exam

(CN I) Olfactory Normal

How Tested Identification of cinnamon sample

(CN II) Optic Nerve Normal

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 WNL - EOM’s intact without lid lag or nystagmus

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

Printed On: 03/31/2026 @ 11:12 Page 6 of 11

History and Physical Exam

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:13:15AM

(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

Gait and station Normal

Romberg test not performed

Muscle tone Normal

No signs of limb weakness, atrophy

and fasciculation

Normal

Deep tendon reflexes are 2+ and

symmetrical

not performed

Plantar responses are down going Normal

Finger- to- nose Normal

Printed On: 03/31/2026 @ 11:12 Page 7 of 11

History and Physical Exam

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:13:15AM

Heel-to-shin Normal

Sensory -

pain/touch/vibration/position

Normal

Lab Results/Consultation/Record

Review

as cleared by ED

Medical Diagnosis

Diagnosis Class Type Priority Date

Code System

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

---- ------

Exam

Personal history of traumatic Medical Working

Z87.820 ICD-10

brain injury

ATTESTATION

I,

Darko, Sylvia

have reviewed and updated the above diagnoses as appropriate

Yes

INITIAL CERTIFICATION

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

Printed On: 03/31/2026 @ 11:12 Page 8 of 11

History and Physical Exam

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:13:15AM

Problem: Altered Cardiac Output – Hypertension/Hypotension (Medication regimen, Verbal report

of history of Hypertension)

 - Dallas will be able to identify signs and symptoms of increased BP by time of discharge

(Goal)

 - Dallas will take medications as ordered (Objective)

 - Nursing staff to administer medication and treatment(s) as ordered per MD (Intervention)

Problem: Nicotine Replacement/Smoking Cessation (Use of nicotine patch or gum per facility

protocol, History of excessive nicotine use)

 - Dallas will be compliant with nicotine replacement (Goal)

 - Dallas will practice an identified coping skill to manage/reduce smoking urges

(Objective)

 - Nursing will administer nicotine replacement protocol as ordered per MD (Intervention)

Problem: Seizures (Alteration In Neurologic Homeostasis) (History of seizures. Last seizure

in 2002 per pt. Pt noncompliant with medications, including seizure prevention meds.)

 - Dallas will follow up with primary care physician for continued issues related to

seizures (Goal)

 - Dallas will exhibit an understanding of their seizure disorder prior to discharge

(Objective)

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

Treatment Plan and Recomendations

Printed On: 03/31/2026 @ 11:12 Page 9 of 11

History and Physical Exam

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:13:15AM

Medication Orders:

Description Brand Dose Route Frequency PRN

Indication

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

----------

amLODIPine Oral 10 mg TAB Norvasc 10 mg PO DAILY

Essential (primary)

hypertension

busPIRone Oral 10 mg TAB BuSpar 10 mg PO BID

Generalized anxiety

disorder

divalproex sodium Oral 500 mg ERT Depakote 500 mg PO DAILY

Epilepsy,unspecified,not

(Once-Daily) ER

intractable,without status

epilepticus

 Notes:Once-Daily

FLUoxetine Oral 20 mg CAP PROzac 40 mg PO DAILY

Bipolar disorder,current

episode manic without

psychotic features,severe

hydroCHLOROthiazide Oral 25 mg TAB Oretic 25 mg PO DAILY

Essential (primary)

hypertension

LORazepam Oral 0.5 mg TAB Ativan 0.5 mg PO BID P

Generalized anxiety

disorder

 Notes:SALAD

nicotine Oral Transmucosal 2 mg Nicorette 4 mg OM Q2H P

Smoking Cessation

GUM

nicotine 21 mg/24 hr Transdermal *nicotine 1 TD DAILY P

Nicotine Dependence

TERF patch PATCH

 21mg

omeprazole Oral 20 mg DRC PriLOSEC 20 mg PO DAILY GERD

 Notes:SALAD

Ancillary Orders:

Description Frequency PRN

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

-Adult_Admit to: Conditional Voluntary Adult

-COMPREHENSIVE METABOLIC PANEL IN AM-UC

-CBC (INCLUDES DIFF/PLT) IN AM-UC

-Assault/Aggression Precautions

-Seizure Precautions

- LOW 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

Printed On: 03/31/2026 @ 11:12 Page 10 of 11

History and Physical Exam

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:13:15AM

-Community Meeting

-Therapeutic Recreation/Activity Therapy

-Psycho-educational 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

-Every 15 Minutes Observation

-Medical Diagnosis:

-Psychiatric Diagnosis:

-Psychotherapy Process Groups

-Dietary Consult: Consult - Nutrition screen score of 3 or More

Recommendations for Treatment

and/or Follow-up

30 y/o male with hx of Bipolar, ASD, GAD, nicotine dependence, Essential HTN,

Epilepsy, GERD is admitted from Boston medical hospital due to threatening

statements. He denies any medical complaints.

ED lab work/screening

as cleared by ED

Assessment

Bipolar, ASD, GAD, nicotine dependence, Essential HTN, Epilepsy, GERD

Plan

Chart reviewed. Patient is medically stable as cleared by ED

Resume home meds

Monitor BP

Seizure precautions

Monitor for safety

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 Darko, Sylvia at 07/23/2025 10:47

Printed On: 03/31/2026 @ 11:12 Page 11 of 11

Inpatient Nursing Admission Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/22/2025 7:25:27PM

Initial

Date/Time 7/22/2025 19:25

Chief Complaint (patient's own

words)

States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Reason for Admission Dallas is a 30 y.o. male presenting to WBHH from Good Samaritan. Pt was

sectioned by police, for HI (stating he was going to kill parents/ hit father) after an

argument with his parents. PPHx of bipolar d/o, ASD, GAD, PDD nos, and ADHD.

PMH of seizure d/o, TBI (brain bleed/ lack of oxygen at birth) and HTN. Allergy to

Reglan. In-house urine tox positive for benzos and thc. Agitated in ED, required IM

medications (Haldol and Ativan) both 7/21 and 7/22. Pt lives with Mom and wanted

to put a restraining order against Mom, though both mom and pt are on the rental

lease.

Pt arrived cooperative but labile, cycling between irritation, crying spells, and

fatigue. Signed CV. VSS. States reason for admission as “It was just a big big

misunderstanding. I talked to my father on the phone and I got pissed with him and

pissed at my mother and I needed to get away.” Pt confirms diagnoses and reports

he had a VP shunt revision 20 years ago. ROI signed for mom (Terry) in order to get

medication information/ appointment information, as pt did not know all of his

meds or doses, stating “they expire so I don’t take them and I didn’t fill them. They

are always expiring”. Mom called for medications list. She states he is

noncompliant and has been off meds for at least “a couple months.” Home

medications include buspirone 10mg bid, amlodipine 10mg, metoprolol (dose

unknown), hydrochlorothiazide 25mg, omeprazole 20mg, fluoxetine 40mg, and

lorazepam 1mg, divalproex 500mg, 0.5 tab PRN for acute anxiety or agitation and 1

tab hs. Daily 1.5 to 2 packs cigarette smoker. Daily 0.5 oz cannabis user. Twice

weekly drinker (6 beers/ 2 shots). Pt has upcoming appt with new therapist on 8/8.

Perseverating on mom being the cause/ reason he is here. Perseverating on

appointment that he thinks he has on Friday, but mom reports his appt isn’t until

8/8. Pt states “There she goes lying again. This is all her fault.”

15-minute checks, low suicide precautions, AA and seizure precautions. Telephone

orders from Dr Marks: Continue medications except metoprolol, decrease PRN

lorazepam to 0.5mg bid. Start nicotine patch and gum PRN.

Preferred Language English

Preferred Name Dallas

Preferred Pronoun He/Him/His

Sexual Orientation

What was your assigned sex at birth? Male

Printed On: 03/31/2026 @ 11:13 Page 1 of 11

Inpatient Nursing Admission Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/22/2025 7:25:27PM

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 Audio and Visual

Cultural or Religious Preferences "Protestant I think"

Motivation to learn (rate) 1

Emotional Barriers to Learning Labile mood and Abuse

Physical/Cognitive Limitations Learning disability

Communication Barriers None

Allergy Type Reaction Severity Date Code System

Comments

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

--------

Initial

metoclopramide Drug Allergy d00298 MULTUM

DRUGID

NO FOOD ALLERGIES Drug Allergy

General Appearance Disheveled. Sunburnt and picking at skin on scalp. Appears older than stated age.

Tobacco Use

Tobacco Use

Have you used tobacco within

previous 30 days

Yes

Choose one Greater than ¼ pack / day or daily use of smokeless tobacco, pipe, cigars

Tobacco Cessation Counseling

Provided

Refused

Printed On: 03/31/2026 @ 11:13 Page 2 of 11

Inpatient Nursing Admission Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/22/2025 7:25:27PM

FDA Approved Cessation Medication

offered

Refused

Tobacco Cessation Provider

Provided

Refused

The Alcohol Use Disorders Identification Test (AUDIT-C)

How often do you have a drink

containing alcohol?

2 to 3 times a week

How many drinks containing alcohol

do you have on a typical day when

you are drinking?

7, 8, or 9

How often do you have six or more

drinks if female, or 8 or more drinks if

male, on one occasion?

Weekly

Audit-C Score 9

Score is 5 or Greater

 **SCORES OF 5 + REQUIRES THE FOLLOWING 7 QUESTIONS TO BE COMPLETED

How often during the last year have

you found that you weren't able to

stop drinking once you started?

Never

How often during the last year have

you failed to do what was normally

expected from you because of

drinking?

Never

How often during the last year have

you been unable to remember what

happened the night before because

you had been drinking?

Never

How often during the last year have

you needed an alcoholic drink first

thing in the morning to get yourself

going after a night of heavy drinking?

Never

How often during the last year have

you had a feeling of guilt or remorse

after drinking?

Never

Have you or someone else been

injured as a result of your drinking?

No

Has a relative, friend, doctor, or

another health professional

expressed concern about your

drinking or suggested you cut down?

Yes, during the last year

AUDIT Score: 4

Printed On: 03/31/2026 @ 11:13 Page 3 of 11

Inpatient Nursing Admission Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/22/2025 7:25:27PM

AUDIT-C and AUDIT Total Score 13

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

Scores between 8 and 15 - Inceasing Risk - Brief Advice

Scores between 16 and 19 - Higher Risk - Brief Advice and/or extended BA

Scores of 20+ - Possible Dependence - Referral to Services

Patient Refused

Physical Status

Physical Status

Systolic Blood Pressure 131 mmHg

Diastolic Blood Pressure 91 mmHg

Blood Pressure 131 / 91

Heart Rate 102 beats/min

Temperature 98 ºF

Respirations 18 brth/min

Height 70 in

Weight 201 lb

SPO2 96 % Room Air

Brief Psychiatric Rating Scale

Somatic Concern (3) Moderate

Guilty Feelings (0) Not Present

Emotional Withdrawal (2) Mild

Printed On: 03/31/2026 @ 11:13 Page 4 of 11

Inpatient Nursing Admission Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/22/2025 7:25:27PM

Conceptual Disorganization (3) Moderate

Tension (3) Moderate

Mannerisms and Posturing (3) Moderate

Grandiosity (2) Mild

Depressive Mood (2) Mild

Hostility (3) Moderate

Suspiciousness (2) Mild

Hallucinatory Behavior (0) Not Present

Motor Retardation (0) Not Present

Blunted Affect (0) Not Present

Uncooperativeness (2) Mild

Unusual Thought Content (0) Not Present

Anxiety (2) Mild

Excitement (3) Moderate

Disorientation (2) Mild

Brief Psychiatric Rating Scale Total 32

Sleep/Vision/Hearing/Speech

Sleep, Vision, Hearing, Speech

Average hours of sleep per day 5 to 6

Hours

Sleep - Check all that apply Insomnia, Early Awakening, Night Time Awakening and Difficulty Falling Asleep

Printed On: 03/31/2026 @ 11:13 Page 5 of 11

Inpatient Nursing Admission Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/22/2025 7:25:27PM

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

No

Immunizations believed to be current No

Have you had a Covid Vaccine? No

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

Nutritional

Nutritional Assessment

BMI 28.8

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

Printed On: 03/31/2026 @ 11:13 Page 6 of 11

Inpatient Nursing Admission Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/22/2025 7:25:27PM

Skin Check

Image

Per Patient Report: Rashes, Burns and Scars

Please explain any reported skin

integrity problems below

Sunburn to head, face, neck and extremities. Surgical scars to abd and head (VP/

VP revision). Rash to right side/ underarm area.

Staff Witness Bah, Abu Bakarr Bakarr

Physical

Pain

Pain

Do you have pain now? Yes

Wong-Baker FACES

Current Pain Score 5

Type of Pain Throbbing and Aching

Frequency Continuous

Tolerable Pain Level 2

Duration Chronic

Location: (specify area) Upper Back and Lower Back

Aggravating factors Sitting

Current pain relief regimens: Somewhat effective

Effects of pain on Daily Activities Somewhat Limiting

Printed On: 03/31/2026 @ 11:13 Page 7 of 11

Inpatient Nursing Admission Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

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 and 8=Substance abuse/Alcohol abuse

Elimination 8=Independent with control of bowel/bladder

Medication 10=No Medications

Ambulation/Balance 7= Independent/Steady gait/Immobile

Nutrition 0=No apparent abnormalities with appetite

Age 8 = Less than 50

Total Score 83

Strengths and Liabilities

Inventory of Strengths and Liabilities

Patient's Strengths Stable Housing, Supportive Family/Friends and Hx of Psychiatric Stability or

Sobriety

Patient's Limitations Lack of Motivation, Unemployed and Perseverating on mom/ blame shifting

Patient & Family Educational Needs Community Resources and Outpatient Programs

Printed On: 03/31/2026 @ 11:13 Page 8 of 11

Inpatient Nursing Admission Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/22/2025 7:25:27PM

Review Of Systems

Past Medical History per Intake Bipolar, Seizures, Suicide attempts and "Bipolar disorder, current episode manic

without psychotic features, severe,Autistic disorder,Generalized anxiety

disorder,Personal history of traumatic brain injury,Alcohol abuse,

uncomplicated,Attention-deficit hyperactivity disorder, unspecified type,Cannabis

abuse, uncomplicated,Epilepsy, unspecified, not intractable, without status

epilepticus,Essential (primary) hypertension,Nicotine dependence, unspecified,

uncomplicated,Pervasive developmental disorder, unspecified,Presence of other

specified devices"

Surgical History VP shunt/ VP revision 20 years ago

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 Seizure disorder and TBI

Gastrointestinal No Complaints

Genitourinary No Complaints

Musculoskeletal Pain

Musculoskeletal Comments Back pain

Integumentary/Breast No Complaints

Printed On: 03/31/2026 @ 11:13 Page 9 of 11

Inpatient Nursing Admission Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/22/2025 7:25:27PM

RN Narrative and Conclusions Dallas is a 30 y.o. male presenting to WBHH from Good Samaritan. Pt was

sectioned by police, for HI (stating he was going to kill parents/ hit father) after an

argument with his parents. PPHx of bipolar d/o, ASD, GAD, PDD nos, and ADHD.

PMH of seizure d/o, TBI (brain bleed/ lack of oxygen at birth) and HTN. Allergy to

Reglan. In-house urine tox positive for benzos and thc. Agitated in ED, required IM

medications (Haldol and Ativan) both 7/21 and 7/22. Pt lives with Mom and wanted

to put a restraining order against Mom, though both mom and pt are on the rental

lease.

Pt arrived cooperative but labile, cycling between irritation, crying spells, and

fatigue. Signed CV. VSS. States reason for admission as “It was just a big big

misunderstanding. I talked to my father on the phone and I got pissed with him and

pissed at my mother and I needed to get away.” Pt confirms diagnoses and reports

he had a VP shunt revision 20 years ago. ROI signed for mom (Terry) in order to get

medication information/ appointment information, as pt did not know all of his

meds or doses, stating “they expire so I don’t take them and I didn’t fill them. They

are always expiring”. Mom called for medications list. She states he is

noncompliant and has been off meds for at least “a couple months.” Home

medications include buspirone 10mg bid, amlodipine 10mg, metoprolol (dose

unknown), hydrochlorothiazide 25mg, omeprazole 20mg, fluoxetine 40mg, and

lorazepam 1mg, divalproex 500mg, 0.5 tab PRN for acute anxiety or agitation and 1

tab hs. Daily 1.5 to 2 packs cigarette smoker. Daily 0.5 oz cannabis user. Twice

weekly drinker (6 beers/ 2 shots). Pt has upcoming appt with new therapist on 8/8.

Perseverating on mom being the cause/ reason he is here. Perseverating on

appointment that he thinks he has on Friday, but mom reports his appt isn’t until

8/8. Pt states “There she goes lying again. This is all her fault.” Pt endorses 2

suicide attempts occuring around 10 years ago (via strangulation). Denies current

SI/HI/AVH. No prior IPLOC hospitalizations.

15-minute checks, low suicide precautions, AA and seizure precautions. Telephone

orders from Dr Marks: Continue medications except metoprolol, decrease PRN

lorazepam to 0.5mg bid. Start nicotine patch and gum PRN.

Review Of Systems

Printed On: 03/31/2026 @ 11:13 Page 10 of 11

Inpatient Nursing Admission Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/22/2025 7:25:27PM

Psychiatric

 Problem - Danger To Others r/t Physicial Aggression, Homicidal (HI statements towards

parents, property destruction,) - Acute Care 07/22/2025

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

diminished Homicidal ideation and/or Danger to others and/or Physical aggression from a 9 to

a 3 07/22/2025 07/30/2025

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

skill to safely manage danger to others, homicidal ideation, and/or physical aggression.

07/22/2025 07/30/2025

 Intervention - Conduct group (art, music, animal, movement, expressive) and monitor

patient progress for the development of new leisure skills to decrease danger to others,

homicidal ideation, and/or physical aggression TWICE A DAY 07/22/2025

Morrison, Edith

 Intervention - .Nursing will when Dallas identified with potential loss of control, ask

Dallas what PRN medication is most helpful and administer medication according to doctor’s

order. TWICE A DAY 07/22/2025 Morrison, Edith

 Intervention - Nursing will monitor Dallas as ordered by physician TWICE A DAY

07/22/2025 Morrison, Edith

 Problem - Danger to Self (drinking -intoxication, punching objects) - Acute Care

07/22/2025

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

skill to safely manage suicidal ideation and/or danger to self. 07/22/2025

07/30/2025

 Intervention - Conduct group (art, music, animal, movement, expressive) and monitor

patient progress for the development of new leisure skills to decrease danger to others,

homicidal ideation, and/or physical aggression TWICE A DAY 07/22/2025

Morrison, Edith

 Intervention - Nursing will monitor Dallas as ordered by physician As Needed

07/22/2025 Morrison, Edith

Medical

 Problem - Altered Cardiac Output – Hypertension/Hypotension (Medication regimen, Verbal

report of history of Hypertension) - Acute Care 07/22/2025

Nursing Signature e-Signed by Avramidis, Angela at 07/22/2025 19:39

Printed On: 03/31/2026 @ 11:13 Page 11 of 11

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Observation Date/Time:

INPATIENT PSYCHIATRIC

PROGRESS NOTE

Date of Service: 7/24/2025 00:00

Chief Complaint "in patient's own

words"

States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Current or Interval Psychiatric History patient continues to display emotional lability and accusatory speech. Despite

expressing a desire for discharge and claiming symptom improvement, he remains

visibly distressed about family issues. The clinical team observes that his affect is

incongruent with his stated mood, and he exhibits some agitation. The patient’s

safety appears maintained at this time; however, his statements suggest ongoing

stress related to family conflicts.

Plan & Recommendations:

Continue inpatient hospitalization for stabilization and safety monitoring

Medications will be maintained and adjusted as needed

The clinical team will arrange a follow-up outpatient appointment

Medication Side Effects No

Compliance with Treatment Yes

Suicidal Ideation No

Homicidal Ideation No

MENTAL STATUS EXAM

Appearance "Neat and Clean"

Behavior Impulsive

Orientation Person and Place

Concentration Inattentive

Speech Normal

Printed On: 03/31/2026 @ 11:13 Page 1 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Insight Poor

Memory Fair

Judgement Poor

Affect Labile

Mood Anxious

Hallucinations Denies

Delusions Patient currently denies

Significant Labs & Dates none

Assessment Unchanged

Rationale for Continued Inpatient

Level of Care

stabilization

MEDICATION / ANCILLARY

ORDERS

Medication Orders:

Printed On: 03/31/2026 @ 11:13 Page 2 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

amLODIPine Oral 10 mg TAB Norvasc 10 mg PO DAILY

Essential (primary)

hypertension

busPIRone Oral 10 mg TAB BuSpar 10 mg PO BID

Generalized anxiety

disorder

cloNIDine (Catapres) Oral 0.1 mg Catapres 0.1 mg PO TID P

Elevated BP above 140/90.

 Notes:Hold if HR<60 OR BP<90/60 or if symptomatic

SALAD

TAB

divalproex sodium Oral 500 mg ERT Depakote 500 mg PO DAILY

Epilepsy,unspecified,not

(Once-Daily) ER

intractable,without status

epilepticus

 Notes:Once-Daily

FLUoxetine Oral 20 mg CAP PROzac 40 mg PO DAILY Bipolar

disorder,current

 episode

manic without

psychotic features,severe

hydroCHLOROthiazide Oral 25 mg TAB Oretic 25 mg PO DAILY

Essential (primary)

hypertension

LORazepam Oral 0.5 mg TAB Ativan 0.5 mg PO BID P

Generalized anxiety

disorder

 Notes:SALAD

nicotine Oral Transmucosal 2 mg Nicorette 4 mg OM Q2H P Smoking

Cessation

GUM

nicotine 21 mg/24 hr Transdermal *nicotine 1 TD DAILY P

Nicotine Dependence

TERF patch PATCH

 21mg

omeprazole Oral 20 mg DRC PriLOSEC 20 mg PO DAILY GERD

 Notes:SALAD

acetaminophen Oral 325 mg TAB *Tylenol 650 mg PO Q6H P pain

 Notes:NTE 3000 mg/day

Ancillary Orders:

Description Frequency PRN

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

-Adult_Admit to: Conditional Voluntary Adult

-COMPREHENSIVE METABOLIC PANEL IN AM-UC

-CBC (INCLUDES DIFF/PLT) IN AM-UC

-Assault/Aggression Precautions

Printed On: 03/31/2026 @ 11:13 Page 3 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

-Seizure Precautions

- LOW 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

-*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

-Every 15 Minutes Observation

-Medical Diagnosis:

-Psychiatric Diagnosis:

-Psychotherapy Process Groups

TREATMENT PLANNING

Problem: Danger To Others r/t Physicial Aggression, Homicidal (HI statements towards parents,

property destruction,)

OBSERVATION LEVELS AND

PRECAUTIONS/CHANGE IN

DIAGNOSIS

Current Level of Observation Every 15 minutes

Current Precautions LOW Suicide, Seizure, Assault/Aggression

Change in Psychiatric

Diagnosis/Treatment

No

Change in Medical

Diagnosis/Treatment

No

Diagnosis Class Type Priority Date Code SyPrinted On: 03/31/2026 @ 11:13 Page 4 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Bipolar disorder, current Psychiatric Provisiona Primary Diagnosis

F31.13 ICD-10

episode manic without l

psychotic features, severe

Autistic disorder Psychiatric Working

F84.0 ICD-10

Generalized anxiety disorder Psychiatric Working

F41.1 ICD-10

Personal history of traumatic Medical Working

Z87.820 ICD-10

brain injury

Alcohol abuse, uncomplicated Working

F10.10 ICD-10

Attention-deficit Working

F90.9 ICD-10

hyperactivity disorder,

unspecified type

Cannabis abuse, uncomplicated Working

F12.10 ICD-10

Epilepsy, unspecified, not Working

G40.909 ICD-10

intractable, without status

epilepticus

Essential (primary) Working

I10 ICD-10

hypertension

Nicotine dependence, Working

F17.200 ICD-10

unspecified, uncomplicated

Pervasive developmental Working

F84.9 ICD-10

disorder, unspecified

Presence of other specified Working

Z97.8 ICD-10

devices

Is it appropriate to bill for this

documentation?

Yes

99231 - Subsequent Hospital Low 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 07/24/2025 12:52

Observation Date/Time:

Printed On: 03/31/2026 @ 11:13 Page 5 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

INPATIENT PSYCHIATRIC

PROGRESS NOTE

Date of Service: 7/25/2025 00:00

Chief Complaint "in patient's own

words"

States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Current or Interval Psychiatric History Patient continues to demonstrate emotional lability and accusatory speech. Despite

expressing a desire for discharge and reporting symptom improvement, he remains

visibly distressed, particularly regarding ongoing family issues. The clinical team

observes that his affect is incongruent with his stated mood, and he exhibits some

agitation, including pacing the milieu.

The patient's safety appears to be maintained at this time. However, his statements

indicate ongoing stress related to family conflicts. He was observed pacing the

milieu, which coincided with increased blood pressure measured by medical staff;

he is currently on amlodipine and has been started on PRN clonidine 0.1 mg for

blood pressure management.

Medication adjustments include an increase of Depakote to 1000 mg daily. Labs

have been ordered for tomorrow to monitor therapeutic levels and overall clinical

status. Continued monitoring of mood, safety, and stress levels is warranted.

Medication Side Effects No

Compliance with Treatment Yes

Suicidal Ideation No

Homicidal Ideation No

MENTAL STATUS EXAM

Appearance "Neat and Clean"

Behavior Impulsive

Orientation Person and Place

Concentration Inattentive

Printed On: 03/31/2026 @ 11:13 Page 6 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Speech Pressured

Insight Poor

Memory Fair

Judgement Poor

Affect Labile

Mood Euthymic

Hallucinations Denies

Delusions Patient currently denies

Significant Labs & Dates none

Assessment Unchanged

Rationale for Continued Inpatient

Level of Care

stabilization

MEDICATION / ANCILLARY

ORDERS

Medication Orders:

Printed On: 03/31/2026 @ 11:13 Page 7 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

amLODIPine Oral 10 mg TAB Norvasc 10 mg PO DAILY

Essential (primary)

hypertension

busPIRone Oral 10 mg TAB BuSpar 10 mg PO BID

Generalized anxiety

disorder

cloNIDine (Catapres) Oral 0.1 mg Catapres 0.1 mg PO TID

Elevated BP above 140/90.

 Notes:Hold if HR<60 OR BP<90/60 or if symptomatic

SALAD

TAB

divalproex sodium Oral 500 mg ERT Depakote 1,000 PO DAILY

Epilepsy,unspecified,not

(Once-Daily) ER mg

intractable,without status

epilepticus

 Notes:Once-Daily

FLUoxetine Oral 20 mg CAP PROzac 20 mg PO DAILY

Anxiety,current episode

 manic

without psychotic

features,severe

hydroCHLOROthiazide Oral 25 mg TAB Oretic 25 mg PO DAILY

Essential (primary)

hypertension

LORazepam Oral 0.5 mg TAB Ativan 0.5 mg PO BID P

Generalized anxiety

disorder

 Notes:SALAD

nicotine Oral Transmucosal 2 mg Nicorette 4 mg OM Q2H P Smoking

Cessation

GUM

nicotine 21 mg/24 hr Transdermal *nicotine 1 TD DAILY P

Nicotine Dependence

TERF patch PATCH

 21mg

omeprazole Oral 20 mg DRC PriLOSEC 20 mg PO DAILY GERD

 Notes:SALAD

acetaminophen Oral 325 mg TAB *Tylenol 650 mg PO Q6H P pain

 Notes:NTE 3000 mg/day

Ancillary Orders:

Description Frequency PRN

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

-Adult_Admit to: Conditional Voluntary Adult

-COMPREHENSIVE METABOLIC PANEL IN AM-UC

-CBC (INCLUDES DIFF/PLT) IN AM-UC

-Assault/Aggression Precautions

Printed On: 03/31/2026 @ 11:13 Page 8 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

-Seizure Precautions

- LOW 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

-Every 15 Minutes Observation

-Medical Diagnosis:

-Psychiatric Diagnosis:

-VALPROIC ACID INAMUC

TREATMENT PLANNING

Problem: Danger To Others r/t Physicial Aggression, Homicidal (HI statements towards parents,

property destruction,)

OBSERVATION LEVELS AND

PRECAUTIONS/CHANGE IN

DIAGNOSIS

Current Level of Observation Every 15 minutes

Current Precautions LOW Suicide, Seizure, Assault/Aggression

Change in Psychiatric

Diagnosis/Treatment

No

Change in Medical

Diagnosis/Treatment

No

Diagnosis Class Type Priority Date Code SyPrinted On: 03/31/2026 @ 11:13 Page 9 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Bipolar disorder, current Psychiatric Provisiona Primary Diagnosis

F31.13 ICD-10

episode manic without l

psychotic features, severe

Autistic disorder Psychiatric Working

F84.0 ICD-10

Generalized anxiety disorder Psychiatric Working

F41.1 ICD-10

Personal history of traumatic Medical Working

Z87.820 ICD-10

brain injury

Alcohol abuse, uncomplicated Working

F10.10 ICD-10

Attention-deficit Working

F90.9 ICD-10

hyperactivity disorder,

unspecified type

Cannabis abuse, uncomplicated Working

F12.10 ICD-10

Epilepsy, unspecified, not Working

G40.909 ICD-10

intractable, without status

epilepticus

Essential (primary) Working

I10 ICD-10

hypertension

Nicotine dependence, Working

F17.200 ICD-10

unspecified, uncomplicated

Pervasive developmental Working

F84.9 ICD-10

disorder, unspecified

Presence of other specified Working

Z97.8 ICD-10

devices

Is it appropriate to bill for this

documentation?

Yes

99231 - Subsequent Hospital Low 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 07/25/2025 11:48

Observation Date/Time:

Printed On: 03/31/2026 @ 11:13 Page 10 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

INPATIENT PSYCHIATRIC

PROGRESS NOTE

Date of Service: 7/26/2025 00:00

Chief Complaint "in patient's own

words"

States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Current or Interval Psychiatric History Patient is visible on the milieu, he is irritable mood continues to be labile, exit

seeking, poorly follows staff redirections, agitated, encouraged medication

adherence, tolerating current dose of Depakote with no reported side effect.

Medication Side Effects No

Compliance with Treatment Yes

Suicidal Ideation No

Homicidal Ideation No

MENTAL STATUS EXAM

Appearance "Neat and Clean"

Behavior Impulsive

Orientation Person and Place

Concentration Inattentive

Speech Pressured

Insight Poor

Memory Fair

Judgement Poor

Affect Labile

Printed On: 03/31/2026 @ 11:13 Page 11 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Mood Euthymic

Hallucinations Denies

Delusions Patient currently denies

Significant Labs & Dates none

Assessment Unchanged

Rationale for Continued Inpatient

Level of Care

stabilization

MEDICATION / ANCILLARY

ORDERS

Medication Orders:

Printed On: 03/31/2026 @ 11:13 Page 12 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

amLODIPine Oral 10 mg TAB Norvasc 10 mg PO DAILY

Essential (primary)

hypertension

busPIRone Oral 10 mg TAB BuSpar 10 mg PO BID

Generalized anxiety

disorder

cloNIDine (Catapres) Oral 0.1 mg Catapres 0.1 mg PO TID

Elevated BP above 140/90.

 Notes:Hold if HR<60 OR BP<90/60 or if symptomatic

SALAD

TAB

divalproex sodium Oral 500 mg ERT Depakote 1,000 PO DAILY

Epilepsy,unspecified,not

(Once-Daily) ER mg

intractable,without status

epilepticus

 Notes:Once-Daily

FLUoxetine Oral 20 mg CAP PROzac 20 mg PO DAILY

Anxiety,current episode

 manic

without psychotic

features,severe

hydroCHLOROthiazide Oral 25 mg TAB Oretic 25 mg PO DAILY

Essential (primary)

hypertension

LORazepam Oral 0.5 mg TAB Ativan 0.5 mg PO BID P

Generalized anxiety

disorder

 Notes:SALAD

nicotine Oral Transmucosal 2 mg Nicorette 4 mg OM Q2H P Smoking

Cessation

GUM

nicotine 21 mg/24 hr Transdermal *nicotine 1 TD DAILY P

Nicotine Dependence

TERF patch PATCH

 21mg

omeprazole Oral 20 mg DRC PriLOSEC 20 mg PO DAILY GERD

 Notes:SALAD

acetaminophen Oral 325 mg TAB *Tylenol 650 mg PO Q6H P pain

 Notes:NTE 3000 mg/day

Ancillary Orders:

Description Frequency PRN

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

-Adult_Admit to: Conditional Voluntary Adult

-COMPREHENSIVE METABOLIC PANEL IN AM-UC

-CBC (INCLUDES DIFF/PLT) IN AM-UC

-Assault/Aggression Precautions

Printed On: 03/31/2026 @ 11:13 Page 13 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

-Seizure Precautions

- LOW 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

-Every 15 Minutes Observation

-Medical Diagnosis:

-Psychiatric Diagnosis:

-VALPROIC ACID INAMUC

TREATMENT PLANNING

Problem: Danger To Others r/t Physicial Aggression, Homicidal (HI statements towards parents,

property destruction,)

OBSERVATION LEVELS AND

PRECAUTIONS/CHANGE IN

DIAGNOSIS

Current Level of Observation Every 15 minutes

Current Precautions LOW Suicide, Seizure, Assault/Aggression

Change in Psychiatric

Diagnosis/Treatment

No

Change in Medical

Diagnosis/Treatment

No

Diagnosis Class Type Priority Date Code SyPrinted On: 03/31/2026 @ 11:13 Page 14 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Bipolar disorder, current Psychiatric Provisiona Primary Diagnosis

F31.13 ICD-10

episode manic without l

psychotic features, severe

Autistic disorder Psychiatric Working

F84.0 ICD-10

Generalized anxiety disorder Psychiatric Working

F41.1 ICD-10

Personal history of traumatic Medical Working

Z87.820 ICD-10

brain injury

Alcohol abuse, uncomplicated Working

F10.10 ICD-10

Attention-deficit Working

F90.9 ICD-10

hyperactivity disorder,

unspecified type

Cannabis abuse, uncomplicated Working

F12.10 ICD-10

Epilepsy, unspecified, not Working

G40.909 ICD-10

intractable, without status

epilepticus

Essential (primary) Working

I10 ICD-10

hypertension

Nicotine dependence, Working

F17.200 ICD-10

unspecified, uncomplicated

Pervasive developmental Working

F84.9 ICD-10

disorder, unspecified

Presence of other specified Working

Z97.8 ICD-10

devices

Is it appropriate to bill for this

documentation?

Yes

99231 - Subsequent Hospital Low 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 07/26/2025 12:09

Observation Date/Time:

Printed On: 03/31/2026 @ 11:13 Page 15 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

INPATIENT PSYCHIATRIC

PROGRESS NOTE

Date of Service: 7/27/2025 00:00

Chief Complaint "in patient's own

words"

States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Current or Interval Psychiatric History Patient is visible on the milieu, keeping to himself, no aggression, taking

medications with good effect, attending groups. No current acute concerns

reported.

Medication Side Effects No

Compliance with Treatment Yes

Suicidal Ideation No

Homicidal Ideation No

MENTAL STATUS EXAM

Appearance "Neat and Clean"

Behavior Impulsive

Orientation Person and Place

Concentration Inattentive

Speech Pressured

Insight Poor

Memory Fair

Judgement Poor

Affect Appropriate to Mood

Printed On: 03/31/2026 @ 11:13 Page 16 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Mood Euthymic

Hallucinations Denies

Delusions Patient currently denies

Significant Labs & Dates none

Assessment Unchanged

Rationale for Continued Inpatient

Level of Care

stabilization

MEDICATION / ANCILLARY

ORDERS

Medication Orders:

Printed On: 03/31/2026 @ 11:13 Page 17 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

amLODIPine Oral 10 mg TAB Norvasc 10 mg PO DAILY

Essential (primary)

hypertension

busPIRone Oral 10 mg TAB BuSpar 10 mg PO BID

Generalized anxiety

disorder

cloNIDine (Catapres) Oral 0.1 mg Catapres 0.1 mg PO TID P

Elevated BP above 140/90.

 Notes:Hold if HR<60 OR BP<90/60 or if symptomatic

SALAD

TAB

divalproex sodium Oral 500 mg ERT Depakote 1,000 PO DAILY

Epilepsy,unspecified,not

(Once-Daily) ER mg

intractable,without status

epilepticus

 Notes:Once-Daily

FLUoxetine Oral 20 mg CAP PROzac 20 mg PO DAILY

Anxiety,current episode

 manic

without psychotic

features,severe

hydroCHLOROthiazide Oral 25 mg TAB Oretic 25 mg PO DAILY

Essential (primary)

hypertension

LORazepam Oral 0.5 mg TAB Ativan 0.5 mg PO BID P

Generalized anxiety

disorder

 Notes:SALAD

nicotine Oral Transmucosal 2 mg Nicorette 4 mg OM Q2H P Smoking

Cessation

GUM

nicotine 21 mg/24 hr Transdermal *nicotine 1 TD DAILY P

Nicotine Dependence

TERF patch PATCH

 21mg

omeprazole Oral 20 mg DRC PriLOSEC 20 mg PO DAILY GERD

 Notes:SALAD

acetaminophen Oral 325 mg TAB *Tylenol 650 mg PO Q6H P pain

 Notes:NTE 3000 mg/day

Ancillary Orders:

Description Frequency PRN

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

-Adult_Admit to: Conditional Voluntary Adult

-COMPREHENSIVE METABOLIC PANEL IN AM-UC

-CBC (INCLUDES DIFF/PLT) IN AM-UC

-Assault/Aggression Precautions

Printed On: 03/31/2026 @ 11:13 Page 18 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

-Seizure Precautions

- LOW 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

-Every 15 Minutes Observation

-Medical Diagnosis:

-Psychiatric Diagnosis:

-VALPROIC ACID INAMUC

TREATMENT PLANNING

Problem: Danger To Others r/t Physicial Aggression, Homicidal (HI statements towards parents,

property destruction,)

OBSERVATION LEVELS AND

PRECAUTIONS/CHANGE IN

DIAGNOSIS

Current Level of Observation Every 15 minutes

Current Precautions LOW Suicide, Seizure, Assault/Aggression

Change in Psychiatric

Diagnosis/Treatment

No

Change in Medical

Diagnosis/Treatment

No

Diagnosis Class Type Priority Date Code SyPrinted On: 03/31/2026 @ 11:13 Page 19 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Bipolar disorder, current Psychiatric Provisiona Primary Diagnosis

F31.13 ICD-10

episode manic without l

psychotic features, severe

Autistic disorder Psychiatric Working

F84.0 ICD-10

Generalized anxiety disorder Psychiatric Working

F41.1 ICD-10

Personal history of traumatic Medical Working

Z87.820 ICD-10

brain injury

Alcohol abuse, uncomplicated Working

F10.10 ICD-10

Attention-deficit Working

F90.9 ICD-10

hyperactivity disorder,

unspecified type

Cannabis abuse, uncomplicated Working

F12.10 ICD-10

Epilepsy, unspecified, not Working

G40.909 ICD-10

intractable, without status

epilepticus

Essential (primary) Working

I10 ICD-10

hypertension

Nicotine dependence, Working

F17.200 ICD-10

unspecified, uncomplicated

Pervasive developmental Working

F84.9 ICD-10

disorder, unspecified

Presence of other specified Working

Z97.8 ICD-10

devices

Is it appropriate to bill for this

documentation?

Yes

99231 - Subsequent Hospital Low 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 07/27/2025 11:58

Observation Date/Time:

Printed On: 03/31/2026 @ 11:13 Page 20 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

INPATIENT PSYCHIATRIC

PROGRESS NOTE

Date of Service: 7/28/2025 00:00

Chief Complaint "in patient's own

words"

States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Current or Interval Psychiatric History Patient is visible on the milieu, keeping to himself, no aggression, taking

medications with good effect, attending groups. No current acute concerns

reported. Discharge planning for Tuesday/ Wednesday pending VPA level

Medication Side Effects No

Compliance with Treatment Yes

Suicidal Ideation No

Homicidal Ideation No

MENTAL STATUS EXAM

Appearance "Neat and Clean"

Behavior Impulsive

Orientation Person and Place

Concentration Inattentive

Speech Normal

Insight Poor

Memory Fair

Judgement Poor

Affect Appropriate to Mood

Printed On: 03/31/2026 @ 11:13 Page 21 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Mood Euthymic

Hallucinations Denies

Delusions Patient currently denies

Significant Labs & Dates none

Assessment Unchanged

Rationale for Continued Inpatient

Level of Care

d/c planning

MEDICATION / ANCILLARY

ORDERS

Medication Orders:

Printed On: 03/31/2026 @ 11:13 Page 22 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

amLODIPine Oral 10 mg TAB Norvasc 10 mg PO DAILY

Essential (primary)

hypertension

busPIRone Oral 10 mg TAB BuSpar 10 mg PO BID

Generalized anxiety

disorder

cloNIDine (Catapres) Oral 0.1 mg Catapres 0.1 mg PO TID P

Elevated BP above 140/90.

 Notes:Hold if HR<60 OR BP<90/60 or if symptomatic

SALAD

TAB

divalproex sodium Oral 500 mg ERT Depakote 1,000 PO DAILY

Epilepsy,unspecified,not

(Once-Daily) ER mg

intractable,without status

epilepticus

 Notes:Once-Daily

FLUoxetine Oral 20 mg CAP PROzac 20 mg PO DAILY

Anxiety,current episode

 manic

without psychotic

features,severe

hydroCHLOROthiazide Oral 25 mg TAB Oretic 25 mg PO DAILY

Essential (primary)

hypertension

LORazepam Oral 0.5 mg TAB Ativan 0.5 mg PO BID P

Generalized anxiety

disorder

 Notes:SALAD

nicotine Oral Transmucosal 2 mg Nicorette 4 mg OM Q2H P Smoking

Cessation

GUM

nicotine 21 mg/24 hr Transdermal *nicotine 1 TD DAILY P

Nicotine Dependence

TERF patch PATCH

 21mg

omeprazole Oral 20 mg DRC PriLOSEC 20 mg PO DAILY GERD

 Notes:SALAD

acetaminophen Oral 325 mg TAB *Tylenol 650 mg PO Q6H P pain

 Notes:NTE 3000 mg/day

Ancillary Orders:

Description Frequency PRN

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

-Adult_Admit to: Conditional Voluntary Adult

-VALPROIC ACID INAMUC

-COMPREHENSIVE METABOLIC PANEL IN AM-UC

-CBC (INCLUDES DIFF/PLT) IN AM-UC

Printed On: 03/31/2026 @ 11:13 Page 23 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

-Assault/Aggression Precautions

-Seizure Precautions

- LOW 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

-Every 15 Minutes Observation

-Medical Diagnosis:

-Psychiatric Diagnosis:

-Patient may shave

 Notes:supervised

-Patient may use for numbers

TREATMENT PLANNING

Problem: Danger To Others r/t Physicial Aggression, Homicidal (HI statements towards parents,

property destruction,)

OBSERVATION LEVELS AND

PRECAUTIONS/CHANGE IN

DIAGNOSIS

Current Level of Observation Every 15 minutes

Current Precautions LOW Suicide, Seizure, Assault/Aggression

Change in Psychiatric

Diagnosis/Treatment

No

Change in Medical

Diagnosis/Treatment

No

Printed On: 03/31/2026 @ 11:13 Page 24 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

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

F31.13 ICD-10

episode manic without l

psychotic features, severe

Autistic disorder Psychiatric Working

F84.0 ICD-10

Generalized anxiety disorder Psychiatric Working

F41.1 ICD-10

Personal history of traumatic Medical Working

Z87.820 ICD-10

brain injury

Alcohol abuse, uncomplicated Working

F10.10 ICD-10

Attention-deficit Working

F90.9 ICD-10

hyperactivity disorder,

unspecified type

Cannabis abuse, uncomplicated Working

F12.10 ICD-10

Epilepsy, unspecified, not Working

G40.909 ICD-10

intractable, without status

epilepticus

Essential (primary) Working

I10 ICD-10

hypertension

Nicotine dependence, Working

F17.200 ICD-10

unspecified, uncomplicated

Pervasive developmental Working

F84.9 ICD-10

disorder, unspecified

Presence of other specified Working

Z97.8 ICD-10

devices

Is it appropriate to bill for this

documentation?

Yes

99231 - Subsequent Hospital Low 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 07/28/2025 12:11

Printed On: 03/31/2026 @ 11:13 Page 25 of 26

Inpatient Psychiatric Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Printed On: 03/31/2026 @ 11:13 Page 26 of 26

Intake Assessment - Nursing Triage

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/22/2025 6:32:50PM

Initial

Date/Time 7/22/2025 18:32

Identification Section

Chief Complaint/Presenting Issues

(in patient's own words)

States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Sex/Current Gender Identity or

Expression

Male

If language/hearing services are needed, please arrange and complete disposition section under inpatient stay

Preferred Language English

Preferred Name Dallas

Race White

Preferred Pronoun He/Him/His

Referal Source Good Samaritan

Is person accompanied by anyone? No

MILITARY HISTORY

Is the patient active or former

military?

No

Does patient have a designated

family caregiver to assist

Yes

Patient caregiver is: Relative

Relationship to patient Mother (Terry)

Phone number 781-815-8001

Is there a guardian signing in patient? No

Was a parent or other person notified

of patient admission?

Yes

Pt's mother notified of admission

Printed On: 03/31/2026 @ 11:13 Page 1 of 4

Intake Assessment - Nursing Triage

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time:

Vital Signs/History

Vital Signs

 CONSULT PROVIDER IF:

Temp: > 100.1 Pulse: <50;>140 or irregular

Resp: <12 or >28 B/P: <90/50 or >180/110

Breathalyzer: > .350 Glucometer <50 or >350

SPO2 <90%

Temperature 98 ºF

Pulse 102 beats/min

Respirations 18 brth/min

Systolic Blood Pressure 131 mmHg

Diastolic Blood Pressure 91 mmHg

Blood Pressure 131 / 91

O2 Sat 96 %

Height 70 in

Weight 201 lb

BMI 28.8

Current Physical Health Status (This section must be completed regardless of Disposition)

Current Medical Problems "Bipolar disorder, current episode manic without psychotic features,

severe,Autistic disorder,Generalized anxiety disorder,Personal history of traumatic

brain injury,Attention-deficit hyperactivity disorder, unspecified type,Essential

(primary) hypertension,Pervasive developmental disorder, unspecified,Presence of

other specified devices" and Seizure d/o-last seizure was 2002 per pt.

Enter/Review Allergies and Reactions

Printed On: 03/31/2026 @ 11:13 Page 2 of 4

Intake Assessment - Nursing Triage

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/22/2025 6:32:50PM

Allergy Type Reaction Severity Date Code System

Comments

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

--------

Vital Signs/History

metoclopramide Drug Allergy d00298 MULTUM

DRUGID

NO FOOD ALLERGIES Drug Allergy

Communicable Disease Exposure - Do you currently have, or have you recently been exposed to, or have you ever had any of

the following

Row Currently Have Recent Exposure (Last 30 days) Had in past Comments

Exposure-V2

Measles No No No

Mumps No No No

Rubella No No No

Chicken Pox No No No

Hepatitis No No No

HIV No No No

Vital Signs/History

Skin Irritation

Do you currently have any or have

you had any recent skin irritations or

rashes?

Yes

Red raised rash to right flank.

Have you been exposed to areas

containing a bed bug infestation?

No

Current Medications Yes

Home Medication Reconciliation to be done on the Orders Home Med List Tab

Vaccination Screen

Is assessment taking place during

Flu Season (October 1 – March 31)

No

Printed On: 03/31/2026 @ 11:13 Page 3 of 4

Intake Assessment - Nursing Triage

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/22/2025 6:32:50PM

Current treatment of any infection or

contagious disease such as

Denies

History of treatment of infection or

contagious disease such as MRSA,

VRE, C DIFF

Denies

Pain Assessment

Indicate pain scale (0-No pain -10) 5

Cause of pain Back pain

Location Back

Open wounds No

Level of Consciousness/Neurological

Deficits

Oriented x 4, Confused/Disoriented, History of seizures, History of TBI and Move all

extremities

Patient presenting for detox No

Patient stable Yes

Can patient be safely treated at this

facility?

Yes

Any medical consultation

recommendations?

No

Nurse Signature e-Signed by Avramidis, Angela at 07/22/2025 18:44

Printed On: 03/31/2026 @ 11:13 Page 4 of 4

Medical Consultation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/24/2025 12:17:27PM

Date of Service: 7/24/2025

Reason for Consultation/Chief

Complaint

Follow up, HTN

History of Present Illness 30 y/o male with hx o0f HTN is seen for follow up and med management. BP is

progressively elevated. Todays BP - 161/90. He states he is very anxious and wants

to be discharge asap. Noted pacing on unit and tensed up. Denies any medical

complaints.

Medical History HTN

Surgical History n/a

Printed On: 03/31/2026 @ 11:13 Page 1 of 6

Medical Consultation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/24/2025 12:17:27PM

Description Brand Dose Route Frequency PRN

Indication

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

----------

amLODIPine Oral 10 mg TAB Norvasc 10 mg PO DAILY

Essential (primary)

hypertension

busPIRone Oral 10 mg TAB BuSpar 10 mg PO BID

Generalized anxiety

disorder

cloNIDine (Catapres) Oral 0.1 mg Catapres 0.1 mg PO TID P

Elevated BP above 140/90.

 Notes:Hold if HR<60 OR BP<90/60 or if symptomatic

SALAD

TAB

divalproex sodium Oral 500 mg ERT Depakote 500 mg PO DAILY

Epilepsy,unspecified,not

(Once-Daily) ER

intractable,without status

epilepticus

 Notes:Once-Daily

FLUoxetine Oral 20 mg CAP PROzac 40 mg PO DAILY

Bipolar disorder,current

episode manic without

psychotic features,severe

hydroCHLOROthiazide Oral 25 mg TAB Oretic 25 mg PO DAILY

Essential (primary)

hypertension

LORazepam Oral 0.5 mg TAB Ativan 0.5 mg PO BID P

Generalized anxiety

disorder

 Notes:SALAD

nicotine Oral Transmucosal 2 mg Nicorette 4 mg OM Q2H P

Smoking Cessation

GUM

nicotine 21 mg/24 hr Transdermal *nicotine 1 TD DAILY P

Nicotine Dependence

TERF patch PATCH

 21mg

omeprazole Oral 20 mg DRC PriLOSEC 20 mg PO DAILY GERD

 Notes:SALAD

acetaminophen Oral 325 mg TAB *Tylenol 650 mg PO Q6H P pain

 Notes:NTE 3000 mg/day

Allergy Type Reaction Severity Date Code System

Comments

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

--------

metoclopramide Drug Allergy d00298 MULTUM

DRUGID

NO FOOD ALLERGIES Drug Allergy

Printed On: 03/31/2026 @ 11:13 Page 2 of 6

Medical Consultation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/24/2025 12:17:27PM

Review of Systems ( All systems

reviewed were without pertinent

findings except as noted)

PE unremarkable

Systolic Blood Pressure 161 mmHg

Diastolic Blood Pressure 90 mmHg

Blood Pressure 161 / 90

Pulse 100 %

Respirations 18 brth/min

Temperature 97.8 ºF

O2 98 %

Vitals Time n/a

Mask Offered No

Vital Signs

Heart Rate 100 beats/min

Height 70 in

Weight 202 lb

SPO2 98 %

Physical Exam

General Apperance Cooperative

Orientation Person and Place

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.

Printed On: 03/31/2026 @ 11:13 Page 3 of 6

Medical Consultation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/24/2025 12:17:27PM

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 psychiatry eval and treatment.

Printed On: 03/31/2026 @ 11:13 Page 4 of 6

Medical Consultation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/24/2025 12:17:27PM

Diagnosis Class Type Priority Date

Code System

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

---- ------

Bipolar disorder, current Psychiatric Provisiona Primary Diagnosis

F31.13 ICD-10

episode manic without l

psychotic features, severe

Autistic disorder Psychiatric Working

F84.0 ICD-10

Generalized anxiety disorder Psychiatric Working

F41.1 ICD-10

Personal history of traumatic Medical Working

Z87.820 ICD-10

brain injury

Alcohol abuse, uncomplicated Working

F10.10 ICD-10

Attention-deficit Working

F90.9 ICD-10

hyperactivity disorder,

unspecified type

Cannabis abuse, uncomplicated Working

F12.10 ICD-10

Epilepsy, unspecified, not Working

G40.909 ICD-10

intractable, without status

epilepticus

Essential (primary) Working

I10 ICD-10

hypertension

Nicotine dependence, Working

F17.200 ICD-10

unspecified, uncomplicated

Pervasive developmental Working

F84.9 ICD-10

disorder, unspecified

Presence of other specified Working

Z97.8 ICD-10

devices

Recommentations A/P

A - HTN ( BP elevated in the setting of anxiety)

Plan

Clonidine 0.1mg TID prn for BP above 140/90.

Monitor BP

Nursing to encouraged prn anxiety meds

Select one Thank you for this consult. We will continue to follow this patient with you

Is it appropriate to bill for this

documentation?

Yes

Printed On: 03/31/2026 @ 11:13 Page 5 of 6

Medical Consultation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time:

Select the appropriate code below:

99232 - Subsequent Care (Medical

Consultation) Moderate

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.

Attending Physician

Review/Comments

as above

Staff Signature e-Signed by Darko, Sylvia at 07/24/2025 12:25

Printed On: 03/31/2026 @ 11:13 Page 6 of 6

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Progress Note

Observation Date/Time:

NURSING PROGRESS NOTE -

INPATIENT

Date/Time 7/23/2025 00:05

Shift Night

Reason for Admission States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

History of Present Illness Refer to Intake

VITAL SIGNS

Systolic Blood Pressure 131 mmHg

Diastolic Blood Pressure 91 mmHg

Blood Pressure 131 / 91

Heart Rate 102 beats/min

Temperature 98 ºF

Respirations 18 brth/min

Height 70 in

Weight 201 lb

SPO2 96 %

**RN: Orders must be renewed daily

Special Interventions This Shift None

Printed On: 03/31/2026 @ 11:13 Page 1 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Medical Interventions This Shift None

Risk Assessments

Current Level of Observation Every 15 minutes

Current Precautions LOW Suicide, Seizure, Assault/Aggression

PAIN

Pain today? No

ELOPEMENT RISK

Is Elopement currently a part of the

patient's presentation?

No

SEXUAL ACTING OUT

Is Sexually Acting out currently a part

of the patient's presentation?

No

Moderate Risk: RN to consult MD for

SAO precaution and discuss any

additional necessary orders or

practices of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes, and/or

room assignment on the unit. -

High Risk (15+): RN to consult MD

for SAO precaution and MD will order

at least one of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes

FALL RISK

Are falls currently a part of the

patient's presentation?

No

SUICIDALITY/C-SSRS RECENT

Printed On: 03/31/2026 @ 11:13 Page 2 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

1.Have you wished you were dead or

wished you could go to sleep and not

wake up?

No

2. Have you actually had any

thoughts of killing yourself?

No

Is the Patient already on Suicide

Precautions?

Yes

If patient answers Yes to Either

Question 1 or Question 2 AND is

NOT already on Suicide Precautions,

CONTACT PROVIDER to review

6. Have you ever done anything,

started to do anything, or prepared to

do anything to end your life?

No

Ex: Collected pills, obtained gun,

gave away valuables, wrote

will/suicide note, took out pills but

didn't swallow, held gun but changed

mind or it was grabbed from your

hand, went to roof but didn't jump; or

actually took pills, tried to shoot

yourself, cut yourself, tried to hang

yourself, etc.

Only Yes to 1 or 2 - Low Risk

Only Yes to1 or 2 and 3 Moderate

Risk

Yes to 4, 5, or 6 High Risk

Risk Level Low Risk

SELF-HARM

Is self-harm currently a part of the

patient's presentation?

No

VULNERABILITY

Printed On: 03/31/2026 @ 11:13 Page 3 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Is Vulnerability currently a part of the

patient's presentation?

No

DYNAMIC APPRAISAL OF SITUATIONAL AGGRESSION (DASA)

Assessing the risk of aggression,

Each item is scored for its presence

(1), or absence (0), i the previous 24

hours.

The items are then summed to

produce a total score.

The risk rating is determined based

on total score.

0 = Low Risk

1 - 3 = Moderate Risk

4 - 7 = High Risk

Assessment

Irritability (0) - The patient has been calm, tolerant and relaxed. She/he is comfortable and

relaxed in the company of other patients with staff.

Impulsivity (0) - The patient has been affectively and/or behaviorally stable and composed.

Unwillingness to Follow Directions (0) - The patient in the last 24 hours has been compliant with any requests and

directions.

Sensitive to Perceived Provocation (0) - In the last 24 hours the patient has not become extraordinarilt angry or seen

everything that occurs around her/him as provocative. She/he is not 'overly

sensitive' or provocative'.

Easily Angered when Requests are

Denied

(0) - The patient has been calm and acception when she/he is asked to wait whilst

her/his request is attended to. She/he has been understanding and acception that

her/his request has been inable to be fulfilled at that time.

Negative Attitudes (0) - No negative attitudes

Verbal Threats (0) - The patient has not been verbally aggressive.

Total Score 0

Record of aggression: During the

previous 24 hours, has the patient

behaved aggressively in any of the

following ways?

Printed On: 03/31/2026 @ 11:13 Page 4 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Physicial aggression against

OBJECTS

No

Verbal aggression against OTHER

PEOPLE

No

Physical Aggression against OTHER

PEOPLE

No

DASA

If patient scored Moderate or High

Risk and not on Aggression/Assault

Precautions notify MD

CURRENT STATUS

L.O.C. Alert and Asleep

Mobility WNL

Activity Normal and Asleep

Awareness Aware of surroundings and Asleep

Behavior In bed

Mood Euthymic

Affect WNL

Thought Process Organized

Thought Content WNL

Speech Normal

Detox Patient No

ADLs Not taking care of ADLs

Printed On: 03/31/2026 @ 11:13 Page 5 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Bathed/Showered No

Appearance Neat/Clean

Sleep Slept throughout night

REVIEW OF SYSTEMS/INTAKE AND OUTPUT

DIETARY INTAKE

Snack Yes

Supplements N/A

Elimination Reports no problem and Asleep

REVIEW OF SYSTEMS

Review of Systems WNL

PATIENT EDUCATION

Topic Medication Adherence

Level of Understanding Partially understands Needs additional support for understanding

Nursing Shift Narrative Isolative in room most of the shift. Out of room for bedtime medication. Appropriate

and pleasant on interaction. No unsafe behavior reported or observed. Slept for

more than 7hrs. Q15 minutes observation maintained.

**RN: Document to the treatment

plan every shift!

PATIENT EDUCATION

 - Nursing will monitor Dallas as ordered by physician (Intervention)

 - Nursing will monitor Dallas as ordered by physician (Intervention)

 - Nursing staff to administer medication and treatment(s) as ordered per MD (Intervention)

 - Nursing will administer nicotine replacement protocol as ordered per MD (Intervention)

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

Nurse Signature e-Signed by Azuike, Judith at 07/23/2025 06:23

Printed On: 03/31/2026 @ 11:13 Page 6 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Progress Note

Observation Date/Time:

NURSING PROGRESS NOTE -

INPATIENT

Date/Time 7/23/2025 16:25

Shift Day

Reason for Admission States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Printed On: 03/31/2026 @ 11:13 Page 7 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

History of Present Illness Presenting Problem:

Patient was taken to the emergency department under Section 12 following

homicidal statements directed toward his parents. He denies current homicidal

ideation but admits to past threats, including an intent to punch his father. He

reports frustration stemming from unresolved family disputes, notably regarding his

uncle's coin collection, which his father is withholding. He attempted to file a

restraining order against his mother but was unable to articulate the specific

reasons.

Psychiatric History:

Diagnosed with Bipolar Disorder, Autism Spectrum Disorder (ASD), Generalized

Anxiety Disorder (GAD), and history of Traumatic Brain Injury (TBI) from birth

complications.

Has a history of suicidal ideation and self-injurious behavior, including choking

himself with a belt during adolescence.

No prior inpatient psychiatric admissions.

Non-compliant with psychiatric medications over the past few months, citing a

preference for a holistic approach.

Behavioral Observations:

Appearance: Calm

Mood: Anxious

Affect: Congruent

Behavior: Cooperative

Speech: Clear

Thought Process: Circumstantial

Thought Content: No current suicidal or homicidal ideation

Orientation: Oriented to person, place, time, and situation

Insight: Poor

Judgment: Impaired

Concentration: Easily distracted

Family and Social History:

Reports a poor relationship with his father; primarily raised by his mother.

Engaged; has no children.

Support system includes family members and friends.

Substance Use History:

Occasional alcohol consumption ("few beers here and there")

Cannabis use

Family history of alcohol abuse (father)

Protective Factors:

Internal: Recognizes reasons for living

External: Beloved pet cats and a supportive social network of family and friends

Assessment Summary:

Patient appeared pressured in speech during the interview but remained

cooperative. He repeatedly stated he was "fine" and expressed a desire to return

home to care for his cats. His mother reported escalating behavioral issues over

recent months, including verbal aggression and property destruction, raising

concerns about his safety. Patient will benefit from inpatient psychiatric admission

for stabilization, medication assessment, and comprehensive aftercare planning.

Printed On: 03/31/2026 @ 11:13 Page 8 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Diagnosis:

Primary: Bipolar Disorder

Secondary: Autism Spectrum Disorder (ASD)

Treatment Plan:

Admit to inpatient psychiatric unit for safety, stabilization, and medication

evaluation.

Psychoeducation and engagement with family and peer support systems.

Develop an individualized aftercare plan, including outpatient follow-up scheduled

for 08/08/2025.

VITAL SIGNS

Systolic Blood Pressure 120 mmHg

Diastolic Blood Pressure 74 mmHg

Blood Pressure 120 / 74

Heart Rate 103 beats/min

Temperature 97.8 ºF

Respirations 16 brth/min

Height 70 in

Weight 202 lb

SPO2 98 %

**RN: Orders must be renewed daily

Special Interventions This Shift PRN Medications

Medical Interventions This Shift None

Risk Assessments

Current Level of Observation Every 15 minutes

Printed On: 03/31/2026 @ 11:13 Page 9 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Current Precautions LOW Suicide, Seizure, Assault/Aggression

PAIN

Pain today? No

ELOPEMENT RISK

Is Elopement currently a part of the

patient's presentation?

No

SEXUAL ACTING OUT

Is Sexually Acting out currently a part

of the patient's presentation?

No

Moderate Risk: RN to consult MD for

SAO precaution and discuss any

additional necessary orders or

practices of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes, and/or

room assignment on the unit. -

High Risk (15+): RN to consult MD

for SAO precaution and MD will order

at least one of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes

FALL RISK

Are falls currently a part of the

patient's presentation?

No

SUICIDALITY/C-SSRS RECENT

1.Have you wished you were dead or

wished you could go to sleep and not

wake up?

No

2. Have you actually had any

thoughts of killing yourself?

No

Printed On: 03/31/2026 @ 11:13 Page 10 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Is the Patient already on Suicide

Precautions?

No

If patient answers Yes to Either

Question 1 or Question 2 AND is

NOT already on Suicide Precautions,

CONTACT PROVIDER to review

6. Have you ever done anything,

started to do anything, or prepared to

do anything to end your life?

No

Ex: Collected pills, obtained gun,

gave away valuables, wrote

will/suicide note, took out pills but

didn't swallow, held gun but changed

mind or it was grabbed from your

hand, went to roof but didn't jump; or

actually took pills, tried to shoot

yourself, cut yourself, tried to hang

yourself, etc.

Only Yes to 1 or 2 - Low Risk

Only Yes to1 or 2 and 3 Moderate

Risk

Yes to 4, 5, or 6 High Risk

Risk Level Low Risk

SELF-HARM

Is self-harm currently a part of the

patient's presentation?

No

VULNERABILITY

Is Vulnerability currently a part of the

patient's presentation?

No

DYNAMIC APPRAISAL OF SITUATIONAL AGGRESSION (DASA)

Printed On: 03/31/2026 @ 11:13 Page 11 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Assessing the risk of aggression,

Each item is scored for its presence

(1), or absence (0), i the previous 24

hours.

The items are then summed to

produce a total score.

The risk rating is determined based

on total score.

0 = Low Risk

1 - 3 = Moderate Risk

4 - 7 = High Risk

Assessment

Irritability (1) - The patient is easily annoyed or angered and inable to tolerate the presence of

others.

Impulsivity (1) - The patient has been impulsive and unpredictable in his/her affect or behavior

or was quick to (over-) react to real and imagined slights, insults, and

disappointments.

Unwillingness to Follow Directions (0) - The patient in the last 24 hours has been compliant with any requests and

directions.

Sensitive to Perceived Provocation (0) - In the last 24 hours the patient has not become extraordinarilt angry or seen

everything that occurs around her/him as provocative. She/he is not 'overly

sensitive' or provocative'.

Easily Angered when Requests are

Denied

(0) - The patient has been calm and acception when she/he is asked to wait whilst

her/his request is attended to. She/he has been understanding and acception that

her/his request has been inable to be fulfilled at that time.

Negative Attitudes (0) - No negative attitudes

Verbal Threats (0) - The patient has not been verbally aggressive.

Total Score 2

Record of aggression: During the

previous 24 hours, has the patient

behaved aggressively in any of the

following ways?

Physicial aggression against

OBJECTS

No

Printed On: 03/31/2026 @ 11:13 Page 12 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Verbal aggression against OTHER

PEOPLE

Yes

Physical Aggression against OTHER

PEOPLE

No

DASA

If patient scored Moderate or High

Risk and not on Aggression/Assault

Precautions notify MD

CURRENT STATUS

L.O.C. Alert

Mobility WNL

Activity Normal

Awareness Aware of surroundings

Behavior Attending groups

Mood Anxious and Irritable

Affect Labile and Flat

Thought Process Disorganized and Confused

Thought Content Delusional

Speech Normal

Detox Patient No

ADLs Taking care of ADLs

Bathed/Showered Yes

Printed On: 03/31/2026 @ 11:13 Page 13 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Appearance Neat/Clean

Sleep Napped during the day

REVIEW OF SYSTEMS/INTAKE AND OUTPUT

DIETARY INTAKE

Meals Eating off unit

Breakfast 100%

Lunch 100%

Dinner 100%

Snack Yes

Supplements N/A

Elimination Reports no problem

REVIEW OF SYSTEMS

Review of Systems WNL

PATIENT EDUCATION

Topic Safety

Level of Understanding Partially understands Needs additional support for understanding

Nursing Shift Narrative Patient presented with a flat affect, alert and verbally responsive. Denies having any

pain or discomfort. Able to make his needs known. Noticed interacting well with

selective peers. Positive for all his meds as ordered. Prn gum 2 mg . Joined the

group meeting and coloring. Transited well at the cafe. He has good appetite. Staff

educated patient how to use his coping skills. No issues reported this shift. will

continue on 15 mins checks for safety.

**RN: Document to the treatment

plan every shift!

Printed On: 03/31/2026 @ 11:13 Page 14 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

PATIENT EDUCATION

 - .Nursing will when Dallas identified with potential loss of control, ask Dallas what PRN

medication is most helpful and administer medication according to doctor’s order.

(Intervention)

 - Nursing will monitor Dallas as ordered by physician (Intervention)

 - Nursing will monitor Dallas as ordered by physician (Intervention)

 - Nursing staff to administer medication and treatment(s) as ordered per MD (Intervention)

 - Nursing will administer nicotine replacement protocol as ordered per MD (Intervention)

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

Nurse Signature e-Signed by Nalunkuma, Faridah, RN at 07/23/2025 16:34

Progress Note

Observation Date/Time:

NURSING PROGRESS NOTE -

INPATIENT

Date/Time 7/23/2025 18:54

Shift Night

Reason for Admission States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Printed On: 03/31/2026 @ 11:13 Page 15 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

History of Present Illness Presenting Problem:

Patient was taken to the emergency department under Section 12 following

homicidal statements directed toward his parents. He denies current homicidal

ideation but admits to past threats, including an intent to punch his father. He

reports frustration stemming from unresolved family disputes, notably regarding his

uncle's coin collection, which his father is withholding. He attempted to file a

restraining order against his mother but was unable to articulate the specific

reasons.

Psychiatric History:

Diagnosed with Bipolar Disorder, Autism Spectrum Disorder (ASD), Generalized

Anxiety Disorder (GAD), and history of Traumatic Brain Injury (TBI) from birth

complications.

Has a history of suicidal ideation and self-injurious behavior, including choking

himself with a belt during adolescence.

No prior inpatient psychiatric admissions.

Non-compliant with psychiatric medications over the past few months, citing a

preference for a holistic approach.

Behavioral Observations:

Appearance: Calm

Mood: Anxious

Affect: Congruent

Behavior: Cooperative

Speech: Clear

Thought Process: Circumstantial

Thought Content: No current suicidal or homicidal ideation

Orientation: Oriented to person, place, time, and situation

Insight: Poor

Judgment: Impaired

Concentration: Easily distracted

Family and Social History:

Reports a poor relationship with his father; primarily raised by his mother.

Engaged; has no children.

Support system includes family members and friends.

Substance Use History:

Occasional alcohol consumption ("few beers here and there")

Cannabis use

Family history of alcohol abuse (father)

Protective Factors:

Internal: Recognizes reasons for living

External: Beloved pet cats and a supportive social network of family and friends

Assessment Summary:

Patient appeared pressured in speech during the interview but remained

cooperative. He repeatedly stated he was "fine" and expressed a desire to return

home to care for his cats. His mother reported escalating behavioral issues over

recent months, including verbal aggression and property destruction, raising

concerns about his safety. Patient will benefit from inpatient psychiatric admission

for stabilization, medication assessment, and comprehensive aftercare planning.

Printed On: 03/31/2026 @ 11:13 Page 16 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Diagnosis:

Primary: Bipolar Disorder

Secondary: Autism Spectrum Disorder (ASD)

Treatment Plan:

Admit to inpatient psychiatric unit for safety, stabilization, and medication

evaluation.

Psychoeducation and engagement with family and peer support systems.

Develop an individualized aftercare plan, including outpatient follow-up scheduled

for 08/08/2025.

VITAL SIGNS

Systolic Blood Pressure 147 mmHg

Diastolic Blood Pressure 90 mmHg

Blood Pressure 147 / 90

Heart Rate 114 beats/min

Temperature 97.3 ºF

Respirations 18 brth/min

Height 70 in

Weight 202 lb

SPO2 98 %

**RN: Orders must be renewed daily

Special Interventions This Shift None

Medical Interventions This Shift None

Risk Assessments

Current Level of Observation Every 15 minutes

Printed On: 03/31/2026 @ 11:13 Page 17 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Current Precautions LOW Suicide, Seizure, Assault/Aggression

PAIN

Pain today? No

ELOPEMENT RISK

Is Elopement currently a part of the

patient's presentation?

No

SEXUAL ACTING OUT

Is Sexually Acting out currently a part

of the patient's presentation?

No

Moderate Risk: RN to consult MD for

SAO precaution and discuss any

additional necessary orders or

practices of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes, and/or

room assignment on the unit. -

High Risk (15+): RN to consult MD

for SAO precaution and MD will order

at least one of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes

FALL RISK

Are falls currently a part of the

patient's presentation?

No

SUICIDALITY/C-SSRS RECENT

1.Have you wished you were dead or

wished you could go to sleep and not

wake up?

No

2. Have you actually had any

thoughts of killing yourself?

No

Printed On: 03/31/2026 @ 11:13 Page 18 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Is the Patient already on Suicide

Precautions?

No

If patient answers Yes to Either

Question 1 or Question 2 AND is

NOT already on Suicide Precautions,

CONTACT PROVIDER to review

6. Have you ever done anything,

started to do anything, or prepared to

do anything to end your life?

No

Ex: Collected pills, obtained gun,

gave away valuables, wrote

will/suicide note, took out pills but

didn't swallow, held gun but changed

mind or it was grabbed from your

hand, went to roof but didn't jump; or

actually took pills, tried to shoot

yourself, cut yourself, tried to hang

yourself, etc.

Only Yes to 1 or 2 - Low Risk

Only Yes to1 or 2 and 3 Moderate

Risk

Yes to 4, 5, or 6 High Risk

Risk Level Low Risk

SELF-HARM

Is self-harm currently a part of the

patient's presentation?

No

VULNERABILITY

Is Vulnerability currently a part of the

patient's presentation?

No

DYNAMIC APPRAISAL OF SITUATIONAL AGGRESSION (DASA)

Printed On: 03/31/2026 @ 11:13 Page 19 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Assessing the risk of aggression,

Each item is scored for its presence

(1), or absence (0), i the previous 24

hours.

The items are then summed to

produce a total score.

The risk rating is determined based

on total score.

0 = Low Risk

1 - 3 = Moderate Risk

4 - 7 = High Risk

Assessment

Irritability (0) - The patient has been calm, tolerant and relaxed. She/he is comfortable and

relaxed in the company of other patients with staff.

Impulsivity (0) - The patient has been affectively and/or behaviorally stable and composed.

Unwillingness to Follow Directions (0) - The patient in the last 24 hours has been compliant with any requests and

directions.

Sensitive to Perceived Provocation (0) - In the last 24 hours the patient has not become extraordinarilt angry or seen

everything that occurs around her/him as provocative. She/he is not 'overly

sensitive' or provocative'.

Easily Angered when Requests are

Denied

(0) - The patient has been calm and acception when she/he is asked to wait whilst

her/his request is attended to. She/he has been understanding and acception that

her/his request has been inable to be fulfilled at that time.

Negative Attitudes (0) - No negative attitudes

Verbal Threats (0) - The patient has not been verbally aggressive.

Total Score 0

Record of aggression: During the

previous 24 hours, has the patient

behaved aggressively in any of the

following ways?

Physicial aggression against

OBJECTS

No

Printed On: 03/31/2026 @ 11:13 Page 20 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Verbal aggression against OTHER

PEOPLE

No

Physical Aggression against OTHER

PEOPLE

No

DASA

If patient scored Moderate or High

Risk and not on Aggression/Assault

Precautions notify MD

CURRENT STATUS

L.O.C. Alert

Mobility WNL

Activity Normal

Awareness Oriented x 4

Behavior In bed

Mood Euthymic

Affect WNL

Thought Process Organized

Thought Content WNL

Speech Normal

Detox Patient No

ADLs Taking care of ADLs

Bathed/Showered Yes

Appearance Neat/Clean

Printed On: 03/31/2026 @ 11:13 Page 21 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Sleep Slept throughout night

REVIEW OF SYSTEMS/INTAKE AND OUTPUT

DIETARY INTAKE

Supplements N/A

Elimination Reports no problem

REVIEW OF SYSTEMS

Review of Systems WNL

PATIENT EDUCATION

Topic safety

Level of Understanding Partially understands Needs additional support for understanding

Nursing Shift Narrative Pt is A&O x 3,visible in the milieu, social with select peers. Pt is compliant with

medications and meals. Pt denied any pain/constipation. Ativan PRN, no pending

labs. Pt slept throughout the night, no SOB discomfort/ no unsafe behavior noted

/reported. ALL level of observation and safety checks maintained, will continue to

monitor, and report any changes.

**RN: Document to the treatment

plan every shift!

PATIENT EDUCATION

 - Conduct group (art, music, animal, movement, expressive) and monitor patient progress for

the development of new leisure skills to decrease danger to others, homicidal ideation, and/or

physical aggression (Intervention)

Nurse Signature e-Signed by Yedena-Wassoua, Loudouba, RN at 07/24/2025 07:39

Progress Note

Observation Date/Time:

NURSING PROGRESS NOTE -

INPATIENT

Printed On: 03/31/2026 @ 11:13 Page 22 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Date/Time 7/24/2025 17:39

Shift Night

Reason for Admission States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Printed On: 03/31/2026 @ 11:13 Page 23 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

History of Present Illness Presenting Problem:

Patient was taken to the emergency department under Section 12 following

homicidal statements directed toward his parents. He denies current homicidal

ideation but admits to past threats, including an intent to punch his father. He

reports frustration stemming from unresolved family disputes, notably regarding his

uncle's coin collection, which his father is withholding. He attempted to file a

restraining order against his mother but was unable to articulate the specific

reasons.

Psychiatric History:

Diagnosed with Bipolar Disorder, Autism Spectrum Disorder (ASD), Generalized

Anxiety Disorder (GAD), and history of Traumatic Brain Injury (TBI) from birth

complications.

Has a history of suicidal ideation and self-injurious behavior, including choking

himself with a belt during adolescence.

No prior inpatient psychiatric admissions.

Non-compliant with psychiatric medications over the past few months, citing a

preference for a holistic approach.

Behavioral Observations:

Appearance: Calm

Mood: Anxious

Affect: Congruent

Behavior: Cooperative

Speech: Clear

Thought Process: Circumstantial

Thought Content: No current suicidal or homicidal ideation

Orientation: Oriented to person, place, time, and situation

Insight: Poor

Judgment: Impaired

Concentration: Easily distracted

Family and Social History:

Reports a poor relationship with his father; primarily raised by his mother.

Engaged; has no children.

Support system includes family members and friends.

Substance Use History:

Occasional alcohol consumption ("few beers here and there")

Cannabis use

Family history of alcohol abuse (father)

Protective Factors:

Internal: Recognizes reasons for living

External: Beloved pet cats and a supportive social network of family and friends

Assessment Summary:

Patient appeared pressured in speech during the interview but remained

cooperative. He repeatedly stated he was "fine" and expressed a desire to return

home to care for his cats. His mother reported escalating behavioral issues over

recent months, including verbal aggression and property destruction, raising

concerns about his safety. Patient will benefit from inpatient psychiatric admission

for stabilization, medication assessment, and comprehensive aftercare planning.

Printed On: 03/31/2026 @ 11:13 Page 24 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Diagnosis:

Primary: Bipolar Disorder

Secondary: Autism Spectrum Disorder (ASD)

Treatment Plan:

Admit to inpatient psychiatric unit for safety, stabilization, and medication

evaluation.

Psychoeducation and engagement with family and peer support systems.

Develop an individualized aftercare plan, including outpatient follow-up scheduled

for 08/08/2025.

VITAL SIGNS

Systolic Blood Pressure 161 mmHg

Diastolic Blood Pressure 90 mmHg

Blood Pressure 161 / 90

Heart Rate 100 beats/min

Temperature 97.8 ºF

Respirations 18 brth/min

Height 70 in

Weight 202 lb

SPO2 98 %

**RN: Orders must be renewed daily

Special Interventions This Shift PRN Medications

Medical Interventions This Shift None

Risk Assessments

Current Level of Observation Every 15 minutes

Printed On: 03/31/2026 @ 11:13 Page 25 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Current Precautions LOW Suicide, Seizure, Assault/Aggression

PAIN

Pain today? No

ELOPEMENT RISK

Is Elopement currently a part of the

patient's presentation?

No

SEXUAL ACTING OUT

Is Sexually Acting out currently a part

of the patient's presentation?

No

Moderate Risk: RN to consult MD for

SAO precaution and discuss any

additional necessary orders or

practices of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes, and/or

room assignment on the unit. -

High Risk (15+): RN to consult MD

for SAO precaution and MD will order

at least one of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes

FALL RISK

Are falls currently a part of the

patient's presentation?

No

SUICIDALITY/C-SSRS RECENT

1.Have you wished you were dead or

wished you could go to sleep and not

wake up?

No

2. Have you actually had any

thoughts of killing yourself?

No

Printed On: 03/31/2026 @ 11:13 Page 26 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Is the Patient already on Suicide

Precautions?

Yes

If patient answers Yes to Either

Question 1 or Question 2 AND is

NOT already on Suicide Precautions,

CONTACT PROVIDER to review

6. Have you ever done anything,

started to do anything, or prepared to

do anything to end your life?

No

Ex: Collected pills, obtained gun,

gave away valuables, wrote

will/suicide note, took out pills but

didn't swallow, held gun but changed

mind or it was grabbed from your

hand, went to roof but didn't jump; or

actually took pills, tried to shoot

yourself, cut yourself, tried to hang

yourself, etc.

Only Yes to 1 or 2 - Low Risk

Only Yes to1 or 2 and 3 Moderate

Risk

Yes to 4, 5, or 6 High Risk

Risk Level Low Risk

SELF-HARM

Is self-harm currently a part of the

patient's presentation?

No

VULNERABILITY

Is Vulnerability currently a part of the

patient's presentation?

No

DYNAMIC APPRAISAL OF SITUATIONAL AGGRESSION (DASA)

Printed On: 03/31/2026 @ 11:13 Page 27 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Assessing the risk of aggression,

Each item is scored for its presence

(1), or absence (0), i the previous 24

hours.

The items are then summed to

produce a total score.

The risk rating is determined based

on total score.

0 = Low Risk

1 - 3 = Moderate Risk

4 - 7 = High Risk

Assessment

Irritability (0) - The patient has been calm, tolerant and relaxed. She/he is comfortable and

relaxed in the company of other patients with staff.

Impulsivity (1) - The patient has been impulsive and unpredictable in his/her affect or behavior

or was quick to (over-) react to real and imagined slights, insults, and

disappointments.

Unwillingness to Follow Directions (1) - The patient has become angry and/or aggressive she/he was asked adhere to

some aspect of her/his treatment or to the ward's routine in the last 24 hours.

Sensitive to Perceived Provocation (0) - In the last 24 hours the patient has not become extraordinarilt angry or seen

everything that occurs around her/him as provocative. She/he is not 'overly

sensitive' or provocative'.

Easily Angered when Requests are

Denied

(0) - The patient has been calm and acception when she/he is asked to wait whilst

her/his request is attended to. She/he has been understanding and acception that

her/his request has been inable to be fulfilled at that time.

Negative Attitudes (0) - No negative attitudes

Verbal Threats (0) - The patient has not been verbally aggressive.

Total Score 2

Record of aggression: During the

previous 24 hours, has the patient

behaved aggressively in any of the

following ways?

Physicial aggression against

OBJECTS

No

Printed On: 03/31/2026 @ 11:13 Page 28 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Verbal aggression against OTHER

PEOPLE

No

Physical Aggression against OTHER

PEOPLE

No

DASA

If patient scored Moderate or High

Risk and not on Aggression/Assault

Precautions notify MD

CURRENT STATUS

L.O.C. Alert

Mobility WNL

Activity Restless and Pacing

Awareness Aware of surroundings

Behavior Non-compliant

Mood Angry, Anxious and Irritable

Affect Labile and Flat

Thought Process Disorganized and Preoccupied

Thought Content Delusional

Speech Normal

Detox Patient No

ADLs Taking care of ADLs

Bathed/Showered No

Printed On: 03/31/2026 @ 11:13 Page 29 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Appearance Disheveled

Sleep Slept throughout night

REVIEW OF SYSTEMS/INTAKE AND OUTPUT

DIETARY INTAKE

Supplements N/A

Elimination Reports no problem

REVIEW OF SYSTEMS

Review of Systems WNL

PATIENT EDUCATION

Topic Safety

Level of Understanding Understood

Nursing Shift Narrative Patient presents with an irritable mood stating that he wants to go home and he has

been rude, demanding and yelling at staff. Patient is visible in the milieu pacing

down the hall way, Pt observed making several calls to his parents. Accepted

scheduled medication and utilized Ativan 0.5 mg with fair effect. No assault, SI or

seizures observed or reported this shift. Q 15 mins check maintained for safety.

**RN: Document to the treatment

plan every shift!

PATIENT EDUCATION

 - .Nursing will when Dallas identified with potential loss of control, ask Dallas what PRN

medication is most helpful and administer medication according to doctor’s order.

(Intervention)

 - Nursing staff to administer medication and treatment(s) as ordered per MD (Intervention)

 - Nursing will administer nicotine replacement protocol as ordered per MD (Intervention)

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

Nurse Signature e-Signed by Chileshe, Chikwanda at 07/24/2025 18:54

Printed On: 03/31/2026 @ 11:13 Page 30 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Progress Note

Observation Date/Time:

NURSING PROGRESS NOTE -

INPATIENT

Date/Time 7/24/2025 23:52

Shift Night

Reason for Admission States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Printed On: 03/31/2026 @ 11:13 Page 31 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

History of Present Illness Presenting Problem:

Patient was taken to the emergency department under Section 12 following

homicidal statements directed toward his parents. He denies current homicidal

ideation but admits to past threats, including an intent to punch his father. He

reports frustration stemming from unresolved family disputes, notably regarding his

uncle's coin collection, which his father is withholding. He attempted to file a

restraining order against his mother but was unable to articulate the specific

reasons.

Psychiatric History:

Diagnosed with Bipolar Disorder, Autism Spectrum Disorder (ASD), Generalized

Anxiety Disorder (GAD), and history of Traumatic Brain Injury (TBI) from birth

complications.

Has a history of suicidal ideation and self-injurious behavior, including choking

himself with a belt during adolescence.

No prior inpatient psychiatric admissions.

Non-compliant with psychiatric medications over the past few months, citing a

preference for a holistic approach.

Behavioral Observations:

Appearance: Calm

Mood: Anxious

Affect: Congruent

Behavior: Cooperative

Speech: Clear

Thought Process: Circumstantial

Thought Content: No current suicidal or homicidal ideation

Orientation: Oriented to person, place, time, and situation

Insight: Poor

Judgment: Impaired

Concentration: Easily distracted

Family and Social History:

Reports a poor relationship with his father; primarily raised by his mother.

Engaged; has no children.

Support system includes family members and friends.

Substance Use History:

Occasional alcohol consumption ("few beers here and there")

Cannabis use

Family history of alcohol abuse (father)

Protective Factors:

Internal: Recognizes reasons for living

External: Beloved pet cats and a supportive social network of family and friends

Assessment Summary:

Patient appeared pressured in speech during the interview but remained

cooperative. He repeatedly stated he was "fine" and expressed a desire to return

home to care for his cats. His mother reported escalating behavioral issues over

recent months, including verbal aggression and property destruction, raising

concerns about his safety. Patient will benefit from inpatient psychiatric admission

for stabilization, medication assessment, and comprehensive aftercare planning.

Printed On: 03/31/2026 @ 11:13 Page 32 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Diagnosis:

Primary: Bipolar Disorder

Secondary: Autism Spectrum Disorder (ASD)

Treatment Plan:

Admit to inpatient psychiatric unit for safety, stabilization, and medication

evaluation.

Psychoeducation and engagement with family and peer support systems.

Develop an individualized aftercare plan, including outpatient follow-up scheduled

for 08/08/2025.

VITAL SIGNS

Systolic Blood Pressure 161 mmHg

Diastolic Blood Pressure 90 mmHg

Blood Pressure 161 / 90

Heart Rate 100 beats/min

Temperature 97.8 ºF

Respirations 18 brth/min

Height 70 in

Weight 202 lb

SPO2 98 %

**RN: Orders must be renewed daily

Special Interventions This Shift None

Medical Interventions This Shift None

Risk Assessments

Current Level of Observation Every 15 minutes

Printed On: 03/31/2026 @ 11:13 Page 33 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Current Precautions LOW Suicide, Seizure, Assault/Aggression

PAIN

Pain today? No

ELOPEMENT RISK

Is Elopement currently a part of the

patient's presentation?

No

SEXUAL ACTING OUT

Is Sexually Acting out currently a part

of the patient's presentation?

No

Moderate Risk: RN to consult MD for

SAO precaution and discuss any

additional necessary orders or

practices of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes, and/or

room assignment on the unit. -

High Risk (15+): RN to consult MD

for SAO precaution and MD will order

at least one of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes

FALL RISK

Are falls currently a part of the

patient's presentation?

No

SUICIDALITY/C-SSRS RECENT

1.Have you wished you were dead or

wished you could go to sleep and not

wake up?

No

2. Have you actually had any

thoughts of killing yourself?

No

Printed On: 03/31/2026 @ 11:13 Page 34 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Is the Patient already on Suicide

Precautions?

No

If patient answers Yes to Either

Question 1 or Question 2 AND is

NOT already on Suicide Precautions,

CONTACT PROVIDER to review

6. Have you ever done anything,

started to do anything, or prepared to

do anything to end your life?

No

Ex: Collected pills, obtained gun,

gave away valuables, wrote

will/suicide note, took out pills but

didn't swallow, held gun but changed

mind or it was grabbed from your

hand, went to roof but didn't jump; or

actually took pills, tried to shoot

yourself, cut yourself, tried to hang

yourself, etc.

Only Yes to 1 or 2 - Low Risk

Only Yes to1 or 2 and 3 Moderate

Risk

Yes to 4, 5, or 6 High Risk

Risk Level Low Risk

SELF-HARM

Is self-harm currently a part of the

patient's presentation?

No

VULNERABILITY

Is Vulnerability currently a part of the

patient's presentation?

No

DYNAMIC APPRAISAL OF SITUATIONAL AGGRESSION (DASA)

Printed On: 03/31/2026 @ 11:13 Page 35 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Assessing the risk of aggression,

Each item is scored for its presence

(1), or absence (0), i the previous 24

hours.

The items are then summed to

produce a total score.

The risk rating is determined based

on total score.

0 = Low Risk

1 - 3 = Moderate Risk

4 - 7 = High Risk

Assessment

Irritability (0) - The patient has been calm, tolerant and relaxed. She/he is comfortable and

relaxed in the company of other patients with staff.

Impulsivity (0) - The patient has been affectively and/or behaviorally stable and composed.

Unwillingness to Follow Directions (0) - The patient in the last 24 hours has been compliant with any requests and

directions.

Sensitive to Perceived Provocation (0) - In the last 24 hours the patient has not become extraordinarilt angry or seen

everything that occurs around her/him as provocative. She/he is not 'overly

sensitive' or provocative'.

Easily Angered when Requests are

Denied

(0) - The patient has been calm and acception when she/he is asked to wait whilst

her/his request is attended to. She/he has been understanding and acception that

her/his request has been inable to be fulfilled at that time.

Negative Attitudes (0) - No negative attitudes

Verbal Threats (0) - The patient has not been verbally aggressive.

Total Score 0

Record of aggression: During the

previous 24 hours, has the patient

behaved aggressively in any of the

following ways?

Physicial aggression against

OBJECTS

No

Printed On: 03/31/2026 @ 11:13 Page 36 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Verbal aggression against OTHER

PEOPLE

No

Physical Aggression against OTHER

PEOPLE

No

DASA

If patient scored Moderate or High

Risk and not on Aggression/Assault

Precautions notify MD

CURRENT STATUS

L.O.C. Asleep

Mobility asleep

Activity Asleep

Awareness Asleep

Behavior In bed

Mood asleep

Affect asleep

Thought Process asleep

Thought Content asleep

Speech asleep

Detox Patient No

ADLs Asleep

Bathed/Showered No

Appearance Neat/Clean and Asleep

Printed On: 03/31/2026 @ 11:13 Page 37 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Sleep Slept throughout night

REVIEW OF SYSTEMS/INTAKE AND OUTPUT

DIETARY INTAKE

Supplements N/A

Elimination Asleep

REVIEW OF SYSTEMS

Review of Systems WNL

PATIENT EDUCATION

Topic safety

Level of Understanding Partially understands Needs additional support for understanding

Nursing Shift Narrative When this writer took over this patient care, pt was already in bed appears to be

sleeping. Pt slept throughout the night, no SOB, no pain or any discomfort/ no

unsafe behavior noted /reported. ALL level of observation and safety checks

maintained, will continue to monitor and report any changes.

**RN: Document to the treatment

plan every shift!

PATIENT EDUCATION

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

manage danger to others, homicidal ideation, and/or physical aggression. (Objective)

Nurse Signature e-Signed by Yedena-Wassoua, Loudouba, RN at 07/25/2025 07:12

Progress Note

Observation Date/Time:

NURSING PROGRESS NOTE -

INPATIENT

Date/Time 7/25/2025 17:16

Printed On: 03/31/2026 @ 11:13 Page 38 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Shift Day

Reason for Admission States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Printed On: 03/31/2026 @ 11:13 Page 39 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

History of Present Illness Presenting Problem:

Patient was taken to the emergency department under Section 12 following

homicidal statements directed toward his parents. He denies current homicidal

ideation but admits to past threats, including an intent to punch his father. He

reports frustration stemming from unresolved family disputes, notably regarding his

uncle's coin collection, which his father is withholding. He attempted to file a

restraining order against his mother but was unable to articulate the specific

reasons.

Psychiatric History:

Diagnosed with Bipolar Disorder, Autism Spectrum Disorder (ASD), Generalized

Anxiety Disorder (GAD), and history of Traumatic Brain Injury (TBI) from birth

complications.

Has a history of suicidal ideation and self-injurious behavior, including choking

himself with a belt during adolescence.

No prior inpatient psychiatric admissions.

Non-compliant with psychiatric medications over the past few months, citing a

preference for a holistic approach.

Behavioral Observations:

Appearance: Calm

Mood: Anxious

Affect: Congruent

Behavior: Cooperative

Speech: Clear

Thought Process: Circumstantial

Thought Content: No current suicidal or homicidal ideation

Orientation: Oriented to person, place, time, and situation

Insight: Poor

Judgment: Impaired

Concentration: Easily distracted

Family and Social History:

Reports a poor relationship with his father; primarily raised by his mother.

Engaged; has no children.

Support system includes family members and friends.

Substance Use History:

Occasional alcohol consumption ("few beers here and there")

Cannabis use

Family history of alcohol abuse (father)

Protective Factors:

Internal: Recognizes reasons for living

External: Beloved pet cats and a supportive social network of family and friends

Assessment Summary:

Patient appeared pressured in speech during the interview but remained

cooperative. He repeatedly stated he was "fine" and expressed a desire to return

home to care for his cats. His mother reported escalating behavioral issues over

recent months, including verbal aggression and property destruction, raising

concerns about his safety. Patient will benefit from inpatient psychiatric admission

for stabilization, medication assessment, and comprehensive aftercare planning.

Printed On: 03/31/2026 @ 11:13 Page 40 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Diagnosis:

Primary: Bipolar Disorder

Secondary: Autism Spectrum Disorder (ASD)

Treatment Plan:

Admit to inpatient psychiatric unit for safety, stabilization, and medication

evaluation.

Psychoeducation and engagement with family and peer support systems.

Develop an individualized aftercare plan, including outpatient follow-up scheduled

for 08/08/2025.

VITAL SIGNS

Patient refused vital signs Yes

Weight (Q Wednesday) 0 lb

**RN: Orders must be renewed daily

Special Interventions This Shift PRN Medications

Medical Interventions This Shift None

Risk Assessments

Current Level of Observation Every 15 minutes

Current Precautions LOW Suicide, Seizure, Assault/Aggression

PAIN

Pain today? No

ELOPEMENT RISK

Is Elopement currently a part of the

patient's presentation?

No

SEXUAL ACTING OUT

Is Sexually Acting out currently a part

of the patient's presentation?

No

Printed On: 03/31/2026 @ 11:13 Page 41 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Moderate Risk: RN to consult MD for

SAO precaution and discuss any

additional necessary orders or

practices of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes, and/or

room assignment on the unit. -

High Risk (15+): RN to consult MD

for SAO precaution and MD will order

at least one of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes

FALL RISK

Are falls currently a part of the

patient's presentation?

No

SUICIDALITY/C-SSRS RECENT

1.Have you wished you were dead or

wished you could go to sleep and not

wake up?

No

2. Have you actually had any

thoughts of killing yourself?

No

Is the Patient already on Suicide

Precautions?

Yes

If patient answers Yes to Either

Question 1 or Question 2 AND is

NOT already on Suicide Precautions,

CONTACT PROVIDER to review

6. Have you ever done anything,

started to do anything, or prepared to

do anything to end your life?

No

Printed On: 03/31/2026 @ 11:13 Page 42 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Ex: Collected pills, obtained gun,

gave away valuables, wrote

will/suicide note, took out pills but

didn't swallow, held gun but changed

mind or it was grabbed from your

hand, went to roof but didn't jump; or

actually took pills, tried to shoot

yourself, cut yourself, tried to hang

yourself, etc.

Only Yes to 1 or 2 - Low Risk

Only Yes to1 or 2 and 3 Moderate

Risk

Yes to 4, 5, or 6 High Risk

Risk Level Low Risk

SELF-HARM

Is self-harm currently a part of the

patient's presentation?

No

VULNERABILITY

Is Vulnerability currently a part of the

patient's presentation?

No

DYNAMIC APPRAISAL OF SITUATIONAL AGGRESSION (DASA)

Assessing the risk of aggression,

Each item is scored for its presence

(1), or absence (0), i the previous 24

hours.

The items are then summed to

produce a total score.

The risk rating is determined based

on total score.

0 = Low Risk

1 - 3 = Moderate Risk

4 - 7 = High Risk

Assessment

Printed On: 03/31/2026 @ 11:13 Page 43 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Irritability (0) - The patient has been calm, tolerant and relaxed. She/he is comfortable and

relaxed in the company of other patients with staff.

Impulsivity (0) - The patient has been affectively and/or behaviorally stable and composed.

Unwillingness to Follow Directions (0) - The patient in the last 24 hours has been compliant with any requests and

directions.

Sensitive to Perceived Provocation (0) - In the last 24 hours the patient has not become extraordinarilt angry or seen

everything that occurs around her/him as provocative. She/he is not 'overly

sensitive' or provocative'.

Easily Angered when Requests are

Denied

(0) - The patient has been calm and acception when she/he is asked to wait whilst

her/his request is attended to. She/he has been understanding and acception that

her/his request has been inable to be fulfilled at that time.

Negative Attitudes (0) - No negative attitudes

Verbal Threats (0) - The patient has not been verbally aggressive.

Total Score 0

Record of aggression: During the

previous 24 hours, has the patient

behaved aggressively in any of the

following ways?

Physicial aggression against

OBJECTS

No

Verbal aggression against OTHER

PEOPLE

No

Physical Aggression against OTHER

PEOPLE

No

DASA

If patient scored Moderate or High

Risk and not on Aggression/Assault

Precautions notify MD

CURRENT STATUS

L.O.C. Alert

Printed On: 03/31/2026 @ 11:13 Page 44 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Mobility WNL

Activity Normal

Awareness Aware of surroundings

Behavior Attending groups

Mood Angry, Anxious and Irritable

Affect Labile

Thought Process Preoccupied

Thought Content WNL

Speech Normal

Detox Patient No

ADLs Not taking care of ADLs

Bathed/Showered No

Appearance Disheveled

Sleep up during the day

REVIEW OF SYSTEMS/INTAKE AND OUTPUT

DIETARY INTAKE

Meals Eating off unit

Supplements N/A

Elimination Reports no problem

REVIEW OF SYSTEMS

Printed On: 03/31/2026 @ 11:13 Page 45 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Review of Systems WNL

PATIENT EDUCATION

Topic Safety

Level of Understanding Understood

Nursing Shift Narrative Patient appears to be calm this this shift . Reported sleeping good at night. Patient

is visible in the milieu and attended groups. Patient eating meals in the cafeteria

without any issues. Accepted scheduled medication and utilized nicotine gum. No

assault, SI or seizures observed or reported this shift. Q 15 mins check maintained

for safety.

**RN: Document to the treatment

plan every shift!

PATIENT EDUCATION

 - .Nursing will when Dallas identified with potential loss of control, ask Dallas what PRN

medication is most helpful and administer medication according to doctor’s order.

(Intervention)

 - Nursing staff to administer medication and treatment(s) as ordered per MD (Intervention)

 - Nursing will administer nicotine replacement protocol as ordered per MD (Intervention)

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

Nurse Signature e-Signed by Chileshe, Chikwanda at 07/26/2025 11:44

Progress Note

Observation Date/Time:

NURSING PROGRESS NOTE -

INPATIENT

Date/Time 7/26/2025 00:38

Shift Night

Reason for Admission States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Printed On: 03/31/2026 @ 11:13 Page 46 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

History of Present Illness Presenting Problem:

Patient was taken to the emergency department under Section 12 following

homicidal statements directed toward his parents. He denies current homicidal

ideation but admits to past threats, including an intent to punch his father. He

reports frustration stemming from unresolved family disputes, notably regarding his

uncle's coin collection, which his father is withholding. He attempted to file a

restraining order against his mother but was unable to articulate the specific

reasons.

Psychiatric History:

Diagnosed with Bipolar Disorder, Autism Spectrum Disorder (ASD), Generalized

Anxiety Disorder (GAD), and history of Traumatic Brain Injury (TBI) from birth

complications.

Has a history of suicidal ideation and self-injurious behavior, including choking

himself with a belt during adolescence.

No prior inpatient psychiatric admissions.

Non-compliant with psychiatric medications over the past few months, citing a

preference for a holistic approach.

Behavioral Observations:

Appearance: Calm

Mood: Anxious

Affect: Congruent

Behavior: Cooperative

Speech: Clear

Thought Process: Circumstantial

Thought Content: No current suicidal or homicidal ideation

Orientation: Oriented to person, place, time, and situation

Insight: Poor

Judgment: Impaired

Concentration: Easily distracted

Family and Social History:

Reports a poor relationship with his father; primarily raised by his mother.

Engaged; has no children.

Support system includes family members and friends.

Substance Use History:

Occasional alcohol consumption ("few beers here and there")

Cannabis use

Family history of alcohol abuse (father)

Protective Factors:

Internal: Recognizes reasons for living

External: Beloved pet cats and a supportive social network of family and friends

Assessment Summary:

Patient appeared pressured in speech during the interview but remained

cooperative. He repeatedly stated he was "fine" and expressed a desire to return

home to care for his cats. His mother reported escalating behavioral issues over

recent months, including verbal aggression and property destruction, raising

concerns about his safety. Patient will benefit from inpatient psychiatric admission

for stabilization, medication assessment, and comprehensive aftercare planning.

Printed On: 03/31/2026 @ 11:13 Page 47 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Diagnosis:

Primary: Bipolar Disorder

Secondary: Autism Spectrum Disorder (ASD)

Treatment Plan:

Admit to inpatient psychiatric unit for safety, stabilization, and medication

evaluation.

Psychoeducation and engagement with family and peer support systems.

Develop an individualized aftercare plan, including outpatient follow-up scheduled

for 08/08/2025.

VITAL SIGNS

Systolic Blood Pressure 141 mmHg

Diastolic Blood Pressure 93 mmHg

Heart Rate 111 beats/min

Temperature 98.1 ºF

Respirations 18 brth/min

SPO2 96 %

**RN: Orders must be renewed daily

Special Interventions This Shift None

Medical Interventions This Shift None

Risk Assessments

Current Level of Observation Every 15 minutes

Current Precautions LOW Suicide, Seizure, Assault/Aggression

PAIN

Pain today? No

Printed On: 03/31/2026 @ 11:13 Page 48 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

ELOPEMENT RISK

Is Elopement currently a part of the

patient's presentation?

No

SEXUAL ACTING OUT

Is Sexually Acting out currently a part

of the patient's presentation?

No

Moderate Risk: RN to consult MD for

SAO precaution and discuss any

additional necessary orders or

practices of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes, and/or

room assignment on the unit. -

High Risk (15+): RN to consult MD

for SAO precaution and MD will order

at least one of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes

FALL RISK

Are falls currently a part of the

patient's presentation?

No

SUICIDALITY/C-SSRS RECENT

1.Have you wished you were dead or

wished you could go to sleep and not

wake up?

No

2. Have you actually had any

thoughts of killing yourself?

No

Is the Patient already on Suicide

Precautions?

No

If patient answers Yes to Either

Question 1 or Question 2 AND is

NOT already on Suicide Precautions,

CONTACT PROVIDER to review

Printed On: 03/31/2026 @ 11:13 Page 49 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

6. Have you ever done anything,

started to do anything, or prepared to

do anything to end your life?

No

Ex: Collected pills, obtained gun,

gave away valuables, wrote

will/suicide note, took out pills but

didn't swallow, held gun but changed

mind or it was grabbed from your

hand, went to roof but didn't jump; or

actually took pills, tried to shoot

yourself, cut yourself, tried to hang

yourself, etc.

Only Yes to 1 or 2 - Low Risk

Only Yes to1 or 2 and 3 Moderate

Risk

Yes to 4, 5, or 6 High Risk

Risk Level Low Risk

SELF-HARM

Is self-harm currently a part of the

patient's presentation?

No

VULNERABILITY

Is Vulnerability currently a part of the

patient's presentation?

No

DYNAMIC APPRAISAL OF SITUATIONAL AGGRESSION (DASA)

Assessing the risk of aggression,

Each item is scored for its presence

(1), or absence (0), i the previous 24

hours.

Printed On: 03/31/2026 @ 11:13 Page 50 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

The items are then summed to

produce a total score.

The risk rating is determined based

on total score.

0 = Low Risk

1 - 3 = Moderate Risk

4 - 7 = High Risk

Assessment

Irritability (0) - The patient has been calm, tolerant and relaxed. She/he is comfortable and

relaxed in the company of other patients with staff.

Impulsivity (0) - The patient has been affectively and/or behaviorally stable and composed.

Unwillingness to Follow Directions (0) - The patient in the last 24 hours has been compliant with any requests and

directions.

Sensitive to Perceived Provocation (0) - In the last 24 hours the patient has not become extraordinarilt angry or seen

everything that occurs around her/him as provocative. She/he is not 'overly

sensitive' or provocative'.

Easily Angered when Requests are

Denied

(0) - The patient has been calm and acception when she/he is asked to wait whilst

her/his request is attended to. She/he has been understanding and acception that

her/his request has been inable to be fulfilled at that time.

Negative Attitudes (0) - No negative attitudes

Verbal Threats (0) - The patient has not been verbally aggressive.

Total Score 0

Record of aggression: During the

previous 24 hours, has the patient

behaved aggressively in any of the

following ways?

Physicial aggression against

OBJECTS

No

Verbal aggression against OTHER

PEOPLE

No

Physical Aggression against OTHER

PEOPLE

No

Printed On: 03/31/2026 @ 11:13 Page 51 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

DASA

If patient scored Moderate or High

Risk and not on Aggression/Assault

Precautions notify MD

CURRENT STATUS

L.O.C. Asleep

Mobility asleep

Activity Asleep

Awareness Asleep and asleep

Behavior asleep

Mood asleep

Affect asleep

Thought Process asleep

Thought Content asleep

Speech asleep

Detox Patient No

ADLs Asleep

Bathed/Showered No

Appearance Asleep

Sleep Slept throughout night

REVIEW OF SYSTEMS/INTAKE AND OUTPUT

DIETARY INTAKE

Printed On: 03/31/2026 @ 11:13 Page 52 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Supplements N/A

Elimination Asleep

REVIEW OF SYSTEMS

Review of Systems WNL

PATIENT EDUCATION

Topic safety

Level of Understanding Partially understands Needs additional support for understanding

Nursing Shift Narrative Resumed care for this patient at 11 pm, pt was already in bed appears to be

sleeping. Pt slept throughout the night, no SOB, no pain or any discomfort/ no

unsafe behavior noted /reported. ALL level of observation and safety checks

maintained, will continue to monitor and report any changes.

**RN: Document to the treatment

plan every shift!

PATIENT EDUCATION

 - Conduct group (art, music, animal, movement, expressive) and monitor patient progress for

the development of new leisure skills to decrease danger to others, homicidal ideation, and/or

physical aggression (Intervention)

Nurse Signature e-Signed by Yedena-Wassoua, Loudouba, RN at 07/26/2025 05:25

Progress Note

Observation Date/Time:

NURSING PROGRESS NOTE -

INPATIENT

Date/Time 7/26/2025 15:52

Shift Day

Printed On: 03/31/2026 @ 11:13 Page 53 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Reason for Admission States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Printed On: 03/31/2026 @ 11:13 Page 54 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

History of Present Illness Presenting Problem:

Patient was taken to the emergency department under Section 12 following

homicidal statements directed toward his parents. He denies current homicidal

ideation but admits to past threats, including an intent to punch his father. He

reports frustration stemming from unresolved family disputes, notably regarding his

uncle's coin collection, which his father is withholding. He attempted to file a

restraining order against his mother but was unable to articulate the specific

reasons.

Psychiatric History:

Diagnosed with Bipolar Disorder, Autism Spectrum Disorder (ASD), Generalized

Anxiety Disorder (GAD), and history of Traumatic Brain Injury (TBI) from birth

complications.

Has a history of suicidal ideation and self-injurious behavior, including choking

himself with a belt during adolescence.

No prior inpatient psychiatric admissions.

Non-compliant with psychiatric medications over the past few months, citing a

preference for a holistic approach.

Behavioral Observations:

Appearance: Calm

Mood: Anxious

Affect: Congruent

Behavior: Cooperative

Speech: Clear

Thought Process: Circumstantial

Thought Content: No current suicidal or homicidal ideation

Orientation: Oriented to person, place, time, and situation

Insight: Poor

Judgment: Impaired

Concentration: Easily distracted

Family and Social History:

Reports a poor relationship with his father; primarily raised by his mother.

Engaged; has no children.

Support system includes family members and friends.

Substance Use History:

Occasional alcohol consumption ("few beers here and there")

Cannabis use

Family history of alcohol abuse (father)

Protective Factors:

Internal: Recognizes reasons for living

External: Beloved pet cats and a supportive social network of family and friends

Assessment Summary:

Patient appeared pressured in speech during the interview but remained

cooperative. He repeatedly stated he was "fine" and expressed a desire to return

home to care for his cats. His mother reported escalating behavioral issues over

recent months, including verbal aggression and property destruction, raising

concerns about his safety. Patient will benefit from inpatient psychiatric admission

for stabilization, medication assessment, and comprehensive aftercare planning.

Printed On: 03/31/2026 @ 11:13 Page 55 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Diagnosis:

Primary: Bipolar Disorder

Secondary: Autism Spectrum Disorder (ASD)

Treatment Plan:

Admit to inpatient psychiatric unit for safety, stabilization, and medication

evaluation.

Psychoeducation and engagement with family and peer support systems.

Develop an individualized aftercare plan, including outpatient follow-up scheduled

for 08/08/2025.

VITAL SIGNS

**RN: Orders must be renewed daily

Special Interventions This Shift None

Medical Interventions This Shift None

Risk Assessments

Current Level of Observation Every 15 minutes

Current Precautions LOW Suicide, Seizure, Assault/Aggression

PAIN

Pain today? No

ELOPEMENT RISK

Is Elopement currently a part of the

patient's presentation?

No

SEXUAL ACTING OUT

Is Sexually Acting out currently a part

of the patient's presentation?

No

Printed On: 03/31/2026 @ 11:13 Page 56 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Moderate Risk: RN to consult MD for

SAO precaution and discuss any

additional necessary orders or

practices of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes, and/or

room assignment on the unit. -

High Risk (15+): RN to consult MD

for SAO precaution and MD will order

at least one of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes

FALL RISK

Are falls currently a part of the

patient's presentation?

No

SUICIDALITY/C-SSRS RECENT

1.Have you wished you were dead or

wished you could go to sleep and not

wake up?

No

2. Have you actually had any

thoughts of killing yourself?

No

Is the Patient already on Suicide

Precautions?

Yes

If patient answers Yes to Either

Question 1 or Question 2 AND is

NOT already on Suicide Precautions,

CONTACT PROVIDER to review

6. Have you ever done anything,

started to do anything, or prepared to

do anything to end your life?

No

Printed On: 03/31/2026 @ 11:13 Page 57 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Ex: Collected pills, obtained gun,

gave away valuables, wrote

will/suicide note, took out pills but

didn't swallow, held gun but changed

mind or it was grabbed from your

hand, went to roof but didn't jump; or

actually took pills, tried to shoot

yourself, cut yourself, tried to hang

yourself, etc.

Only Yes to 1 or 2 - Low Risk

Only Yes to1 or 2 and 3 Moderate

Risk

Yes to 4, 5, or 6 High Risk

Risk Level Low Risk

SELF-HARM

Is self-harm currently a part of the

patient's presentation?

No

VULNERABILITY

Is Vulnerability currently a part of the

patient's presentation?

No

DYNAMIC APPRAISAL OF SITUATIONAL AGGRESSION (DASA)

Assessing the risk of aggression,

Each item is scored for its presence

(1), or absence (0), i the previous 24

hours.

The items are then summed to

produce a total score.

The risk rating is determined based

on total score.

0 = Low Risk

1 - 3 = Moderate Risk

4 - 7 = High Risk

Assessment

Printed On: 03/31/2026 @ 11:13 Page 58 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Irritability (0) - The patient has been calm, tolerant and relaxed. She/he is comfortable and

relaxed in the company of other patients with staff.

Impulsivity (0) - The patient has been affectively and/or behaviorally stable and composed.

Unwillingness to Follow Directions (0) - The patient in the last 24 hours has been compliant with any requests and

directions.

Sensitive to Perceived Provocation (0) - In the last 24 hours the patient has not become extraordinarilt angry or seen

everything that occurs around her/him as provocative. She/he is not 'overly

sensitive' or provocative'.

Easily Angered when Requests are

Denied

(0) - The patient has been calm and acception when she/he is asked to wait whilst

her/his request is attended to. She/he has been understanding and acception that

her/his request has been inable to be fulfilled at that time.

Negative Attitudes (0) - No negative attitudes

Verbal Threats (0) - The patient has not been verbally aggressive.

Total Score 0

Record of aggression: During the

previous 24 hours, has the patient

behaved aggressively in any of the

following ways?

Physicial aggression against

OBJECTS

No

Verbal aggression against OTHER

PEOPLE

No

Physical Aggression against OTHER

PEOPLE

No

DASA

If patient scored Moderate or High

Risk and not on Aggression/Assault

Precautions notify MD

CURRENT STATUS

L.O.C. Alert

Printed On: 03/31/2026 @ 11:13 Page 59 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Mobility WNL

Activity Normal

Awareness Aware of surroundings

Behavior Attending groups

Mood Anxious and Irritable

Affect Labile

Thought Process Organized

Thought Content WNL

Speech Normal

Detox Patient No

ADLs Taking care of ADLs

Bathed/Showered No

Appearance Neat/Clean

Sleep Awake during the day.

REVIEW OF SYSTEMS/INTAKE AND OUTPUT

DIETARY INTAKE

Meals Eating off unit

Supplements N/A

Elimination Reports no problem

REVIEW OF SYSTEMS

Printed On: 03/31/2026 @ 11:13 Page 60 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Review of Systems WNL

PATIENT EDUCATION

Topic Safety

Level of Understanding Understood

Nursing Shift Narrative Patient appears to be calm this this shift . Reported sleeping good at night. Patient

is visible in the milieu and attended groups. Patient eating meals in the cafeteria

without any issues. Accepted scheduled medication and utilized prn Ativan 0.5mg

and nicotine gum. No assault, SI or seizures observed or reported this shift. Q 15

mins check maintained for safety.

**RN: Document to the treatment

plan every shift!

PATIENT EDUCATION

 - Conduct group (art, music, animal, movement, expressive) and monitor patient progress for

the development of new leisure skills to decrease danger to others, homicidal ideation, and/or

physical aggression (Intervention)

 - .Nursing will when Dallas identified with potential loss of control, ask Dallas what PRN

medication is most helpful and administer medication according to doctor’s order.

(Intervention)

 - Nursing will administer nicotine replacement protocol as ordered per MD (Intervention)

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

Nurse Signature e-Signed by Chileshe, Chikwanda at 07/26/2025 20:01

Progress Note

Observation Date/Time:

NURSING PROGRESS NOTE -

INPATIENT

Date/Time 7/27/2025 02:55

Shift Night

Reason for Admission States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Printed On: 03/31/2026 @ 11:13 Page 61 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

History of Present Illness Presenting Problem:

Patient was taken to the emergency department under Section 12 following

homicidal statements directed toward his parents. He denies current homicidal

ideation but admits to past threats, including an intent to punch his father. He

reports frustration stemming from unresolved family disputes, notably regarding his

uncle's coin collection, which his father is withholding. He attempted to file a

restraining order against his mother but was unable to articulate the specific

reasons.

Psychiatric History:

Diagnosed with Bipolar Disorder, Autism Spectrum Disorder (ASD), Generalized

Anxiety Disorder (GAD), and history of Traumatic Brain Injury (TBI) from birth

complications.

Has a history of suicidal ideation and self-injurious behavior, including choking

himself with a belt during adolescence.

No prior inpatient psychiatric admissions.

Non-compliant with psychiatric medications over the past few months, citing a

preference for a holistic approach.

Behavioral Observations:

Appearance: Calm

Mood: Anxious

Affect: Congruent

Behavior: Cooperative

Speech: Clear

Thought Process: Circumstantial

Thought Content: No current suicidal or homicidal ideation

Orientation: Oriented to person, place, time, and situation

Insight: Poor

Judgment: Impaired

Concentration: Easily distracted

Family and Social History:

Reports a poor relationship with his father; primarily raised by his mother.

Engaged; has no children.

Support system includes family members and friends.

Substance Use History:

Occasional alcohol consumption ("few beers here and there")

Cannabis use

Family history of alcohol abuse (father)

Protective Factors:

Internal: Recognizes reasons for living

External: Beloved pet cats and a supportive social network of family and friends

Assessment Summary:

Patient appeared pressured in speech during the interview but remained

cooperative. He repeatedly stated he was "fine" and expressed a desire to return

home to care for his cats. His mother reported escalating behavioral issues over

recent months, including verbal aggression and property destruction, raising

concerns about his safety. Patient will benefit from inpatient psychiatric admission

for stabilization, medication assessment, and comprehensive aftercare planning.

Printed On: 03/31/2026 @ 11:13 Page 62 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Diagnosis:

Primary: Bipolar Disorder

Secondary: Autism Spectrum Disorder (ASD)

Treatment Plan:

Admit to inpatient psychiatric unit for safety, stabilization, and medication

evaluation.

Psychoeducation and engagement with family and peer support systems.

Develop an individualized aftercare plan, including outpatient follow-up scheduled

for 08/08/2025.

VITAL SIGNS

Systolic Blood Pressure 128 mmHg

Diastolic Blood Pressure 90 mmHg

Heart Rate 98 beats/min

Temperature 98.0 ºF

Respirations 18 brth/min

SPO2 97 %

**RN: Orders must be renewed daily

Special Interventions This Shift None

Medical Interventions This Shift None

Risk Assessments

Current Level of Observation Every 15 minutes

Current Precautions LOW Suicide, Seizure, Assault/Aggression

PAIN

Pain today? No

Printed On: 03/31/2026 @ 11:13 Page 63 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

ELOPEMENT RISK

Is Elopement currently a part of the

patient's presentation?

No

SEXUAL ACTING OUT

Is Sexually Acting out currently a part

of the patient's presentation?

No

Moderate Risk: RN to consult MD for

SAO precaution and discuss any

additional necessary orders or

practices of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes, and/or

room assignment on the unit. -

High Risk (15+): RN to consult MD

for SAO precaution and MD will order

at least one of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes

FALL RISK

Are falls currently a part of the

patient's presentation?

No

SUICIDALITY/C-SSRS RECENT

1.Have you wished you were dead or

wished you could go to sleep and not

wake up?

No

2. Have you actually had any

thoughts of killing yourself?

No

Is the Patient already on Suicide

Precautions?

No

If patient answers Yes to Either

Question 1 or Question 2 AND is

NOT already on Suicide Precautions,

CONTACT PROVIDER to review

Printed On: 03/31/2026 @ 11:13 Page 64 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

6. Have you ever done anything,

started to do anything, or prepared to

do anything to end your life?

No

Ex: Collected pills, obtained gun,

gave away valuables, wrote

will/suicide note, took out pills but

didn't swallow, held gun but changed

mind or it was grabbed from your

hand, went to roof but didn't jump; or

actually took pills, tried to shoot

yourself, cut yourself, tried to hang

yourself, etc.

Only Yes to 1 or 2 - Low Risk

Only Yes to1 or 2 and 3 Moderate

Risk

Yes to 4, 5, or 6 High Risk

Risk Level Low Risk

SELF-HARM

Is self-harm currently a part of the

patient's presentation?

No

VULNERABILITY

Is Vulnerability currently a part of the

patient's presentation?

No

DYNAMIC APPRAISAL OF SITUATIONAL AGGRESSION (DASA)

Assessing the risk of aggression,

Each item is scored for its presence

(1), or absence (0), i the previous 24

hours.

Printed On: 03/31/2026 @ 11:13 Page 65 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

The items are then summed to

produce a total score.

The risk rating is determined based

on total score.

0 = Low Risk

1 - 3 = Moderate Risk

4 - 7 = High Risk

Assessment

Irritability (0) - The patient has been calm, tolerant and relaxed. She/he is comfortable and

relaxed in the company of other patients with staff.

Impulsivity (0) - The patient has been affectively and/or behaviorally stable and composed.

Unwillingness to Follow Directions (0) - The patient in the last 24 hours has been compliant with any requests and

directions.

Sensitive to Perceived Provocation (0) - In the last 24 hours the patient has not become extraordinarilt angry or seen

everything that occurs around her/him as provocative. She/he is not 'overly

sensitive' or provocative'.

Easily Angered when Requests are

Denied

(0) - The patient has been calm and acception when she/he is asked to wait whilst

her/his request is attended to. She/he has been understanding and acception that

her/his request has been inable to be fulfilled at that time.

Negative Attitudes (0) - No negative attitudes

Verbal Threats (0) - The patient has not been verbally aggressive.

Total Score 0

Record of aggression: During the

previous 24 hours, has the patient

behaved aggressively in any of the

following ways?

Physicial aggression against

OBJECTS

No

Verbal aggression against OTHER

PEOPLE

No

Physical Aggression against OTHER

PEOPLE

No

Printed On: 03/31/2026 @ 11:13 Page 66 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

DASA

If patient scored Moderate or High

Risk and not on Aggression/Assault

Precautions notify MD

CURRENT STATUS

L.O.C. Asleep

Mobility WNL

Activity Asleep

Awareness Asleep

Behavior In bed

Mood Euthymic

Affect WNL

Thought Process Organized

Thought Content WNL

Speech Normal

Detox Patient No

ADLs Asleep

Bathed/Showered No

Appearance Neat/Clean and Asleep

Sleep Awake throughout night

REVIEW OF SYSTEMS/INTAKE AND OUTPUT

DIETARY INTAKE

Printed On: 03/31/2026 @ 11:13 Page 67 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Supplements N/A

Elimination Asleep

REVIEW OF SYSTEMS

Review of Systems WNL

PATIENT EDUCATION

Topic Safety

Level of Understanding Understood

Nursing Shift Narrative Pt is visible on the unit, social with staff and peers, pleasant upon approach.

Attended nursing group with full participation, compliant with scheduled

medications, utilizing prn Ativan 0.5mg. Expressed frustration and increased anxiety

surrounding pending discharge, per pt. Pt reports he is discharging Tuesday and is

becoming restless having to wait. Encouraged pt to reframe thinking to "3 sleep

overs". Pt was appreciative of 1:1 support stating "That makes me feel better, to

think of it that way, that's manageable". Pt denies SI/SIB/HI/AH/VH at this time, feels

safe on the unit. No s/sx of seizure activity observed or reported.

Pt is observed resting quietly in assigned bed; eyes closed, respirations even and

unlabored, appears to be asleep.

Pt is maintained on 15-minute observation checks for safety, no safety concerns at

this time. Continue to monitor for safety, report any acute changes in

medical/mental status to on call provider and provide support as needed.

**RN: Document to the treatment

plan every shift!

PATIENT EDUCATION

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

Nurse Signature e-Signed by Pizzi, Carolyn at 07/27/2025 06:20

Progress Note

Observation Date/Time:

Printed On: 03/31/2026 @ 11:13 Page 68 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

NURSING PROGRESS NOTE -

INPATIENT

Date/Time 7/27/2025 17:59

Shift Day

Reason for Admission States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Printed On: 03/31/2026 @ 11:13 Page 69 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

History of Present Illness Presenting Problem:

Patient was taken to the emergency department under Section 12 following

homicidal statements directed toward his parents. He denies current homicidal

ideation but admits to past threats, including an intent to punch his father. He

reports frustration stemming from unresolved family disputes, notably regarding his

uncle's coin collection, which his father is withholding. He attempted to file a

restraining order against his mother but was unable to articulate the specific

reasons.

Psychiatric History:

Diagnosed with Bipolar Disorder, Autism Spectrum Disorder (ASD), Generalized

Anxiety Disorder (GAD), and history of Traumatic Brain Injury (TBI) from birth

complications.

Has a history of suicidal ideation and self-injurious behavior, including choking

himself with a belt during adolescence.

No prior inpatient psychiatric admissions.

Non-compliant with psychiatric medications over the past few months, citing a

preference for a holistic approach.

Behavioral Observations:

Appearance: Calm

Mood: Anxious

Affect: Congruent

Behavior: Cooperative

Speech: Clear

Thought Process: Circumstantial

Thought Content: No current suicidal or homicidal ideation

Orientation: Oriented to person, place, time, and situation

Insight: Poor

Judgment: Impaired

Concentration: Easily distracted

Family and Social History:

Reports a poor relationship with his father; primarily raised by his mother.

Engaged; has no children.

Support system includes family members and friends.

Substance Use History:

Occasional alcohol consumption ("few beers here and there")

Cannabis use

Family history of alcohol abuse (father)

Protective Factors:

Internal: Recognizes reasons for living

External: Beloved pet cats and a supportive social network of family and friends

Assessment Summary:

Patient appeared pressured in speech during the interview but remained

cooperative. He repeatedly stated he was "fine" and expressed a desire to return

home to care for his cats. His mother reported escalating behavioral issues over

recent months, including verbal aggression and property destruction, raising

concerns about his safety. Patient will benefit from inpatient psychiatric admission

for stabilization, medication assessment, and comprehensive aftercare planning.

Printed On: 03/31/2026 @ 11:13 Page 70 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Diagnosis:

Primary: Bipolar Disorder

Secondary: Autism Spectrum Disorder (ASD)

Treatment Plan:

Admit to inpatient psychiatric unit for safety, stabilization, and medication

evaluation.

Psychoeducation and engagement with family and peer support systems.

Develop an individualized aftercare plan, including outpatient follow-up scheduled

for 08/08/2025.

VITAL SIGNS

Systolic Blood Pressure 142 mmHg

Diastolic Blood Pressure 60 mmHg

Heart Rate 77 beats/min

Temperature 98.7 ºF

Respirations 18 brth/min

SPO2 97 %

**RN: Orders must be renewed daily

Special Interventions This Shift PRN Medications

Medical Interventions This Shift None

Risk Assessments

Current Level of Observation Every 15 minutes

Current Precautions LOW Suicide, Seizure, Assault/Aggression

PAIN

Pain today? No

Printed On: 03/31/2026 @ 11:13 Page 71 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

ELOPEMENT RISK

Is Elopement currently a part of the

patient's presentation?

No

SEXUAL ACTING OUT

Is Sexually Acting out currently a part

of the patient's presentation?

No

Moderate Risk: RN to consult MD for

SAO precaution and discuss any

additional necessary orders or

practices of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes, and/or

room assignment on the unit. -

High Risk (15+): RN to consult MD

for SAO precaution and MD will order

at least one of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes

FALL RISK

Are falls currently a part of the

patient's presentation?

No

SUICIDALITY/C-SSRS RECENT

1.Have you wished you were dead or

wished you could go to sleep and not

wake up?

No

2. Have you actually had any

thoughts of killing yourself?

No

Is the Patient already on Suicide

Precautions?

No

If patient answers Yes to Either

Question 1 or Question 2 AND is

NOT already on Suicide Precautions,

CONTACT PROVIDER to review

Printed On: 03/31/2026 @ 11:13 Page 72 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

6. Have you ever done anything,

started to do anything, or prepared to

do anything to end your life?

No

Ex: Collected pills, obtained gun,

gave away valuables, wrote

will/suicide note, took out pills but

didn't swallow, held gun but changed

mind or it was grabbed from your

hand, went to roof but didn't jump; or

actually took pills, tried to shoot

yourself, cut yourself, tried to hang

yourself, etc.

Only Yes to 1 or 2 - Low Risk

Only Yes to1 or 2 and 3 Moderate

Risk

Yes to 4, 5, or 6 High Risk

Risk Level Low Risk

SELF-HARM

Is self-harm currently a part of the

patient's presentation?

No

VULNERABILITY

Is Vulnerability currently a part of the

patient's presentation?

No

DYNAMIC APPRAISAL OF SITUATIONAL AGGRESSION (DASA)

Assessing the risk of aggression,

Each item is scored for its presence

(1), or absence (0), i the previous 24

hours.

Printed On: 03/31/2026 @ 11:13 Page 73 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

The items are then summed to

produce a total score.

The risk rating is determined based

on total score.

0 = Low Risk

1 - 3 = Moderate Risk

4 - 7 = High Risk

Assessment

Irritability (1) - The patient is easily annoyed or angered and inable to tolerate the presence of

others.

Impulsivity (0) - The patient has been affectively and/or behaviorally stable and composed.

Unwillingness to Follow Directions (1) - The patient has become angry and/or aggressive she/he was asked adhere to

some aspect of her/his treatment or to the ward's routine in the last 24 hours.

Sensitive to Perceived Provocation (1) - The patient has tended to see others' actions as deliberate and harmful. She/he

may misinterpret other people's behavior or respond with anger in a

disproportionate manner to the extent of provocation. She/he has been been

orickly, overly sensitive, and quick(1) to anger.

Easily Angered when Requests are

Denied

(0) - The patient has been calm and acception when she/he is asked to wait whilst

her/his request is attended to. She/he has been understanding and acception that

her/his request has been inable to be fulfilled at that time.

Negative Attitudes (0) - No negative attitudes

Verbal Threats (0) - The patient has not been verbally aggressive.

Total Score 3

Record of aggression: During the

previous 24 hours, has the patient

behaved aggressively in any of the

following ways?

Physicial aggression against

OBJECTS

No

Verbal aggression against OTHER

PEOPLE

No

Physical Aggression against OTHER

PEOPLE

No

Printed On: 03/31/2026 @ 11:13 Page 74 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

DASA

If patient scored Moderate or High

Risk and not on Aggression/Assault

Precautions notify MD

CURRENT STATUS

L.O.C. Alert

Mobility WNL

Activity Normal

Awareness Aware of surroundings

Behavior Attending groups

Mood Anxious and Irritable

Affect Labile

Thought Process Disorganized

Thought Content Delusional

Speech Normal

Detox Patient No

ADLs Taking care of ADLs

Bathed/Showered No

Appearance Neat/Clean

Sleep Napped during the day

REVIEW OF SYSTEMS/INTAKE AND OUTPUT

Printed On: 03/31/2026 @ 11:13 Page 75 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

DIETARY INTAKE

Meals Eating off unit

Breakfast 100%

Lunch 100%

Dinner 100%

Snack Yes

Supplements N/A

Elimination Reports no problem

REVIEW OF SYSTEMS

Review of Systems WNL

PATIENT EDUCATION

Topic Safety

Level of Understanding Partially understands Needs additional support for understanding

Nursing Shift Narrative Patient presented with a flat affect, alert and verbally responsive. Denies having any

pain or discomfort. Able to make his needs known. Noticed interacting well with

selective peers. Positive for all his meds as ordered. Prn gum 2 mg . Joined the

group meeting and coloring. Transited well at the cafe. He has good appetite. Staff

educated patient how to use his coping skills. No issues reported this shift. will

continue on 15 mins checks for safety.

**RN: Document to the treatment

plan every shift!

PATIENT EDUCATION

Printed On: 03/31/2026 @ 11:13 Page 76 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

 - .Nursing will when Dallas identified with potential loss of control, ask Dallas what PRN

medication is most helpful and administer medication according to doctor’s order.

(Intervention)

 - Nursing staff to administer medication and treatment(s) as ordered per MD (Intervention)

 - Nursing will administer nicotine replacement protocol as ordered per MD (Intervention)

Nurse Signature e-Signed by Nalunkuma, Faridah, RN at 07/28/2025 18:52

Progress Note

Observation Date/Time:

NURSING PROGRESS NOTE -

INPATIENT

Date/Time 7/27/2025 22:57

Shift Night

Reason for Admission States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Printed On: 03/31/2026 @ 11:13 Page 77 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

History of Present Illness Presenting Problem:

Patient was taken to the emergency department under Section 12 following

homicidal statements directed toward his parents. He denies current homicidal

ideation but admits to past threats, including an intent to punch his father. He

reports frustration stemming from unresolved family disputes, notably regarding his

uncle's coin collection, which his father is withholding. He attempted to file a

restraining order against his mother but was unable to articulate the specific

reasons.

Psychiatric History:

Diagnosed with Bipolar Disorder, Autism Spectrum Disorder (ASD), Generalized

Anxiety Disorder (GAD), and history of Traumatic Brain Injury (TBI) from birth

complications.

Has a history of suicidal ideation and self-injurious behavior, including choking

himself with a belt during adolescence.

No prior inpatient psychiatric admissions.

Non-compliant with psychiatric medications over the past few months, citing a

preference for a holistic approach.

Behavioral Observations:

Appearance: Calm

Mood: Anxious

Affect: Congruent

Behavior: Cooperative

Speech: Clear

Thought Process: Circumstantial

Thought Content: No current suicidal or homicidal ideation

Orientation: Oriented to person, place, time, and situation

Insight: Poor

Judgment: Impaired

Concentration: Easily distracted

Family and Social History:

Reports a poor relationship with his father; primarily raised by his mother.

Engaged; has no children.

Support system includes family members and friends.

Substance Use History:

Occasional alcohol consumption ("few beers here and there")

Cannabis use

Family history of alcohol abuse (father)

Protective Factors:

Internal: Recognizes reasons for living

External: Beloved pet cats and a supportive social network of family and friends

Assessment Summary:

Patient appeared pressured in speech during the interview but remained

cooperative. He repeatedly stated he was "fine" and expressed a desire to return

home to care for his cats. His mother reported escalating behavioral issues over

recent months, including verbal aggression and property destruction, raising

concerns about his safety. Patient will benefit from inpatient psychiatric admission

for stabilization, medication assessment, and comprehensive aftercare planning.

Printed On: 03/31/2026 @ 11:13 Page 78 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Diagnosis:

Primary: Bipolar Disorder

Secondary: Autism Spectrum Disorder (ASD)

Treatment Plan:

Admit to inpatient psychiatric unit for safety, stabilization, and medication

evaluation.

Psychoeducation and engagement with family and peer support systems.

Develop an individualized aftercare plan, including outpatient follow-up scheduled

for 08/08/2025.

VITAL SIGNS

Systolic Blood Pressure 143 mmHg

Diastolic Blood Pressure 92 mmHg

Heart Rate 100 beats/min

Temperature 98.2 ºF

Respirations 18 brth/min

SPO2 98 %

**RN: Orders must be renewed daily

Special Interventions This Shift None

Medical Interventions This Shift None

Risk Assessments

Current Level of Observation Every 15 minutes

Current Precautions LOW Suicide, Seizure, Assault/Aggression

PAIN

Pain today? No

Printed On: 03/31/2026 @ 11:13 Page 79 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

ELOPEMENT RISK

Is Elopement currently a part of the

patient's presentation?

No

SEXUAL ACTING OUT

Is Sexually Acting out currently a part

of the patient's presentation?

No

Moderate Risk: RN to consult MD for

SAO precaution and discuss any

additional necessary orders or

practices of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes, and/or

room assignment on the unit. -

High Risk (15+): RN to consult MD

for SAO precaution and MD will order

at least one of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes

FALL RISK

Are falls currently a part of the

patient's presentation?

No

SUICIDALITY/C-SSRS RECENT

1.Have you wished you were dead or

wished you could go to sleep and not

wake up?

No

2. Have you actually had any

thoughts of killing yourself?

No

Is the Patient already on Suicide

Precautions?

No

If patient answers Yes to Either

Question 1 or Question 2 AND is

NOT already on Suicide Precautions,

CONTACT PROVIDER to review

Printed On: 03/31/2026 @ 11:13 Page 80 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

6. Have you ever done anything,

started to do anything, or prepared to

do anything to end your life?

No

Ex: Collected pills, obtained gun,

gave away valuables, wrote

will/suicide note, took out pills but

didn't swallow, held gun but changed

mind or it was grabbed from your

hand, went to roof but didn't jump; or

actually took pills, tried to shoot

yourself, cut yourself, tried to hang

yourself, etc.

Only Yes to 1 or 2 - Low Risk

Only Yes to1 or 2 and 3 Moderate

Risk

Yes to 4, 5, or 6 High Risk

Risk Level Low Risk

SELF-HARM

Is self-harm currently a part of the

patient's presentation?

No

VULNERABILITY

Is Vulnerability currently a part of the

patient's presentation?

No

DYNAMIC APPRAISAL OF SITUATIONAL AGGRESSION (DASA)

Assessing the risk of aggression,

Each item is scored for its presence

(1), or absence (0), i the previous 24

hours.

Printed On: 03/31/2026 @ 11:13 Page 81 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

The items are then summed to

produce a total score.

The risk rating is determined based

on total score.

0 = Low Risk

1 - 3 = Moderate Risk

4 - 7 = High Risk

Assessment

Irritability (0) - The patient has been calm, tolerant and relaxed. She/he is comfortable and

relaxed in the company of other patients with staff.

Impulsivity (0) - The patient has been affectively and/or behaviorally stable and composed.

Unwillingness to Follow Directions (0) - The patient in the last 24 hours has been compliant with any requests and

directions.

Sensitive to Perceived Provocation (0) - In the last 24 hours the patient has not become extraordinarilt angry or seen

everything that occurs around her/him as provocative. She/he is not 'overly

sensitive' or provocative'.

Easily Angered when Requests are

Denied

(0) - The patient has been calm and acception when she/he is asked to wait whilst

her/his request is attended to. She/he has been understanding and acception that

her/his request has been inable to be fulfilled at that time.

Negative Attitudes (0) - No negative attitudes

Verbal Threats (0) - The patient has not been verbally aggressive.

Total Score 0

Record of aggression: During the

previous 24 hours, has the patient

behaved aggressively in any of the

following ways?

Physicial aggression against

OBJECTS

No

Verbal aggression against OTHER

PEOPLE

No

Physical Aggression against OTHER

PEOPLE

No

Printed On: 03/31/2026 @ 11:13 Page 82 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

DASA

If patient scored Moderate or High

Risk and not on Aggression/Assault

Precautions notify MD

CURRENT STATUS

L.O.C. Alert

Mobility WNL

Activity Normal

Awareness Oriented x 4

Behavior In bed

Mood Euthymic

Affect WNL

Thought Process Organized

Thought Content WNL

Speech Normal

Detox Patient No

ADLs Taking care of ADLs

Bathed/Showered No

Appearance Neat/Clean

Sleep Slept throughout night

REVIEW OF SYSTEMS/INTAKE AND OUTPUT

DIETARY INTAKE

Printed On: 03/31/2026 @ 11:13 Page 83 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Supplements N/A

Elimination Reports no problem

REVIEW OF SYSTEMS

Review of Systems WNL

PATIENT EDUCATION

Topic safety

Level of Understanding Partially understands Needs additional support for understanding

Nursing Shift Narrative Pt is A&O x 3,visible in the milieu, social with select peers. Pt is compliant with

medications and meals. Pt denied any pain/constipation. Ativan PRN, no pending

labs. Pt slept throughout the night, no SOB discomfort/ no unsafe behavior noted

/reported. ALL level of observation and safety checks maintained, will continue to

monitor, and report any changes.

**RN: Document to the treatment

plan every shift!

PATIENT EDUCATION

 - Conduct group (art, music, animal, movement, expressive) and monitor patient progress for

the development of new leisure skills to decrease danger to others, homicidal ideation, and/or

physical aggression (Intervention)

Nurse Signature e-Signed by Yedena-Wassoua, Loudouba, RN at 07/28/2025 06:57

Progress Note

Observation Date/Time:

NURSING PROGRESS NOTE -

INPATIENT

Date/Time 7/28/2025 18:52

Shift Day

Printed On: 03/31/2026 @ 11:13 Page 84 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Reason for Admission States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Printed On: 03/31/2026 @ 11:13 Page 85 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

History of Present Illness Presenting Problem:

Patient was taken to the emergency department under Section 12 following

homicidal statements directed toward his parents. He denies current homicidal

ideation but admits to past threats, including an intent to punch his father. He

reports frustration stemming from unresolved family disputes, notably regarding his

uncle's coin collection, which his father is withholding. He attempted to file a

restraining order against his mother but was unable to articulate the specific

reasons.

Psychiatric History:

Diagnosed with Bipolar Disorder, Autism Spectrum Disorder (ASD), Generalized

Anxiety Disorder (GAD), and history of Traumatic Brain Injury (TBI) from birth

complications.

Has a history of suicidal ideation and self-injurious behavior, including choking

himself with a belt during adolescence.

No prior inpatient psychiatric admissions.

Non-compliant with psychiatric medications over the past few months, citing a

preference for a holistic approach.

Behavioral Observations:

Appearance: Calm

Mood: Anxious

Affect: Congruent

Behavior: Cooperative

Speech: Clear

Thought Process: Circumstantial

Thought Content: No current suicidal or homicidal ideation

Orientation: Oriented to person, place, time, and situation

Insight: Poor

Judgment: Impaired

Concentration: Easily distracted

Family and Social History:

Reports a poor relationship with his father; primarily raised by his mother.

Engaged; has no children.

Support system includes family members and friends.

Substance Use History:

Occasional alcohol consumption ("few beers here and there")

Cannabis use

Family history of alcohol abuse (father)

Protective Factors:

Internal: Recognizes reasons for living

External: Beloved pet cats and a supportive social network of family and friends

Assessment Summary:

Patient appeared pressured in speech during the interview but remained

cooperative. He repeatedly stated he was "fine" and expressed a desire to return

home to care for his cats. His mother reported escalating behavioral issues over

recent months, including verbal aggression and property destruction, raising

concerns about his safety. Patient will benefit from inpatient psychiatric admission

for stabilization, medication assessment, and comprehensive aftercare planning.

Printed On: 03/31/2026 @ 11:13 Page 86 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Diagnosis:

Primary: Bipolar Disorder

Secondary: Autism Spectrum Disorder (ASD)

Treatment Plan:

Admit to inpatient psychiatric unit for safety, stabilization, and medication

evaluation.

Psychoeducation and engagement with family and peer support systems.

Develop an individualized aftercare plan, including outpatient follow-up scheduled

for 08/08/2025.

VITAL SIGNS

Systolic Blood Pressure 136 mmHg

Diastolic Blood Pressure 84 mmHg

Heart Rate 100 beats/min

Temperature 98.3 ºF

Respirations 18 brth/min

SPO2 96 %

**RN: Orders must be renewed daily

Special Interventions This Shift PRN Medications

Medical Interventions This Shift None

Risk Assessments

Current Level of Observation Every 15 minutes

Current Precautions LOW Suicide, Seizure, Assault/Aggression

PAIN

Pain today? No

Printed On: 03/31/2026 @ 11:13 Page 87 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

ELOPEMENT RISK

Is Elopement currently a part of the

patient's presentation?

No

SEXUAL ACTING OUT

Is Sexually Acting out currently a part

of the patient's presentation?

No

Moderate Risk: RN to consult MD for

SAO precaution and discuss any

additional necessary orders or

practices of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes, and/or

room assignment on the unit. -

High Risk (15+): RN to consult MD

for SAO precaution and MD will order

at least one of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes

FALL RISK

Are falls currently a part of the

patient's presentation?

No

SUICIDALITY/C-SSRS RECENT

1.Have you wished you were dead or

wished you could go to sleep and not

wake up?

No

2. Have you actually had any

thoughts of killing yourself?

No

Is the Patient already on Suicide

Precautions?

No

If patient answers Yes to Either

Question 1 or Question 2 AND is

NOT already on Suicide Precautions,

CONTACT PROVIDER to review

Printed On: 03/31/2026 @ 11:13 Page 88 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

6. Have you ever done anything,

started to do anything, or prepared to

do anything to end your life?

No

Ex: Collected pills, obtained gun,

gave away valuables, wrote

will/suicide note, took out pills but

didn't swallow, held gun but changed

mind or it was grabbed from your

hand, went to roof but didn't jump; or

actually took pills, tried to shoot

yourself, cut yourself, tried to hang

yourself, etc.

Only Yes to 1 or 2 - Low Risk

Only Yes to1 or 2 and 3 Moderate

Risk

Yes to 4, 5, or 6 High Risk

Risk Level Low Risk

SELF-HARM

Is self-harm currently a part of the

patient's presentation?

No

VULNERABILITY

Is Vulnerability currently a part of the

patient's presentation?

No

DYNAMIC APPRAISAL OF SITUATIONAL AGGRESSION (DASA)

Assessing the risk of aggression,

Each item is scored for its presence

(1), or absence (0), i the previous 24

hours.

Printed On: 03/31/2026 @ 11:13 Page 89 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

The items are then summed to

produce a total score.

The risk rating is determined based

on total score.

0 = Low Risk

1 - 3 = Moderate Risk

4 - 7 = High Risk

Assessment

Irritability (1) - The patient is easily annoyed or angered and inable to tolerate the presence of

others.

Impulsivity (0) - The patient has been affectively and/or behaviorally stable and composed.

Unwillingness to Follow Directions (1) - The patient has become angry and/or aggressive she/he was asked adhere to

some aspect of her/his treatment or to the ward's routine in the last 24 hours.

Sensitive to Perceived Provocation (1) - The patient has tended to see others' actions as deliberate and harmful. She/he

may misinterpret other people's behavior or respond with anger in a

disproportionate manner to the extent of provocation. She/he has been been

orickly, overly sensitive, and quick(1) to anger.

Easily Angered when Requests are

Denied

(0) - The patient has been calm and acception when she/he is asked to wait whilst

her/his request is attended to. She/he has been understanding and acception that

her/his request has been inable to be fulfilled at that time.

Negative Attitudes (0) - No negative attitudes

Verbal Threats (0) - The patient has not been verbally aggressive.

Total Score 3

Record of aggression: During the

previous 24 hours, has the patient

behaved aggressively in any of the

following ways?

Physicial aggression against

OBJECTS

No

Verbal aggression against OTHER

PEOPLE

No

Physical Aggression against OTHER

PEOPLE

No

Printed On: 03/31/2026 @ 11:13 Page 90 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

DASA

If patient scored Moderate or High

Risk and not on Aggression/Assault

Precautions notify MD

CURRENT STATUS

L.O.C. Alert

Mobility WNL

Activity Normal

Awareness Aware of surroundings

Behavior Attending groups

Mood Anxious

Affect Labile

Thought Process Disorganized

Thought Content Delusional

Speech Normal

Detox Patient No

ADLs Taking care of ADLs

Bathed/Showered Yes

Appearance Neat/Clean

Sleep Napped during the day

REVIEW OF SYSTEMS/INTAKE AND OUTPUT

Printed On: 03/31/2026 @ 11:13 Page 91 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

DIETARY INTAKE

Meals Eating off unit

Breakfast 100%

Lunch 100%

Dinner 100%

Snack Yes

Supplements N/A

Elimination Reports no problem

REVIEW OF SYSTEMS

Review of Systems WNL

PATIENT EDUCATION

Topic Safety

Level of Understanding Partially understands Needs additional support for understanding

Nursing Shift Narrative Patient presented with a flat affect, alert and verbally responsive. Denies having any

pain or discomfort. Able to make his needs known. Noticed interacting well with

selective peers. Positive for all his meds as ordered. Prn gum 2 mg . Joined the

group meeting and coloring. Transited well at the cafe. He has good appetite. Staff

educated patient how to use his coping skills. No issues reported this shift. will

continue on 15 mins checks for safety.

**RN: Document to the treatment

plan every shift!

PATIENT EDUCATION

Printed On: 03/31/2026 @ 11:13 Page 92 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

 - .Nursing will when Dallas identified with potential loss of control, ask Dallas what PRN

medication is most helpful and administer medication according to doctor’s order.

(Intervention)

 - Nursing staff to administer medication and treatment(s) as ordered per MD (Intervention)

 - Nursing will administer nicotine replacement protocol as ordered per MD (Intervention)

Nurse Signature e-Signed by Nalunkuma, Faridah, RN at 07/28/2025 18:55

Progress Note

Observation Date/Time:

NURSING PROGRESS NOTE -

INPATIENT

Date/Time 7/29/2025 02:04

Shift Night

Reason for Admission States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Printed On: 03/31/2026 @ 11:13 Page 93 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

History of Present Illness Presenting Problem:

Patient was taken to the emergency department under Section 12 following

homicidal statements directed toward his parents. He denies current homicidal

ideation but admits to past threats, including an intent to punch his father. He

reports frustration stemming from unresolved family disputes, notably regarding his

uncle's coin collection, which his father is withholding. He attempted to file a

restraining order against his mother but was unable to articulate the specific

reasons.

Psychiatric History:

Diagnosed with Bipolar Disorder, Autism Spectrum Disorder (ASD), Generalized

Anxiety Disorder (GAD), and history of Traumatic Brain Injury (TBI) from birth

complications.

Has a history of suicidal ideation and self-injurious behavior, including choking

himself with a belt during adolescence.

No prior inpatient psychiatric admissions.

Non-compliant with psychiatric medications over the past few months, citing a

preference for a holistic approach.

Behavioral Observations:

Appearance: Calm

Mood: Anxious

Affect: Congruent

Behavior: Cooperative

Speech: Clear

Thought Process: Circumstantial

Thought Content: No current suicidal or homicidal ideation

Orientation: Oriented to person, place, time, and situation

Insight: Poor

Judgment: Impaired

Concentration: Easily distracted

Family and Social History:

Reports a poor relationship with his father; primarily raised by his mother.

Engaged; has no children.

Support system includes family members and friends.

Substance Use History:

Occasional alcohol consumption ("few beers here and there")

Cannabis use

Family history of alcohol abuse (father)

Protective Factors:

Internal: Recognizes reasons for living

External: Beloved pet cats and a supportive social network of family and friends

Assessment Summary:

Patient appeared pressured in speech during the interview but remained

cooperative. He repeatedly stated he was "fine" and expressed a desire to return

home to care for his cats. His mother reported escalating behavioral issues over

recent months, including verbal aggression and property destruction, raising

concerns about his safety. Patient will benefit from inpatient psychiatric admission

for stabilization, medication assessment, and comprehensive aftercare planning.

Printed On: 03/31/2026 @ 11:13 Page 94 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Diagnosis:

Primary: Bipolar Disorder

Secondary: Autism Spectrum Disorder (ASD)

Treatment Plan:

Admit to inpatient psychiatric unit for safety, stabilization, and medication

evaluation.

Psychoeducation and engagement with family and peer support systems.

Develop an individualized aftercare plan, including outpatient follow-up scheduled

for 08/08/2025.

VITAL SIGNS

Systolic Blood Pressure 136 mmHg

Diastolic Blood Pressure 84 mmHg

Heart Rate 100 beats/min

Temperature 98.3 ºF

Respirations 18 brth/min

SPO2 96 %

**RN: Orders must be renewed daily

Special Interventions This Shift None

Medical Interventions This Shift None

Risk Assessments

Current Level of Observation Every 15 minutes

Current Precautions LOW Suicide, Seizure, Assault/Aggression

PAIN

Pain today? No

Printed On: 03/31/2026 @ 11:13 Page 95 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

ELOPEMENT RISK

Is Elopement currently a part of the

patient's presentation?

No

SEXUAL ACTING OUT

Is Sexually Acting out currently a part

of the patient's presentation?

No

Moderate Risk: RN to consult MD for

SAO precaution and discuss any

additional necessary orders or

practices of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes, and/or

room assignment on the unit. -

High Risk (15+): RN to consult MD

for SAO precaution and MD will order

at least one of the following: blocked

room/"no roommate" status,

"distance rule" from peers,

observation level changes

FALL RISK

Are falls currently a part of the

patient's presentation?

No

SUICIDALITY/C-SSRS RECENT

1.Have you wished you were dead or

wished you could go to sleep and not

wake up?

No

2. Have you actually had any

thoughts of killing yourself?

No

Is the Patient already on Suicide

Precautions?

No

If patient answers Yes to Either

Question 1 or Question 2 AND is

NOT already on Suicide Precautions,

CONTACT PROVIDER to review

Printed On: 03/31/2026 @ 11:13 Page 96 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

6. Have you ever done anything,

started to do anything, or prepared to

do anything to end your life?

No

Ex: Collected pills, obtained gun,

gave away valuables, wrote

will/suicide note, took out pills but

didn't swallow, held gun but changed

mind or it was grabbed from your

hand, went to roof but didn't jump; or

actually took pills, tried to shoot

yourself, cut yourself, tried to hang

yourself, etc.

Only Yes to 1 or 2 - Low Risk

Only Yes to1 or 2 and 3 Moderate

Risk

Yes to 4, 5, or 6 High Risk

Risk Level Low Risk

SELF-HARM

Is self-harm currently a part of the

patient's presentation?

No

VULNERABILITY

Is Vulnerability currently a part of the

patient's presentation?

No

DYNAMIC APPRAISAL OF SITUATIONAL AGGRESSION (DASA)

Assessing the risk of aggression,

Each item is scored for its presence

(1), or absence (0), i the previous 24

hours.

Printed On: 03/31/2026 @ 11:13 Page 97 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

The items are then summed to

produce a total score.

The risk rating is determined based

on total score.

0 = Low Risk

1 - 3 = Moderate Risk

4 - 7 = High Risk

Assessment

Irritability (0) - The patient has been calm, tolerant and relaxed. She/he is comfortable and

relaxed in the company of other patients with staff.

Impulsivity (0) - The patient has been affectively and/or behaviorally stable and composed.

Unwillingness to Follow Directions (0) - The patient in the last 24 hours has been compliant with any requests and

directions.

Sensitive to Perceived Provocation (0) - In the last 24 hours the patient has not become extraordinarilt angry or seen

everything that occurs around her/him as provocative. She/he is not 'overly

sensitive' or provocative'.

Easily Angered when Requests are

Denied

(0) - The patient has been calm and acception when she/he is asked to wait whilst

her/his request is attended to. She/he has been understanding and acception that

her/his request has been inable to be fulfilled at that time.

Negative Attitudes (0) - No negative attitudes

Verbal Threats (0) - The patient has not been verbally aggressive.

Total Score 0

Record of aggression: During the

previous 24 hours, has the patient

behaved aggressively in any of the

following ways?

Physicial aggression against

OBJECTS

No

Verbal aggression against OTHER

PEOPLE

No

Physical Aggression against OTHER

PEOPLE

No

Printed On: 03/31/2026 @ 11:13 Page 98 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

DASA

If patient scored Moderate or High

Risk and not on Aggression/Assault

Precautions notify MD

CURRENT STATUS

L.O.C. Alert

Mobility WNL

Activity Asleep

Awareness Aware of surroundings

Behavior In bed and calm

Mood Euthymic

Affect Flat

Thought Process Disorganized

Thought Content WNL

Speech Normal

Detox Patient No

ADLs Taking care of ADLs

Bathed/Showered No

Appearance Neat/Clean

Sleep Slept throughout night

REVIEW OF SYSTEMS/INTAKE AND OUTPUT

DIETARY INTAKE

Printed On: 03/31/2026 @ 11:13 Page 99 of 100

Nursing Progress Note

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Westborough Behavioral Health Hospital

PCU: Adult A

Snack Yes

Supplements N/A

Elimination Reports no problem and Asleep

REVIEW OF SYSTEMS

Review of Systems WNL

PATIENT EDUCATION

Topic coping strategies

Level of Understanding Partially understands Needs additional support for understanding

Nursing Shift Narrative Patient visible on the unit during change of shift conversing with his peers. No

exhibition of aggression/assault. Mood calm with flat affect. Denies SI and q15 min

checks maintained for safety and location. Sleeping throughout the night with eyes

closed and active respiration.

**RN: Document to the treatment

plan every shift!

PATIENT EDUCATION

 - Conduct group (art, music, animal, movement, expressive) and monitor patient progress for

the development of new leisure skills to decrease danger to others, homicidal ideation, and/or

physical aggression (Intervention)

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

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

 - Dallas will take medications as ordered (Objective)

 - Dallas will practice an identified coping skill to manage/reduce smoking urges (Objective)

Nurse Signature e-Signed by Gutheru, Annie at 07/29/2025 06:46

Printed On: 03/31/2026 @ 11:13 Page 100 of 100

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

Initial

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

Chief Complaint (Patient's own

words)

States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Printed On: 03/31/2026 @ 11:13 Page 1 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

History Of Present Illness Presenting Problem:

Patient was taken to the emergency department under Section 12 following

homicidal statements directed toward his parents. He denies current homicidal

ideation but admits to past threats, including an intent to punch his father. He

reports frustration stemming from unresolved family disputes, notably regarding

his uncle's coin collection, which his father is withholding. He attempted to file a

restraining order against his mother but was unable to articulate the specific

reasons.

Psychiatric History:

Diagnosed with Bipolar Disorder, Autism Spectrum Disorder (ASD), Generalized

Anxiety Disorder (GAD), and history of Traumatic Brain Injury (TBI) from birth

complications.

Has a history of suicidal ideation and self-injurious behavior, including choking

himself with a belt during adolescence.

No prior inpatient psychiatric admissions.

Non-compliant with psychiatric medications over the past few months, citing a

preference for a holistic approach.

Behavioral Observations:

Appearance: Calm

Mood: Anxious

Affect: Congruent

Behavior: Cooperative

Speech: Clear

Thought Process: Circumstantial

Thought Content: No current suicidal or homicidal ideation

Orientation: Oriented to person, place, time, and situation

Insight: Poor

Judgment: Impaired

Concentration: Easily distracted

Family and Social History:

Reports a poor relationship with his father; primarily raised by his mother.

Engaged; has no children.

Support system includes family members and friends.

Substance Use History:

Occasional alcohol consumption ("few beers here and there")

Cannabis use

Family history of alcohol abuse (father)

Protective Factors:

Internal: Recognizes reasons for living

External: Beloved pet cats and a supportive social network of family and friends

Assessment Summary:

Patient appeared pressured in speech during the interview but remained

cooperative. He repeatedly stated he was "fine" and expressed a desire to return

home to care for his cats. His mother reported escalating behavioral issues over

recent months, including verbal aggression and property destruction, raising

concerns about his safety. Patient will benefit from inpatient psychiatric admission

for stabilization, medication assessment, and comprehensive aftercare planning.

Printed On: 03/31/2026 @ 11:13 Page 2 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

Diagnosis:

Primary: Bipolar Disorder

Secondary: Autism Spectrum Disorder (ASD)

Treatment Plan:

Admit to inpatient psychiatric unit for safety, stabilization, and medication

evaluation.

Psychoeducation and engagement with family and peer support systems.

Develop an individualized aftercare plan, including outpatient follow-up scheduled

for 08/08/2025.

Psychiatric History see above

Has the patient been in treatment

previously?

No

Patient admits to substance abuse Yes

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.)

Substance Use

1 Nicotine 18 1.5 to 2 Daily 12 years Prior to ED Inhalation

 packs daily Admittance

2 Cannabis 18 0.5 ounce Daily 12 years Prior to ED Inhalation

 daily Admittance

3 ETOH Unknown Twice Twice Unknown Unknown PO

 weekly: 6 weekly

 beers/ 2

 shots

Initial

Legal Status Conditional Voluntary

Abuse/Neglect/Trauma

Abuse/Neglect/Trauma

Medical

Printed On: 03/31/2026 @ 11:13 Page 3 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

Medical History Bipolar, Seizures, Suicide attempts and "Bipolar disorder, current episode manic

without psychotic features, severe,Autistic disorder,Generalized anxiety

disorder,Personal history of traumatic brain injury,Alcohol abuse,

uncomplicated,Attention-deficit hyperactivity disorder, unspecified type,Cannabis

abuse, uncomplicated,Epilepsy, unspecified, not intractable, without status

epilepticus,Essential (primary) hypertension,Nicotine dependence, unspecified,

uncomplicated,Pervasive developmental disorder, unspecified,Presence of other

specified devices"

Developmental/Educational / Vocational History

Developmental/Educational /

Vocational History

unk

MIlitary

MILITARY HISTORY

Is the patient active or former

military?

No

Social

Current Living Situation Mother-Terry

Family Relationships Parents and fiance. New OP therapist appt booked on 8/8/25.

Social History / Support Networks Family

Family History of Suicide/Mental

Health/ Substance Abuse

Yes

Family hx of bipolar, anxiety, depression and SUD.

Assessment

Allergies

Allergy Type Reaction Severity Date Code System

Comments

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

--------

Assessment

metoclopramide Drug Allergy d00298 MULTUM

DRUGID

NO FOOD ALLERGIES Drug Allergy

Printed On: 03/31/2026 @ 11:13 Page 4 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

Home Medications and Admission Med Rec Review

Printed On: 03/31/2026 @ 11:13 Page 5 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

Home Meds:

Description Brand Dose Route Frequency PRN

Indication

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

----------

Although a patient record was

found, no medications were

available.

amLODIPine Oral 10 mg TAB Norvasc 10 mg PO DAILY

Essential (primary)

hypertension

busPIRone Oral 10 mg TAB BuSpar 10 mg PO BID

Generalized anxiety

disorder

divalproex sodium Oral 500 mg ERT Depakote 500 mg PO DAILY

Epilepsy, unspecified, not

(Once-Daily) ER

intractable, without status

epilepticus

 Notes:Once-Daily

FLUoxetine 40 mg CAP PROzac 40 mg PO DAILY

Bipolar disorder, current

episode manic without

psychotic features, severe

hydroCHLOROthiazide Oral 25 mg TAB Oretic 25 mg PO DAILY

Essential (primary)

hypertension

LORazepam Oral 0.5 mg TAB Ativan 0.5 mg PO BID P

Generalized anxiety

disorder

 Notes:SALAD

omeprazole Oral 20 mg DRC PriLOSEC 20 mg PO DAILY GERD

 Notes:SALAD

Admission Meds:

Description Brand Dose Route Frequency PRN

Indication

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

----------

amLODIPine Oral 10 mg TAB Norvasc 10 mg PO DAILY

Essential (primary)

hypertension

busPIRone Oral 10 mg TAB BuSpar 10 mg PO BID

Generalized anxiety

disorder

divalproex sodium Oral 500 mg ERT Depakote 500 mg PO DAILY

Epilepsy, unspecified, not

(Once-Daily) ER

intractable, without status

Printed On: 03/31/2026 @ 11:13 Page 6 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

epilepticus

 Notes:Once-Daily

FLUoxetine 40 mg CAP PROzac 40 mg PO DAILY

Bipolar disorder, current

episode manic without

psychotic features, severe

hydroCHLOROthiazide Oral 25 mg TAB Oretic 25 mg PO DAILY

Essential (primary)

hypertension

LORazepam Oral 0.5 mg TAB Ativan 0.5 mg PO BID P

Generalized anxiety

disorder

 Notes:SALAD

omeprazole Oral 20 mg DRC PriLOSEC 20 mg PO DAILY GERD

 Notes:SALAD

Review of Systems

Constitutional No Complaints

Eyes No Complaints

ENMT No Complaints

Cardiovascular No Complaints

Respiratory No Complaints

Gastrointestinal No Complaints

Genitourinary No Complaints

Musculoskeletal Pain

Musculoskeletal Comments Back pain

Integumentary/Breast No Complaints

Neurological No Complaints

Psychiatric No Complaints

Printed On: 03/31/2026 @ 11:13 Page 7 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

Endocrine No Complaints

Hematologic/Lymphatic No Complaints

Allergic/Immunologic No Complaints

Gait & Station No deficits

Abnormal Movements None present

Physical Complaints Denies

Vital Signs

Systolic Blood Pressure 131 mmHg

Diastolic Blood Pressure 91 mmHg

Blood Pressure 120 / 74

Heart Rate 102 beats/min

Temperature 98 ºF

Respirations 18 brth/min

SPO2 96 %

Mental Status Exam

General Appearance Neat

Attitude/Behavior Cooperative

Affect Appropriate

Mood Euthymic

Speech/Language: Quantity Spontaneous

Speech/Language: Rate Normal

Printed On: 03/31/2026 @ 11:13 Page 8 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

Speech/Language: Volume Normal

Speech/Language: Rhythm Clear

Thought Process Circumstantial

Thought Content Appropriate to situation

Suicidal Denies

Homicidal/Violent Denies

Perception: Hallucination(s) Denies

Orientation Person and Place

Attention Span Intact

(Direct Questioning) How

Tested/Assessed

Digit span

Recent Memory Not Impaired

(Direct Questioning) How

Tested/Assessed

Name

Remote Memory Not Impaired

(Direct Questioning) How

Tested/Assessed

Name of childhood town

Abstract Reasoning Not Impaired

(Direct Questioning) How

Tested/Assessed

Similarities

Intelligence Average

How Tested/Assessed Vocabulary

Judgement Poor

How Tested/Assessed Difficulty predicting results of choices

Insight Poor

How Tested/Assessed Patient inability to understand: nature of illness

Printed On: 03/31/2026 @ 11:13 Page 9 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

Suicidal Ideations Patient currently denies

Homicidal Ideations Patient currently denies

Suicidal Ideation - Since Last Contact

Ask questions 1 and 2. If both are negative, proceed to "Suicidal Behavior" section. If the answer to question 2 is "yes", ask

questions 3, 4 and 5. If the answer to question 1 and/or 2 is "yes", complete "Intensity of Ideation" section below.

1. Wish to be Dead No

2. Non-Specific Active Suicidal

Thoughts

No

Are the answers to Question one (1)

or Question two (2) yes?

No

Suicidal Behavior

Actual Attempt:

A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in part thought of as

method to kill oneself. Intent does not have to be 100%.

 If there is any intent/desire to die associated with the act then it can be considered an actual suicide attempt. There does not

have to be an injury or harm, just the potential for injury or harm. If person pulls trigger while gun is in mouth but gun is broken so

no injury results,

this is considered an attempt.

Inferring Intent: Even if an individual denies intent/wish to die, it may be inferred clinically from the behavior or circumstances.

For example, a highly lethal act that is clearly not an accident so no other intent but suicide can be inferred

(e.g. gunshot to head, jumping from window of a high floor/story). Also if someone denies intent to die, but they thought that what

they did could be lethal, intent may be inferred.

Have you made a suicide attempt? No

Has subject engaged in Non-Suicidal

Self-Injurious Behavior?

No

Interrupted Attempt

When the person is interrupted (by an outside circumstance) from starting the potentially self-injurious act (if not for that, actual

attempt would have occurred).

Overdose: Person has pills in hand but is stopped from ingesting.

Once they ingest any pills, this becomes an attempt rather than an interrupted attempt. Shooting: Person has gun pointed toward

self, gun is taken away by someone else, or is somehow prevented from pulling trigger. Once they pull the trigger, even if the

gun fails to fire, it is an attempt.

Jumping: Person is poised to jump, is grabbed and taken down from ledge. Hanging: Person has noose around neck but has not

yet started to hang - is stopped from doing so.

Printed On: 03/31/2026 @ 11:13 Page 10 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

Has there been a time when you

started to do something to end your

life but someone or something

stopped you before you actually did

anything?

No

Aborted or Self-Interrupted Attempt

When person begins to take steps toward making a suicide attempt, but stops themselves before they actually have engaged in

any self-destructive behavior. Examples are similar to interrupted attempts, except that the individual stops him/herself, instead

of being stopped by something else.

Has there been a time when you

started to do something to try to end

your life but you stopped yourself

before you actually did anything?

No

Preparatory Acts of Behavior

Acts or preparation towards imminently making a suicide attempt. This can include anything beyond a verbalization or thought,

such as assembling a specific method. (e.g. buying pills, purchasing a gun) or preparing for one's death by suicide (e.g. giving

things away, writing a suicide note).

Have you taken any steps towards

making a suicide attempt or

preparing to kill yourself (such as

collecting pills, getting a gun, giving

valuables away or writing a suicide

note)?

No

Actual Lethality/Medical Damage

0. No physical damage or very minor physical damage (e.g., surface scratches).

1. Minor physical damage (e.g., lethargic speech; first-degree burns; mild bleeding; sprains).

2. Moderate physical damage; medical attention needed (e.g., conscious but sleepy, somewhat responsive, second-degree

burns; bleeding of major vessel).

3. Moderately severe physical damage; medical hospitalization and likely intensive care (e.g., comatose with reflexes intact;

third-degree burns less than 20% of body; extensive blood loss but can recover; major fractures).

4. Severe physical damage; medical hospitalization with intensive care required (e.g., comatose without reflexes; third-degree

burns over 20% of body; extensive blood loss with unstable vital signs; major damage to a vital area)

Most Lethal Attempt Date na

Enter Code na

Potential Lethality: Only Answer if Actual Lethality = 0

Likely lethality of actual attempt if no medical damage (the following examples, while having no actual medical damage, had

potential for very serious lethality;

put gun in mouth and pulled the trigger but gun fails to fire so no medical damage; laying on train tracks with oncoming train but

pulled away before run over).

Printed On: 03/31/2026 @ 11:13 Page 11 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time:

0 = Behavior not likely to result in injury

1 = Behavior likely to result in injury but likely to cause death

2 = Behavior likely to result in death despite available medical care

Enter Code representing Most Lethal

Attempt

na

1.EXTREMITY MOVEMENTS

Stand 0=None

Upper 0=none

Lower 0=None

Trunk 0=None

2.FACIAL AND ORAL MOVEMENTS

Mouth 0=None

Muscles of Facial Expression 0=None

Lips and Peri-oral Area 0=None

Jaw 0=None

Tongue 0=None

3.GLOBAL JUDGEMENTS

Severity of abnormal movements 0=None

Incapacitation due to abnormal

movements

0=None

Patient's awareness of abnormal

movements

0=None, Normal

4.DENTAL STATUS

Any current problems with teeth

and/or dentures?

0=No

Printed On: 03/31/2026 @ 11:13 Page 12 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

Does patient usually wear dentures? 0=No

5.AIMS TOTAL

AIMS TOTAL: 0

Assets/Strengths/Liabilities/Special Needs

Patient Assets and Strengths Stable Housing, Supportive Family/Friends and Hx of Psychiatric Stability or

Sobriety

Patient Liabilities and Special Needs Lack of Motivation, Unemployed and Perseverating on mom/ blame shifting

Plan of Care

Problems to be addressed Manic Symptomatology

Dangerousness to Self

Medical Problem(s) see h and P

Short Term Goals Decrease agitation/anxiety/panic and Stabilize on medication

Current Level of Observation Every 15 minutes

Current Precautions LOW Suicide, Seizure, Assault/Aggression

Estimated Length of Stay (days) 14 Days

Prognosis good with mood stabilizer

Initial Treatment Plan Initial pharmacologic approach, "Psychiatric rounds to clarify diagnosis, manage

medication" and Begin discharge planning for placement

Preliminary Discharge Plan Home

Diagnostic Formulation see notes

Initial Diagnosis

Printed On: 03/31/2026 @ 11:13 Page 13 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

Diagnosis Class Type Priority Date

Code System

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

---- ------

Plan of Care

Bipolar disorder, current Psychiatric Provisiona Primary Diagnosis

F31.13 ICD-10

episode manic without l

psychotic features, severe

Autistic disorder Psychiatric Working

F84.0 ICD-10

Generalized anxiety disorder Psychiatric Working

F41.1 ICD-10

Personal history of traumatic Medical Working

Z87.820 ICD-10

brain injury

Alcohol abuse, uncomplicated Working

F10.10 ICD-10

Attention-deficit Working

F90.9 ICD-10

hyperactivity disorder,

unspecified type

Cannabis abuse, uncomplicated Working

F12.10 ICD-10

Epilepsy, unspecified, not Working

G40.909 ICD-10

intractable, without status

epilepticus

Essential (primary) Working

I10 ICD-10

hypertension

Nicotine dependence, Working

F17.200 ICD-10

unspecified, uncomplicated

Pervasive developmental Working

F84.9 ICD-10

disorder, unspecified

Presence of other specified Working

Z97.8 ICD-10

devices

ATTESTATION

I,

Okorafor, Ayodeji E, DNP

have reviewed and updated the above diagnoses as appropriate

Yes

INITIAL CERTIFICATION

Printed On: 03/31/2026 @ 11:13 Page 14 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

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

Psychosocial Stressors Social environment and Primary support system

Plan of Care

Printed On: 03/31/2026 @ 11:13 Page 15 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

Medication Orders:

Description Brand Dose Route Frequency PRN

Indication

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

----------

amLODIPine Oral 10 mg TAB Norvasc 10 mg PO DAILY

Essential (primary)

hypertension

busPIRone Oral 10 mg TAB BuSpar 10 mg PO BID

Generalized anxiety

disorder

divalproex sodium Oral 500 mg ERT Depakote 500 mg PO DAILY

Epilepsy,unspecified,not

(Once-Daily) ER

intractable,without status

epilepticus

 Notes:Once-Daily

FLUoxetine Oral 20 mg CAP PROzac 40 mg PO DAILY

Bipolar disorder,current

episode manic without

psychotic features,severe

hydroCHLOROthiazide Oral 25 mg TAB Oretic 25 mg PO DAILY

Essential (primary)

hypertension

LORazepam Oral 0.5 mg TAB Ativan 0.5 mg PO BID P

Generalized anxiety

disorder

 Notes:SALAD

nicotine Oral Transmucosal 2 mg Nicorette 4 mg OM Q2H P

Smoking Cessation

GUM

nicotine 21 mg/24 hr Transdermal *nicotine 1 TD DAILY P

Nicotine Dependence

TERF patch PATCH

 21mg

omeprazole Oral 20 mg DRC PriLOSEC 20 mg PO DAILY GERD

 Notes:SALAD

Ancillary Orders:

Description Frequency PRN

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

-Adult_Admit to: Conditional Voluntary Adult

-COMPREHENSIVE METABOLIC PANEL IN AM-UC

-CBC (INCLUDES DIFF/PLT) IN AM-UC

-Assault/Aggression Precautions

-Seizure Precautions

- LOW 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

Printed On: 03/31/2026 @ 11:13 Page 16 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

-Community Meeting

-Therapeutic Recreation/Activity Therapy

-Psycho-educational 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

-Every 15 Minutes Observation

-Medical Diagnosis:

-Psychiatric Diagnosis:

-Psychotherapy Process Groups

-Dietary Consult: Consult - Nutrition screen score of 3 or More

Coordination of Care clinical team

Is it appropriate to bill for this

documentation?

Yes

90791 - Psychiatric Diagnostic

Interview W/O Medical

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.

Signature

Psychiatrist Signature e-Signed by Okorafor, Ayodeji E, DNP at 07/23/2025 11:47

Abuse/Neglect/Trauma

Printed On: 03/31/2026 @ 11:13 Page 17 of 18

Psychiatric Evaluation

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 9:16:07AM

Row Yes/No Victim/Perp Documention/T Police report CPS/DCS Name of

 ime Frame of required at report person filing

 Occurrence this time required at report (s)

 this time

Physical Yes Victim Childhood by No No

 father

Emotional Yes Victim Childhood by No No

 father

Sexual No

Child Yes Victim Childhood No No

Elder/Depend No

ent Adult

Domestic No

Violence

Other types No

of

Trauma/Histo

ry

Harm to Self No

or Others in

a Treatment

Setting

Printed On: 03/31/2026 @ 11:13 Page 18 of 18

Psychosocial Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time:

Initial

Attempts made for completion (Attempts are made every shift until completed)

Start Time 7/23/2025 19:00

End Time 6/23/2025 22:44

Acute Symptoms Depressed Mood/ Hopelessness, Feelings of Worthlessness, Inability to

Concentrate, Suicidal Ideation w/Plan, Chemical Dependency, Family/Marital

Discord, Homicidal/Danger to Others and Severe Anxiety/Panic Attack

Chief Complaint (as stated by patient

at Intake)

States reason for admission as “It was just a big big misunderstanding. I talked to

my father on the phone and I got pissed with him and pissed at my mother and I

needed to get away.”

Chief Complaint (as stated by patient

to clinician)

"My father is an inconsiderate prix, I was having an off day, and me and my father

was bickering back and forth which escalated, and he was yelling because my

uncle left some coins for the children and I called and asked for some money

because my uncle has a blood clot in his lungs and the sale /distributions of the

coins has been paused for about a year and a half. I also tried to get my mother to

talk to him and she was not calling and or understanding what I'm saying which got

me even more frustrated and I felt like I wanted to give them a straight punch. My

mother called the ambulance, and I was sectioned"

How is the Chief Complaint impacting

activities of daily living?

"I can take care of myself, a few days ago I cook steak for my mother and self"

Has the patient been in treatment

previously?

No

History and Current Risk Factors

History and Current Risk Factors

Legal Issues: I have no legal issues

Family/Social/Cultural/Spiritual

FAMILY INVOLVEMENT IN TREATMENT

Family Involvement in Treatment Patient does not want family involvement

ROI Obtained Yes

SOCIAL/PEER RELATIONSHIPS

Printed On: 03/31/2026 @ 11:13 Page 1 of 8

Psychosocial Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 7:31:53PM

Describe current social functioning "I had a few friends, but we grew apart"

Significantly different from past social

functioning?

"Growing up I was constantly harassed bullied"

Who does patient identify as current

support system?

Fiancé, mother

Has current illness/behavior affected

patient’s ability to utilize support

system?

No

FAMILY HISTORY OF MENTAL ILLNESS

Family of Mental Illness Yes

Family hx of bipolar, anxiety, depression and SUD.

CURRENT MARITAL/FAMILY RELATIONSHIPS

Marital Status Engaged

Are there current or past issues

related to patient’s relationship

status?

No

Describe current relationship status,

identify children and relevant family

relationships

"I never get along with my father, but I somewhat get along with my mother and my

fiancé"

Sexual Orientation Hetrosexual

CULTURAL/ETHNIC DIVERSITY

Gender Identity Male

Cultural Concerns nothing noted

Special needs surrounding patient

identity

nothing noted

SPIRITUAL

Identified spiritual support, believe in

a higher power or have any religious

involvement?

Yes

Religion Protestant

Does the patient want clergy

involvement?

Yes

Identified values and belief system "I believe in God"

Printed On: 03/31/2026 @ 11:13 Page 2 of 8

Psychosocial Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 7:31:53PM

Stated Leisure/Recreation Interests Arts/Crafts, Music, Plants/Gardening, Reading, TV/Movies, Outdoor and "fishing,

shoot pool, outdoors"

Possible Leisure/Recreation Barriers Social Skills, Financial and Communication

Educational/Vocational Functioning

MILITARY HISTORY

Is the patient active or former

military?

No

EDUCATIONAL HISTORY

Highest Level of Education

Completed

I left school at 10th grade

Vocational Rehab Needed Yes

Has Job/School been impacted by

current illness?

No

Is patient currently in school? No

Learning Disability Yes

Explain ADHD

BARRIERS TO LEARNING

Barriers to Learning Cognitive Capacity Deficits

BEHAVIORAL ISSUES

Behavioral Issues None

Patient interview

Patient Interview

Mood/Affect Optimistic

Cognitive Functioning/Thought

Process

Alert, Oriented and Attentive

Patient's Strengths Stable Housing, Supportive Family/Friends and Hx of Psychiatric Stability or

Sobriety

Printed On: 03/31/2026 @ 11:13 Page 3 of 8

Psychosocial Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 7:31:53PM

Patient's Limitations Lack of Motivation, Unemployed and Perseverating on mom/ blame shifting

Patient admits to substance abuse Yes

CD Referral Yes

Current Medical Conditions Patient Denies, "Bipolar disorder, current episode manic without psychotic

features, severe,Autistic disorder,Generalized anxiety disorder,Personal history of

traumatic brain injury,Attention-deficit hyperactivity disorder, unspecified

type,Essential (primary) hypertension,Pervasive developmental disorder,

unspecified,Presence of other specified devices" and Seizure d/o-last seizure was

2002 per pt.

Discharge Information/Recommendations

Discharge Information/Recommendations

Current Living Situation Lives with Family

Can Patient Return Yes

Identify Supports in Home Parents and fiance. New OP therapist appt booked on 8/8/25.

Income Source/Job Status Food Stamps and SSI/SSA/SSD/SDI

Referrals Outpatient and Primary care Physician

Support Involvement Provide education for patient/family/significant others regarding MD/CD issues and

Provide education for patient/family significant others regarding discharge

plan/aftercare options which will promote recovery

Coordination of Care

Is patient or guardian willing and able

to share information about their

current outpatient providers including

their PCP?

Yes

Has the patient's PCP been notified

of their admission as appropriate?

No

Pt denied having a PCP because he was trying a holist approach.

Initial Discharge Plan (Check all that

apply)

Return to previous living arrangements and Outpatient psychiatrist

Printed On: 03/31/2026 @ 11:13 Page 4 of 8

Psychosocial Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 7:31:53PM

Post Discharge Goals(s) "patient's

own words"

"I want to go home and relax "

Printed On: 03/31/2026 @ 11:13 Page 5 of 8

Psychosocial Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 7:31:53PM

Narrative Summary Pt is a 30-year-old engaged English-speaking Caucasian male admitted to WBHH on

07/22/2025. Pt report that "My father is an inconsiderate prix, I was having an off

day, and me and my father was bickering back and forth which escalated, and he

was yelling because my uncle left some coins for the children and I called and

asked for some money because my uncle has a blood clot in his lungs and the sale

/distributions of the coins has been paused for about a year and a half. I also tried

to get my mother to talk to him and she was not calling and or understanding what I

am saying which got me even more frustrated and I felt like I wanted to give them a

straight punch. My mother called the ambulance, and I was sectioned" Pt is

diagnosed with Bipolar disorder, Autistic disorder, Generalized anxiety disorder,

Personal history of traumatic brain injury, Alcohol abuse, Attention-deficit

hyperactivity disorder, Cannabis abuse. Psychosocial stressors include lack of

coping skills, emotion, depression, aggression, and his mental health issues.

Throughout the assessment, the patient was cooperative, appropriate, engaging,

attentive, alert, and fully oriented to person, place, and time. He reports that he was

born and raised in Massachusetts. He stated that he was primarily brought up by

his mother, with whom he currently resides with his two cats. He reports a strained

relationship with his father, who has a history of substance abuse, and identifies

his father as his number one emotional trigger. He reports that he has three

maternal half-siblings. He denies any history of legal involvement or exposure to

domestic violence. He also denies any history of sexual abuse but endorse a

history of physical, or emotional abuse and states that he has not experienced any

trauma to his knowledge; however, he reports that at birth, he suffered a brain

bleed due to the umbilical cord being wrapped around his neck, He also report that

he was born dead. He identifies as both religious and spiritual and follows the

Protestant faith. He reports that he is engaged to his fiancé and denies having any

children. He states that he was bullied and ostracized in school, and notes that he

was only able to complete up to the 10th grade. He acknowledges that he has

learning disabilities but does not know their specific names. He denies

hallucinations, both visual and auditory, and denies suicidal ideation or attempts.

However, he does report an incident from his teenage years where he tried to choke

himself with a belt. He reports that at times he can be impulsive and that he has

difficulty with anger, which per ED record his mother described as constant since

he stops taking his medication. He reports a history of past psychiatric

hospitalization and acknowledges issues with sleep, though he states his appetite

is good. He also reports that he takes medication to help him sleep. He reports that

he has not been taking his psychiatric medication for about two months prior to

admission, as he was attempting to follow a more holistic approach to managing

his mental health. However, since being hospitalized, he reports that he has

resumed taking his medication diligently. Per ED records his family members report

that the patient has a history of verbal and aggression and threatening behaviors.

The patient endorsed current homicidal ideation and stated that he had attempted

to file a restraining order. He denies suicidal ideation currently. He reports a history

of being pushed into the street by a stranger, which resulted in a back injury. He

has lost a significant amount of weight, dropping from 260 to 202 pounds. He

reports occasional alcohol use and social marijuana use. He also reports allergic to

metoclopramide.

While at WBHH, Pt will likely benefit from medication intervention and monitoring to

address negative symptoms of his mental health, group therapy for healthy coping

skills development and identification of triggers, as well as referrals and aftercare

Printed On: 03/31/2026 @ 11:13 Page 6 of 8

Psychosocial Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 7:31:53PM

planning to include follow up appointments for continuation of care and further

recovery. Pt will be discharged once he has stabilized in medications, negative

behaviors have resolved, negative symptoms of his mental health have improved or

his WBHH team deems him appropriate to be discharge.

Patient agrees with Discharge Plan Yes

Family agrees with Discharge Plan N/A

Signature

**I (staff) discussed the importance

of participating in program milleu and

participating in groups.

Yes

Therapy Staff Signature e-Signed by Richards, Kevin at 07/23/2025 22:44

Supervisior's Signature (if required) e-Signed by Foster, Margaret, LICSW at 07/25/2025 08:01

Row Yes/No Victim/Perp Documention/T Police report CPS/DCS Name of

 ime Frame of required at report person filing

 Occurrence this time required at report (s)

 this time

Abuse/Neglect/Trauma

Physical Yes Victim Childhood by No No

 father

Emotional Yes Victim Childhood by No No

 father

Sexual No

Child Yes Victim Childhood No No

Elder/Depend No

ent Adult

Domestic No

Violence

Other types No

of

Trauma/Histo

ry

Harm to Self No

or Others in

a Treatment

Setting

Printed On: 03/31/2026 @ 11:13 Page 7 of 8

Psychosocial Assessment

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/23/2025 7:31:53PM

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.)

Substance Use

1 Nicotine 18 1.5 to 2 Daily 12 years Prior to ED Inhalation

 packs daily Admittance

2 Cannabis 18 0.5 ounce Daily 12 years Prior to ED Inhalation

 daily Admittance

3 ETOH Unknown Twice Twice Unknown Unknown PO

 weekly: 6 weekly

 beers/ 2

 shots

Row Provider Name Focus/Specialty/Rol Provider Contact ROI Signed Optional Notes

 e in patient Info

 wellness

Current outpatient providers including PCP

1 Alanya Bouchard Therapist 508-663-3809 Yes

Printed On: 03/31/2026 @ 11:13 Page 8 of 8

Master Treatment Plan

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/24/2025 5:09:48PM

Reason For Admission (In Patient’s

Words)

Dallas is a 30 y.o. male presenting to WBHH from Good Samaritan. Pt was

sectioned by police, for HI (stating he was going to kill parents/ hit father) after an

argument with his parents. PPHx of bipolar d/o, ASD, GAD, PDD nos, and ADHD.

PMH of seizure d/o, TBI (brain bleed/ lack of oxygen at birth) and HTN. Allergy to

Reglan. In-house urine tox positive for benzos and thc. Agitated in ED, required IM

medications (Haldol and Ativan) both 7/21 and 7/22. Pt lives with Mom and wanted

to put a restraining order against Mom, though both mom and pt are on the rental

lease.

Pt arrived cooperative but labile, cycling between irritation, crying spells, and

fatigue. Signed CV. VSS. States reason for admission as “It was just a big big

misunderstanding. I talked to my father on the phone and I got pissed with him and

pissed at my mother and I needed to get away.” Pt confirms diagnoses and reports

he had a VP shunt revision 20 years ago. ROI signed for mom (Terry) in order to get

medication information/ appointment information, as pt did not know all of his

meds or doses, stating “they expire so I don’t take them and I didn’t fill them. They

are always expiring”. Mom called for medications list. She states he is

noncompliant and has been off meds for at least “a couple months.” Home

medications include buspirone 10mg bid, amlodipine 10mg, metoprolol (dose

unknown), hydrochlorothiazide 25mg, omeprazole 20mg, fluoxetine 40mg, and

lorazepam 1mg, divalproex 500mg, 0.5 tab PRN for acute anxiety or agitation and 1

tab hs. Daily 1.5 to 2 packs cigarette smoker. Daily 0.5 oz cannabis user. Twice

weekly drinker (6 beers/ 2 shots). Pt has upcoming appt with new therapist on 8/8.

Perseverating on mom being the cause/ reason he is here. Perseverating on

appointment that he thinks he has on Friday, but mom reports his appt isn’t until

8/8. Pt states “There she goes lying again. This is all her fault.”

15-minute checks, low suicide precautions, AA and seizure precautions. Telephone

orders from Dr Marks: Continue medications except metoprolol, decrease PRN

lorazepam to 0.5mg bid. Start nicotine patch and gum PRN.

Printed On: 03/31/2026 @ 11:13 Page 1 of 5

Master Treatment Plan

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/24/2025 5:09:48PM

Diagnosis Class Type Priority Date

Code System

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

---- ------

Bipolar disorder, current Psychiatric Provisiona Primary Diagnosis

F31.13 ICD-10

episode manic without l

psychotic features, severe

Autistic disorder Psychiatric Working

F84.0 ICD-10

Generalized anxiety disorder Psychiatric Working

F41.1 ICD-10

Personal history of traumatic Medical Working

Z87.820 ICD-10

brain injury

Alcohol abuse, uncomplicated Working

F10.10 ICD-10

Attention-deficit Working

F90.9 ICD-10

hyperactivity disorder,

unspecified type

Cannabis abuse, uncomplicated Working

F12.10 ICD-10

Epilepsy, unspecified, not Working

G40.909 ICD-10

intractable, without status

epilepticus

Essential (primary) Working

I10 ICD-10

hypertension

Nicotine dependence, Working

F17.200 ICD-10

unspecified, uncomplicated

Pervasive developmental Working

F84.9 ICD-10

disorder, unspecified

Presence of other specified Working

Z97.8 ICD-10

devices

Admission Status Conditional Voluntary

Printed On: 03/31/2026 @ 11:13 Page 2 of 5

Master Treatment Plan

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/24/2025 5:09:48PM

Psychiatric

 Problem - Danger To Others r/t Physicial Aggression, Homicidal (HI statements towards

parents, property destruction,) - Acute Care 07/22/2025

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

skill to safely manage danger to others, homicidal ideation, and/or physical aggression.

07/22/2025 07/31/2025

 Intervention - Conduct group (art, music, animal, movement, expressive) and monitor

patient progress for the development of new leisure skills to decrease danger to others,

homicidal ideation, and/or physical aggression TWICE A DAY 07/24/2025 Morton,

Kristen, OT, MS, OTR/L 10912

 Intervention - .Nursing will when Dallas identified with potential loss of control, ask

Dallas what PRN medication is most helpful and administer medication according to doctor’s

order. TWICE A DAY 07/24/2025 Achang, Zainabu, RN BSN

 Problem - Danger to Self (drinking -intoxication, punching objects) - Acute Care

07/22/2025

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

skill to safely manage suicidal ideation and/or danger to self. 07/22/2025

07/31/2025

Medical

 Problem - Altered Cardiac Output – Hypertension/Hypotension (Medication regimen, Verbal

report of history of Hypertension) - Acute Care 07/22/2025

 Goal - Dallas will be able to identify signs and symptoms of increased BP by time of

discharge 07/22/2025 07/31/2025

 Objective - Dallas will take medications as ordered 07/22/2025 07/31/2025

 Intervention - Nursing staff to administer medication and treatment(s) as ordered per

MD ONCE A DAY 07/23/2025 Avramidis, Angela

 Problem - Nicotine Replacement/Smoking Cessation (Use of nicotine patch or gum per

facility protocol, History of excessive nicotine use) - Acute Care 07/22/2025

 Goal - Dallas will be compliant with nicotine replacement 07/22/2025

07/31/2025

 Objective - Dallas will practice an identified coping skill to manage/reduce smoking

urges 07/22/2025 07/31/2025

 Intervention - Nursing will administer nicotine replacement protocol as ordered per MD

As Needed 07/22/2025 Avramidis, Angela

 Problem - Seizures (Alteration In Neurologic Homeostasis) (History of seizures. Last

seizure in 2002 per pt. Pt noncompliant with medications, including seizure prevention meds.)

- Acute Care 07/22/2025

Printed On: 03/31/2026 @ 11:13 Page 3 of 5

Master Treatment Plan

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/24/2025 5:09:48PM

 Goal - Dallas will follow up with primary care physician for continued issues related

to seizures 07/22/2025 07/31/2025

 Objective - Dallas will exhibit an understanding of their seizure disorder prior to

discharge 07/22/2025 07/31/2025

 Intervention - .Staff will monitor patient as ordered by physician EVERY SHIFT (8HRS)

07/22/2025 Avramidis, Angela

Strengths/Protective Factors Ability To Communicate and Able To Meet Basic Needs

Limitations/Stressors Angry/Agitated, Lack Of Insight To Illness, Marital/Family Conflict and Substance

Abuse

Initial Discharge Plan Attend PHP and/or IOP, Attend Recovery Group/Program, Individual Outpatient

Therapy, Outpatient Psychiatrist, Primary Care Physician Follow-Up and Return To

Previous Living Arrangements

Post-Discharge Goal(s) "I want to go home and relax "

PATIENT INVOLVEMENT IN TREATMENT PLAN

The Treatment Plan Has Been Developed With Input From Me And I Have Been Given The Opportunity To Participate In

Planning My Care During My Hospitalization.

Yes – With Individual Staff

PATIENT/GUARDIAN STATEMENT

The Treatment Plan Has Been Developed With Input From Me And I Have Been Given The Opportunity To Participate In

Planning My Care During My Hospitalization.

Patient willing to sign? Yes

Patient Signature Verbal Consent obtained from Flaherty, Dallas G at 07/24/2025 17:23

Row Signature Credentials Or Relationship

Treatment Plan Signatures

Printed On: 03/31/2026 @ 11:13 Page 4 of 5

Master Treatment Plan

Admit Date: 07/22/2025

DOB: 11/03/1994

Hosp #: 2501689

MR#: 109931

Flaherty, Dallas G

Observation Date/Time: 7/24/2025 5:09:48PM

Nursing Staff e-Signed by Achang, Zainabu, RN BSN

 at 07/25/2025 08:39

e-Signed by Achang, Social Services

Zainabu, RN BSN at

07/25/2025 08:39

e-Signed by Campbell, Activity Therapy Staff

Deanna at 07/24/2025

17:24

e-Signed by Morton,

Kristen, OT, MS, OTR/L

10912 at 07/25/2025

07:40

PHYSICIAN CERTIFICATION OF THE LEVEL OF CARE: 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 for diagnostic

study.

Estimated Length of Stay: 7 Days

Physician Signature e-Signed by Okorafor, Ayodeji E, DNP at 07/25/2025 10:09

Printed On: 03/31/2026 @ 11:13 Page 5 of 5