The mental health establishment referred to in sub-section (7) of section 103 shall conform to the minimum standards and procedures as specified in Schedule.
Form – A APPLICATION FOR BASIC MEDICAL RECORDS [See rule 6 (2)] To, The Medical Officer in-charge _______________ _______________ Sir/Madam, Subject: - Request for copy of my basic medical records /basic medical records of ………………….. (If application is by nominated representative) Hospital Number (if known) __________________ I Mr. /Mrs. ____________________residing at __________________aged _______ son/daughter of Mr. /Mrs. _______________________ was treated at your mental health establishment from ___________ to ____________.
Kindly provide me a copy of the medical records of my treatment.
Address Signature Date Name N.B.:- Please strike off those which are not required.
24 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)] Form-B [See rule 6 (3)] Basic Medical Records:
The mental health establishment shall maintain specific minimum records at their level for various types of patients they are dealing with. The requirement of records to be maintained for in-patients, out patients and community outreach may vary and is accordingly specified below. A graded approach in minimum records to be maintained may be followed:
Community outreach register shall consist of information from (a) to (h) of the basic medical record of outpatient specified in paragraph 1 below.
The mental health establishments shall maintain and provide on demand the following basic medical record to the person with mental illness or his nominated representative.
1. Basic Medical Record of all out-patients (at hospitals, nursing homes, private clinics, camps, mobile clinics, primary health care centers and other community outreach programmes, and the like matters):
(In hard copy format) a) Name of the mental health establishment/doctor____________ b) Date___________________ c) Hospital registration number___________________ d) Advance Directive YES/NO e) Patient’s Name _____________________________ f) Age ________Sex __________ g) Father’s/Mother’s name_________________________________ Address _____________________Mobile No.________________ h) Chief complaints _____________________ i) Provisional diagnosis ________________ j) Treatment advised and follow-up recommendations_____________
2. Basic Medical Record of In-Patient a) Name of the hospital/nursing home____________ b) Date________________ c) Patient’s name ___________ d) Father’s/Mother’s name_________________________________ e) Age ________Sex ________ f) Address _____________________ ¹Hkkx IIµ[k.M 3(i)º Hkkjr dk jkti=k % vlk/kj.k 25 g) Patient accompanied by (Name, age and nature of relationship) ________________________ h) Hospital registration number__________________ i) Identification marks _______________ j) Nominated representative __________________________ k) Advanced Directive - Yes or No; If yes salient features of the content l) Date of admission___________Date of discharge ____________ m) Mode of admission (section under Mental Healthcare Act, 2017): Independent/ Supported n) Chief complaints o) Summary of Medical Examination Laboratory investigations p) Provisional/differential/ final diagnosis q) Course in the hospital (Treatment and Progress) r) Condition at discharge or discharge at request or leave against medical advice or person with mental illness absconding or others s) Treatment advice at discharge t) Follow-up recommendations
3. Basic Psychological Assessment Report (facilities where persons with mental illness undergoes psychological assessment):
Clinic Record No. ------------------------------------- Name: Age: Gender:
Education: Occupation: Date of testing:
Referred by: Language tested in:
Reason for referral:
IQ assessment Specific learning disability assessment Neuropsychological assessment(Specify domain if the assessment is domain specific) Personality assessment Psychopathology assessment Any other (Mention the specific domain such as interpersonal relationship) Comments if any (may give brief detail of the referral purpose; e.g., ‘the individual has mental illness and he has been referred for current psychopathology assessment as well as to ascertain the level of disability’) Brief background information (e.g., the nature of the problem, when it started, any previous assessments and like details):
26 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)] Informant: Self Others Specify Salient behavioral observations (Comment on alertness, attention, cooperativeness, affect, comprehension and any other relevant information) Tests/ Scales administered (Standardized tests/ scales):
Salient scores (if applicable such as Intelligence Quotient, scores obtained on cognitive function tests, severity rating on psychopathology scales, disability percentage and like details) Impression:
Recommendations:
Further assessment Specify Therapy Specify Any other Specify Assessed by Verified/ supervised by (if applicable) Name: Name:
Date: Date:
Qualification: Qualification:
Signature: Signature:
4. Basic Minimum Standard Guidelines for Recording of Therapy Report (facilities where persons with mental illness are provided with therapy for any mental health problem) Minimum Basic Standard Guidelines for Recording of Therapy (Name of the Institute/Hospital/Centre with address) Clinic record no._____________ THERAPIST SESSION NOTES Patient name:
Age:
Gender:
Psychiatric diagnosis:
Session number and date:
Duration of session: Session Participants:
Therapy method:
Individual Couple/Family Objectives of the session:
1.
2.
¹Hkkx IIµ[k.M 3(i)º Hkkjr dk jkti=k % vlk/kj.k 27 Group Other _______
3.
4.
Key issues/themes discussed: (Psychosocial stressors/Interpersonal problems/Intrapsychic conflicts/Crisis situations/Conduct difficulties/Behavioral difficulties/ Emotional difficulties/ Developmental difficulties/ Adjustment issues/ Addictive behaviours/Others).
Therapy techniques used:
Therapist observations and reflections:
Plan for next session: Date for next session:
Therapist Supervised by (if applicable) Name: Name:
Date: Date:
Qualification: Qualification:
Signature: Signature:
Form – C REQUEST FOR INDEPENDENT ADMISSION [See rule 8] To, The Medical Officer in-charge __________________ __________________ Sir/Madam, I, Mr. /Mrs. _______________________________, ___________________ age_____ son/daughter of __________, residing at _______________________I have mental illness with following symptoms since ___
1. ______________
2. ______________
3. ______________ The following papers related to my illness as available with me are enclosed:
1. ______________
2. ______________
3. ______________ I wish to be admitted in your establishment for treatment and request you to please admit me as an independent patient. A self- attested copy of my Identity Proof is enclosed (optional).
Address Signature 28 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)] Date Name Enclosures:
__________________ __________________ __________________ __________________ N.B.:- Please strike off those which are not required.
Form - D REQUEST FOR ADMISSION OF A MINOR [See rule 8] To, The Medical Officer in-charge __________________ __________________ Sir/Madam, I, Mr. /Mrs. ____________________________residing at ___________________, who is the nominated representative (being legal guardian) of Master/Miss _____________, request you to admit Master/Miss ___________ aged _____ son/daughter of __________, for treatment of mental illness:
He/she is having the following symptoms since ___
1. ______________
2. ______________
3. ______________ The following papers related to my being the nominated representative and his/her illness are enclosed:
1. ______________
2. ______________
3. ______________
4. ______________ Kindly admit him/her in your establishment as minor patient.
Address:
Mobile:
E-mail: Signature Date: Name N.B.:- Please strike off those which are not required.
¹Hkkx IIµ[k.M 3(i)º Hkkjr dk jkti=k % vlk/kj.k 29 Form - E REQUEST FOR ADMISSION WITH HIGH SUPPORT NEEDS [See rule 8] To, The Medical Officer in-charge __________________ __________________ Sir/Madam, I, Mr. /Mrs. _________________________residing at ______________, nominated representative of Mr. /Mrs. __________,aged _____ son/daughter of __________request for his/her admission in your establishment for treatment of mental illness.
Mr. /Mrs. is having the following symptoms since ______________.
1. ______________
2. ______________
3. ______________ The following papers regarding my appointment as nominated representative and related to his/her illness are enclosed:
1. ______________
2. ______________
3. ______________ Kindly admit him/her in your establishment as patient with high support needs.
Name Address Mobile and E-mail Signature Date N.B.:- Please strike off those which are not required.
Form - F REQUEST FOR CONTINUOUS ADMISSION WITH HIGH SUPPORT NEEDS [See rule 8] To, The Medical Officer in-charge __________________ __________________ 30 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)] Sir/Madam, I, Mr. /Mrs. _______________, residing at _______________________ nominated representative of Mr. /Mrs. _____________, who is/was an inpatient in your establishment under supported admission category, requests for his/her continued admission beyond thirty days/readmission within seven days of discharge for the reasons stated below:
Kindly continue his/her admission/readmit him/her in your establishment as patient with high support needs Address Signature Date Name N.B.:- Please strike off those which are not required.
Form - G REQUEST FOR DISCHARGE BY INDEPENDENT PATIENT [See rule 8] To, The Medical Officer in-charge __________________ __________________ Sir/Madam, Subject: - Request for discharge.
I, Mr. /Mrs. _____________________residing at ___________aged _____ son/daughter of __________, was admitted in your mental health establishment as an Independent admission patient on _________. I now feel better and wish to be discharged. Kindly arrange to discharge me immediately.
Address Signature Date Mobile E-mail Name N.B.:- Please strike off those which are not required.
¹Hkkx IIµ[k.M 3(i)º Hkkjr dk jkti=k % vlk/kj.k 31 Form - H REQUEST FOR DISCHARGE OF A MINOR BY ITS NOMINATED REPRESENTATIVE [See rule 8] To, The Medical Officer in-charge __________________ __________________ Sir/Madam, Subject: - Request for discharge.
I am the nominated representative of Mr. /Ms. _____________________residing at ___________aged _____ son/daughter of __________ who was admitted in your mental health establishment as a minor patient on _________. Mr./Ms. ______________now feel better and wish to be discharged. Kindly arrange to discharge him/her immediately.
Address Signature Date Mobile E-mail Name N.B.:- Please strike off those which are not required.
Form - I REQUEST FOR LEAVE OF ABSENCE (By Nominated Representative) [See rule 9] To The Medical Officer in-charge ______________________ 32 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)] Sir/Madam, Subject: Request for leave of absence Mr. / MS ________________residing at ___________________ aged ___________ years was admitted on ____________to your mental health establishment.
I, as nominated representative ofMr. /MS ____________ request that he/she be granted leave of absence from ________ to __________, for the reason stated below:
The proof of my appointment as nominated representative is enclosed.
I will be responsible for care and treatment of _________________ while he/she is on leave of absence from the mental health establishment.
Address Signature Date Name Mobile and E-mail N.B.:- Please strike off those which are not required.
Form-J INTIMATION TO POLICE ABOUT UNAUTHORIZED ABSENCE FROM MENTAL HEALTH ESTABLISHMENT [See rule 9] URGENT/FOR IMMEDIATE ACTION To, The Station in-charge ________ Police Station _____________ Sir/Madam, Subject: - Intimation about unauthorized absence (without leave or discharge) of a prisoner with mental illness This is to inform you that Mr. /Mrs. _________________________________ aged ____ years, son/daughter of Mr. /Mrs. _____________, with identification marks
1. ___________________________________________________
2. ___________________________________________________ was admitted at our establishment, as a prisoner with mental illness under Section 103 of Mental Health Care Act, 2017 (10 of 2017), on (date).He/she has been missing from his/her ward since ________ (date). An internal enquiry report in this regard is enclosed.
Kindly register a missing case, take him in to your protection when found and hand him over to us.
Thanking you, ¹Hkkx IIµ[k.M 3(i)º Hkkjr dk jkti=k % vlk/kj.k 33 Signature Date Name Seal Enclosures: copy of the Aadhar Card, Recent Photograph and Internal Report N.B.:- Please strike off those which are not required.
Schedule (See rule 11) Minimum standards and procedures for mental health care services in prisons Minimum Standard for Mental Health care in Prison
1. Prompt and proper identification of persons with mental health problems should be done.
2. Screening of all inmates during the time of entry to prison including the following:
a. Mandatory physical and mental status examination b. Questionnaire screening for substance use c. Urine testing for common drugs of abuse d. Periodic random urine drug testing
3. Identification of persons with serious mental illness and proper treatment and follow-up for this group.
4. Ensuring the availability of minimum psychiatric medication in the prison to facilitate prompt treatment (Antipsychotic medication, antidepressant medication, anxiolytic medication, mood stabilizers, anticonvulsant medication, etc).
5. Availability of psycho-social interventions for prisoners with a range of mental health problems.
6. Protocols for dealing with prisoners with suicidal risk, with behavioural problems and crises related to mental illnesses as well as to prison life.
7. Suitable rehabilitation services for prisoners with mental illness. Specific attention to the aftercare needs of prisoners with mental illness including providing medication after release, education of family members, steps to ensure treatment compliance and follow-up, vocational arrangements, and for those without families, arrangements for shelter.
8. Implementing of National Mental Health Program inside the central prisons
9. Dealing with the psychological stress of prison life a. Counselling for stress needs to be provided to all prisoners in both individual and group settings.
b. Prisoners must be encouraged to proactively seek help for any emotional problems, substance use problems or physical health problems.
c. Training the prison staff in simple counselling skills. Empowering some of the sensitive, motivated convicted prisoners to be effective peer counsellors.
34 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)] d. One to one counselling upon entry, during periods of crises and upon need or request.
10. Addressing substance use problems a. Identification of substance use problems through questionnaires, behavioural observation and urine drug screening.
b. Detoxification services and making suitable pharmacotherapy available for detoxification.
c. For persons with dependence, making available long-term medication as well as motivational and relapse prevention counselling.
d. Specific interventions to be made available include the following:
i. Tobacco cessation services (behavioural counselling, nicotine replacement therapy, other long-term tobacco cessation pharmacotherapy.
ii. Alcohol – benzodiazepines for detoxification, vitamin supplementation for associated nutritional problems, counselling and long-term medication.
iii. For Opiates – buprenorphine or clonidine detoxification, long-term medication including opioid substitution (methadone/buprenorphine; opioid antagonists like naltrexone).
iv. All drug users need to be evaluated for injecting use, for HIV/STI (including Hepatitis B and C screening) and appropriately treated.
v. There is a need for urgent human resource enhancement.
11. Professional Human Resources in the Prison. [All central prisons must ensure the presence of at least]:
i. 1 doctor for every 500 patients. In addition, every prison must have one each of the following specialists providing care – physician, psychiatrist, dermatologist, gynecologist and surgeon.
ii. 2 nurses for every 500 prisoners iii. 4 counsellors for every 500 prisoners. These trained counsellors (with a degree in any social sciences/any recognized degree with counselling experience (medical counselling/legal counselling/ psychosocial counselling/rehabilitation/education) can carry out the following tasks a. Assessment b. Counselling c. Crisis intervention (family crisis, bail rejection, verdict pronouncement, interpersonal difficulties, life events, serious physical or psychiatric illness) d. Legal counselling, pre-discharge counselling e. Rehabilitation counselling f. Substance use counselling g. Training prison staff and peer counsellors
12. Inpatient services a. At least a 20-bedded psychiatric facility for every 500 prisoners
13. Prison aftercare services a. All prisoners should have pre-discharge counselling on coping strategies, healthy life style practices and support systems they can access b. For persons with mental illness they shall be referred to any mental health establishment for after care in community ¹Hkkx IIµ[k.M 3(i)º Hkkjr dk jkti=k % vlk/kj.k 35
14. Documentation a. Computerised data base and tracking system for all prisoners b. Surveillance of health conditions on a regular basis with adequate emphasis on confidentiality and proper information regarding these procedures to the prisoners c. Health records for prisoners with basic health information, pre-existing health problems, health problems that develop during imprisonment, details of evaluation and treatment, hospitalization details, health status and advice at release d. This information must be given to the prisoner to facilitate continuing health care after release.
15. All central prisons shall have dedicated tele-medicine services to provide health care
16. Following medicines shall be made available Risperidone, Olanzpine, Clozapine, Haloperidol, Chloropromazine, Trihexyphendyl, Imipramine, Amitriptyline, Fluoxetine, Sertraline, Paroxetine, Valproate, Carabamazapine, Lithium, Clonidine, Atomoxetine, Lorezpam, Diazepam, Oxezepam Disulfiram, Naltrexone, Acamprosate, Nicotine Gums, Varenicline, InjFluphenazine Inj Haloperidol, InjFluphenthixol, InjLorezpam, Inj Diazepam, Inj Promethazine Inj Thiamine/Multivitamin [F. No. V-15011/09/2017-PH-I (iv)] LAV AGARWAL, Jt. Secy.
Uploaded by Dte. of Printing at Government of India Press, Ring Road, Mayapuri, New Delhi-110064 and Published by the Controller of Publications, Delhi-110054.
2018-05-31T19:07:44+0530 RAKESH SUKUL