Reference

Process Guide
for Nurses

Revised April 2021

Table of Contents
Order of Accepting Clients at CRESST……………………………………………………………………3
Referring Clients to CRESST…………………………………………………………………………………….
Receiving Referrals
Screening Referrals
Referral Accepted- Client Suitable

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Referral Declined- Client Unsuitable

Admission Procedures CRESST
Processing Doctor’s Orders
Practitioners/Physicians
Changing an Order
Discontinuation of an order
Reordering
Discharging Clients from CRESST
Actions taken
Paris Discharge
Hospital Transfer
Against Medical Advise (AMA)
Missing Client (AWOL)
Clozapine Clients- PTOP
Client On BC Controlled Medication
Acquiring Health Records for Collateral

ORDER OF ACCEPTING CLIENTS

Weekdays (Monday to Friday):
 Emergency/Step down
o Prior to 1100hrs congestion call:
 SMH has priority for CRESST SF
 ARM & CGH has priority for CRESST EAST
o After the 1100 congestion call, the PCC will give nurses direction for
which acute site has priority.
 PTOP (please refer to page….)
 COMMUNITY
- After 1400hrs, community has priority (View waitlisted clients)
o Prior to placing a client on the waitlist: completed referral, current
physical/psychiatric Rx, treatment consent, Covid screening and
collateral information must be obtained.

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*Please report any new acute referrals faxed to facility if sent prior to 1100hrs to
Acting PCC (person going on telecon)
Weekends (Saturday & Sunday)
All completed referrals are accepted and there is no specific order – based on first
come first serve unless specified by management.
 Hospital and private clinics referrals: CRESST staff will need to make a PARIS
referral for these clients if accepted (these facilities do not use Paris)
NOTE:
 Any Community referrals should be sent VIA PARIS from referring agency and
can be viewed on Duty Desk

REFERRALS
 HOSPITALS (i.e. ER, inpatient, etc.): referrals are hard copies faxed to
CRESST
 PRIVATE CLINICS (GPs): referrals are hard copies faxed to CRESST
 MENTAL HEALTH CENTRES (community) MUST be sent and received
through PARIS and found on duty desk.
o Once found on Duty Desk, print off a copy of the referral and place in
the “Community Referrals” folder.
o Check that referral is “MHSU CRESST Referral” and “MHSU
Emergency services” type
o Fill out the Paris Referrals Track Sheet in the front of the folder once
this is done. (unsure what this is?)
 For Private clinics and MHT referrals, only add the client’s name to the
“Standby List Binder” if a full referral is sent including the following:
o Completed referral
o Current physical/psychiatric Rx with PRNs
o Signed treatment consent form
o Covid screening form
o Collateral information

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o NOTE: Clients are placed on the Standby list for 72 BUSINESS HOURS
(excluding weekends). Referring agencies will need to contact the
facility to extend same – if extension is warranted.

SCREENING NEW REFERRALS

Screen Referrals in chronological order on the Standby List with the “Admission
Screening Tool.”
o Begin by putting the time the referral was received by the receiving agency
in the top right corner of the form.
o Before screening, phone the referring agency and let them know you
received the referral, will be screening it and will call back with questions
once fully screened.

o Fill out the top box of the form’s information.

o Fill out the remainder of the form below answering yes or no to whether or
not items were received.
o Documentation Required for Admission
 Recent COVID 19 Screening Tool Sent and complete
 Consent to facility admission filled out and signed by client
 Is there Sufficient Collateral provided?
 Nursing notes and a doctor’s summary outlining how the
client presents on the unit, sufficient history, diagnosis,
specific reasoning for why client needs mental health
interventions/observations.
 AT LEAST 3 days nursing notes and a doctor’s
consult/assessment is needed minimum.
 Safety concerns (with date of last incident when possible and
explanation if client has any concerns with the below 6 bullets)
 Suicide
 Violence
 Substance use
 Fire Setting
 Sexual Issues
 Legal Issues

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o Extended Leave
 Is the client on Extended Leave? If yes, MUST have preferably
all forms before the client is able to come to the facility and AT
LEAST form 6 and form 20.
 Record when the extended leave renewal date is
 Check all forms for completion and correct dates
o Physical Health Problems and Allergies
 Does the client have any medical health problems? If so, ask
the referring agency to elaborate on concerns if not clear or if
the client will need additional physical support while at
CRESST.
 Does the client have any OTC medications and list the client’s
allergies.
o Medications
 Is there a prescription with all regular drugs and PO PRNs
written and sent with referral?
 Rx. must be received before client is put on the Standby List.
 If there is an IM/Depot, when was the last injection date and
when is the next one due?
 If the client is on any narcotics, a duplicate Rx is needed for the
Pharmacy to dispense the medication.
 See ‘Client On BC Controlled Medication’ section
 Does the client have medication coverage? If so, what type? If
not listed, ask the referring agency for more information.
o Discharge Plan
 Once client has completed treatment at CRESST are they
returning home, transitioning to an alternate facility?
 Does the client need to find housing? Is there a housing issue?
Make sure to ask the referring agency when you phone.
o Write any notes or questions you may have on the back of the page for
when you phone the referring agency.
o Once the referral has been screened, if it does not have the pertinent
information needed, phone the referring agency to review any questions
you have, ask for documents that are outstanding explain the rules and

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regulations of CRESST to the nurse to ensure the client is aware (make sure
they let the client know these) and ask, if needed, for a day’s medication in
case pharmacy does not send the medication in time.
o If necessary, the referral may need to be denied/rejected and then re-
submitted at a later time. If declined, complete Declined Referral Rationale
tool.

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ADMISSION SCREENING TOOL

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REFERRING CLIENTS ON CLOZAPINE

(When a referring client is taking clozapine, the following NEEDS to occur prior to the client
being accepted to CRESST.)

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DECLINING A REFERRAL
(Complete this form if the client is not suitable for CRESST before putting in the
“Incomplete/Declined Referrals” bin.)
 Notify the referring agency on the premise of why we declined it

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 The completed form needs to be sent to the referring agency via email or fax
 Appeal process from doctor to doctor is the next step

ADMISSION PROCEDURES PRIOR TO CLIENT

ARRIVING AT CRESST

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If a referral has been screened and the client is suitable for CRESST the following
must occur:
Preparation for Admission Procedures:
1. Contact referring agency to let them know the client is suitable. If client is a community
referral, the referring agent will contact the client. If unable to reach the referring
agent, leave a voice message indicating:
a. The referred client is suitable for the facility and a bed is available
b. The time you called
c. The time that you will be moving onto the next potential client on the standby
list (typically 1 hour- discuss with co-nurse regarding same as this time frame
may be flexible).
2. Arrange an arrival time for the client with the referring agent. If the client is coming
from the hospital, ask the nurse to phone you when the client is leaving so you are
aware the client is on their way.
3. Discuss with co-nurse which room would be most suitable for client in relation to their
specific health needs. Discuss if client’s need to be in Room 4 or 5 if they need a call bell.
Write client’s name and ETA on the white board.
4. Be sure to notify the HCW and kitchen of a new admission promptly and what the ETA
will be.
5. Put client’s Statistical Client Information from into the “STATS 2021” binder in the front
of the other forms present and fill out the next line in the notebook in the binder.
Include the client’s admission date, last name, first name and birthday.
6. Add client to the Kardex top sheet called “Pending Discharges.”
7. Fax to pharmacy the client’s prescription. Write at the bottom: CRESST SF, PLEASE FAX
THE MAR TO CRESST.
a. After faxing, phone the pharmacy to make sure they have received it. Confirm
pharmacy will send MAR with the medications.

Preparing a Chart for a New Client:

New charts are made by night staff HCWs and are placed on the bottom shelf below the client’s
charts. Take a new binder from this pile. Put a sticker with the room number on it at the top
and put an allergy sticker (found in the top right hand drawer of the desk next to this shelf) on
the spine or the binder. Write any allergies the client has and secure with tape going across it.
If client is a violence risk, put a purple dot on the spine as well also found in this drawer.
Create labels
b. Open Microsoft word and follow the below template:

o LAST NAME, FIRST NAME Make the print as large as

DOB: 30/01/0000 (AGE) GENDER
possible and bold
PHN: 5555 555 555

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c. Review the information to ensure correctness.

d. Click the top button in word marked, “Mailings.”
e. Click the button labeled “Labels” on the left top side.
f. A window will pop up. Click on the right hand side on the label and select “5660
Easy Peel Address Labels” from the pull down tab. Click “OK”
g. Make sure the left side of the pop up window has “Full Page of Same Labels”
clicked. Press button marked, “New Document.”
h. A new word document will show up with multiple labels on it.

i. Place a label sheet, labels up, in the front slot of printer feeder (ask for
assistance from co-staff if unsure) and print one sheet. If all is correct, print
another. Should have a total of two label sheets for the client.
1. Put labels on the spine of the chart and on the following forms and prepare them for
when client arrives:
a. COVID 19 Screening tool
b. Statistical Client Information
c. MAR & Vitals
d. Kardex (2 pages)- including Care Plan
e. Client Identification Sheet (MHW will get client’s ID and make two copies of this
one for the front of the chart and one for the client’s tab in the MAR.) Mark in
red pen client’s allergies on this page if applicable or NKDA if not.
f. Ministry of Health Self-Reporting Client Information Form (MMR)
g. Initial Assessment HONOS
h. Fill out the FAX coversheet addressing it to the Mental Health Team, Doctor or
Person client is working with in the community. In comments write
“Confirmation of Admission.”
i. Fill out Confirmation of Admission Form
j. Physician Standing Order
k. Physician’s Order Sheet
l. Nursing Responsibilities While a Client at CRESST
m. Suicide Risk Assessment Tool sheet

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n. Progress Note
2. Complete Kardex by filling in appropriate information. Please confirm Address and
phone number with client. Make sure PARIS is updated as well.
3. Clip the room key to the chart

ADMISSION PROCEDURES ONCE CLIENT

ARRIVES TO CRESST
1. When client arrives to the facility, notify the HCW.
2. Retrieve all psychiatric and medical medications (including OTC medications, ointments,
and vitamins if possible at this time.
3. HCW will orient the client and check client’s belongings with them. Retrieve all sharps
(including nail clippers and razors) and contraband from clients.
4. Refer to PARIS- Admitting Clients
5. All forms in the chart need to be completed and signed appropriately. Once client is
done doing vitals, meal monitoring sheet, behavioural contract, tour facility, hygiene
schedule form, sit down to have an interview with client to discuss forms promptly and
thoroughly.
Forms to be done with the client:
 COVID 19 Screening tool
 Statistical Client Information
 Ministry of Health Self-Reporting Client Information (MMR)
 Initial Assessment HONOS
 Suicide Risk Assessment Tool
6. Initial charting on client must include the following:
a. Arrival time, form of transportation, who came with client, where did client come from
(ie. Hospital, home), referring agency
b. Appearance, pertinent descriptors (height, weight, etc.) and age
c. Personal belongings checked, oriented to facility, behaviour contract reviewed and
signed, COVID screen completed and room keys given.
d. Diagnosis upon admission
e. History of presenting problem
f. Reason for entering hospital/ needing referral
g. Suicidal Risk Assessment results, safety risks, protective factors, history of suicidal
attempts
h. Physical concerns
i. Food and medication allergies
j. Substance use history
k. Legal involvement
l. Aggressive or violent behaviour history or alerts

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m. Initial Mental Status Exam/Current presenting problems

n. Any other pertinent information
7. Fax client’s Confirmation of Admission sheet using the Fax Coversheet already filled out.

PROCESSING DOCTOR’S ORDERS

a. Fax the new order to pharmacy.
b. Stamp FAXED on the order and initial the stamp.
c. Transcribe the order to the MAR. Be sure to include doctor name, times, dose,
frequency, and the date the order was made.
d. Sign and date Progress Notes sheet:
a. Doctor’s Orders Processed (1600) -----------------------------------------------initial,
designation
e. Flag the order in the binder so that staff are aware there is a change the doctor has
made. This means lift the Physician’s Order Sheet up in the binder by using the two
upper binder rings.

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Mirtazapine 45mg PO QHS X 2

weeks

Dr. Name Date 2000

DISCONTINUING/CHANGING A DOCTOR’S ORDER

a. On the MAR, cross off any old orders in RED and write in red either “Discontinued” or
“New Order, Order Changed.” Include the date and your initials as well.

Mirtazapine 45mg PO QHS X 2

Order Changed
weeks
Date, Initial
Dr. Name Date
2000

Mirtazapine 30mg PO QHS X 2

weeks

Dr. Name Date 2000

New order written below.

b. Sign and date Progress Notes sheet:

a. Doctor’s Orders Processed (1600) -----------------------------------------------initial,
designation
c. Flag the order in the binder so that staff are aware there is a change the doctor has
made. This means lift the Physician’s Order Sheet up in the binder by using the two
upper binder rings.

TRANSCRIBING VERBAL/TEXT ORDER

NOTE: If the order is a verbal or text order, nurse must transcribe the order on the Doctor’s
Order Sheet. Example:

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Once complete, refer to “Processing Doctor’s Orders” on page 15 and follow the steps for
further instructions.

ORDER FROM A DOCTOR OUTSIDE OF THE

FACILITY (PSYCHIATRIST, NP, GP)
a. First photocopy the prescription and place original in the pharmacy return bin.
b. Write client information on the photocopy/stick a label on it.
c. Fax the photocopied order with the above information to the pharmacy.
d. Stamp faxed on the photocopied order with initial.
e. Transcription is similar to the Verbal/Text order above.

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“Copied Rx by Dr. Name, transcribed by “your name”, designation.”

Once complete, refer to “Processing Doctor’s Orders” on page 15 and follow the steps for
further instructions.

DISCHARGING PROCEDURES
PREPARING FOR CLIENT DISCHARGE
a. Have client complete safety plan and questionnaire the evening prior to discharge
b. If a discharge Rx. Is written by the doctor, the Rx. needs to be photocopied. The original
is to be pinned to the white board in the medication room, on the bottom left corner.
Photocopy placed in the client’s chart in the front sleeve.
c. The doctor will make a decision to release psychiatric medications, release medical
medications, release both psychiatric and medical medications or not to release any. If
psychiatric medications released (a written order stating so), staff is to pack up the
allotted amount the order is stating (ex. 1 week, 2 weeks, etc.).
d. Staff is to also include in discharge package client’s safety plan, photocopy of the MAR,
the vitals record, a pharmacy letter found beside the whiteboard in the medication
room and the original discharge Rx written by the doctor. This should be placed inside a
bag with the released medication with a client label on it.
e. If not released, remove all of client’s medications, including PRNs, from the medication
cupboards and place in the return pharmacy bin.
f. Make sure all of client’s belongings from the office are in a bag with the client’s name on
it.
ACTIONS TAKEN
a. Confirm client has ALL belongings (check room bin inside nursing station).
b. Ensure room key is returned and sanitized.
c. Review contents of discharge package (Rx, medications, etc.).
d. Remind of any upcoming appointments with mental health team/case manager.
e. Review safety plan, if client declined written copy discuss safety plan verbally.
f. If client is connected to a mental health team or center:
i. Call to notify team/case manager of client’s discharge from CRESST
ii. Fax copy of MAR, Rx, safety plan, and extended leave/mental health forms to
CM
iii. Notify of next depot IM date and/or EL renewal date
g. Document discharge:
i. Note the time client exited facility and how they left (ie. Picked up by family
member, via taxi, etc).
ii. Document any medications that were released, discharge package provided.
iii. Discussion of safety plan.
iv. Note any collateral faxed to MHC and CM notification of discharge.
v. Depot IM due date and/or extended leave renewal date.

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PARIS DISCHARGE
After logging into PARIS, locate client’s name from the Team Caseload under “Angela” or
type in client’s PHN.
Setting up Discharge Summary
 Select “MHSU Docs” on the PARIS home page.
 Client the “ASSESSMENT” tab then select “Create a new Assessment” at the top of
the window.
 From the list of two, select “MHSU CRESST SOUTH.”
 When the “SEARCH” window appears, click the small magnifying glass next to
“Assessment Group.” From the list that pops up, select “MHSU-COMMON.”
 Then click the “Search” at the top of the window and a dropdown menu will open.
Double click on “MHSU DISCHARGE SUMMARY.” Finally, click “ACCEPT CHANGES.”

Completing Summary Pages

 “ASSESSMENT CLIENT SUMMARY” (P. 1-4) opens. Fill in the client’s information as much
as possible.
o The Pages tab is located in the bottom. (Client Summary, Health Information,
Substance Use and Disposition).
o For START DATE type in the Admission date (dd/mm/yyyy). This date can be back
tracked if you use the code Ctrl + t (this shortcut brings up the current date).
o For END DATE type in the Discharge date (dd/mm/yyyy). Leave this until the end
otherwise it will be inaccessible.

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FIRE SAFETY MONTHLY TESTING

CRESST South conducts monthly fire drills, where all client and staff evacuate the building from
the closest emergency exit. Dates are on the calendar.

Pre-Fire Drill Procedures

The person in charge of the facility, must instruct all staff members of the fire drill procedure.
The person in charge will also ensure that all hallways should be checked to ensure that doors
are free to open and that no obstructions exist.
Contact Bartec to inform them of the upcoming fire drill to set alarm to “Test”.
Bartec Fire Drill # 604 421 9276
Acct Code 08057762
Password #8E007762
Ensure to notify Bartec with the estimated timeline to conduct the fire drill.
When the fire drill commences, all activities around the facility must stop.
Initiating the Fire Drill
 After the fire alarm monitoring company have been notified, start the fire drill by
activating the manual pull station
During the Fire Drill

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Direct/assist clients and visitors to evacuate the premises using the nearest safe exit
Delegate a staff to bring the MAR and Emergency First aid kit
Assemble at designated assembly point (front of the facility or backyard)
The following matters are to be evaluated and recorded:
 Were clients remain calm and proceeding towards the nearest exit?
 Were clients assembled at the designated assembly point?
 Were all clients and staff accounted for?
 Were individuals given the clear notification to re-enter the building?

After the Fire Drill

Ensure the followings steps are completed:
 Record the total evacuation time in the evacuation checklist report.
 Silence the alarms, reset the manual pull station and reset the fire alarm system.
 Ensure the fire alarm system is back to normal operating condition.
 Inform clients that they can re-enter the building.
 Contact the fire alarm monitoring company – Bartec - to advise that the fire drill is
complete.
 Re-evaluate any concerns that arose during the fire drill and discuss among staff.
 Complete the fire drill report and keep it onsite along with the Fire Safety Plan.

MHCW to do:
1. Fire Alarm batteries shall be checked to ensure that:
A. Terminals are clean and lubricated where necessary.
B. Terminal clamps are clean and tight where necessary.
C. Electrolyte level and specific gravity, where applicable are as specified by the
manufacturer.
2. Every emergency lighting system shall be tested at least once every month to ensure security
of operation, where batteries are used as a source of supply for emergency systems, the
batteries shall be kept:
A. In proper condition.
B. Fully charged.
C. In an adequately ventilated battery room.
3. Portable extinguishers shall be examined monthly to ensure that the extinguisher is in its
proper location and has no apparent defects.
4. Portable extinguishers having defects shall be repaired or recharged immediately to ensure
the extinguisher will operate effectively and safely.
5. A permanent record containing the maintenance check to date, the examiner's name and a
description of any maintenance work or hydrostatic testing carried out shall be prepared and
maintained for each portable extinguisher.
6. Each portable extinguisher shall have a tag securely attached to it showing the maintenance

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of recharge date, the servicing agency and the signature of the person who performed the
service.

The items on this checklist are BC Fire Code requirements:

As a healthcare facility, it is best practice to not only meet the minimum requirements, but
ensure all areas of the building are in complete compliance.

CHECKLIST:
Exit Doors – must not be blocked from either the inside or outside. Must be unlocked
from the inside while the building is occupied.
Fire Doors – must not be blocked or wedged open, including stairwell doors. Must have a
closure, and no hold open devices are permitted, except a magnetic hold open connected to the fire
alarm.
Exit Routes – hallways and exits must remain free and accessible at all times. Equipment
kept in the hallway must be easily movable, kept on one side of the hall, not impede access to fire
safety equipment.
Exit Signs – must be visible and remain internally illuminated any time the building is
occupied
Fire Safety Equipment – must be unobstructed at all times. Do not block access to
fire alarm pull stations, fire extinguishers, hose cabinets, sprinkler valve cabinets, etc.

HOSPITAL TRANSFER
AGAINST MEDICAL ADVISE (AMA)
MISSING CLIENT (AWOL) *incomplete! Sorry!
If client is voluntary:
a. Call MRP and notify of AWOL. Discuss safety risk/suicide risk assessment.
b. Check cameras to see what time client eloped. Note what client is wearing/their
appearance.
c.
B. If client is certified/on extended leave:
a. Call MRP and notify of AWOL.

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b. Complete a directors warrant (form 21) and fax to police (604-599-8894). Call police
(604-599-0502) to notify of same, ensure to get and document file number.
c. Check cameras to see what time client eloped. Note what client is wearing and
inform police of same.
d.

CLOZAPINE CLIENTS- PTOP

CLIENT ON BC CONTROLLED MEDICATION
When accepting a client on BC Controlled Medication, staff is to ask the referring
agency to fax the BC Controlled Prescription to CRESST and sent the original with
the client. Example: SMH additions doctor will have to provide a prescription for
the length of stay at CRESST. If they are only agreeable for one week then staff
will need to determine who the client’s prescriber is for the BC controlled

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medication is. If unable to reach during the admission process and the client is
assigned to Dr. Leung, staff can ask if he is willing to prescribe same.
Suboxone and any other BC Controlled Prescriptions EXCEPT methadone, can be
filled by Rexall.
Rexall does NOT fill any methadone prescriptions, Surrey Pharmacy is our
alternate pharmacy that will dispense and deliver to our facility.
When accepting a Methadone Prescription, please make sure the below is
followed:
1. Methadone prescription is written on a BC Controlled Prescription pad.
Example:

2. Methadone order needs to be transcribed in on the Physician’s Order sheet

and copy of same placed in client’s chart. The order needs to be
transcribed on the client’s MAR even though same will be dispensed by the
pharmacist. See pages 15 and 16 for Processing Doctor’s Orders and
Transcribing Orders.

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ACQUIRING HEALTH RECORDS FOR

COLLATERAL

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