January 31, Equestrian Year 3613
0800 hrs
Ponyville Hospital
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Admittance Form 0-13
Ponyville Hospital, Psych. Ward
210 Oak Field Lane
Ponyville, Equestria
I: Identifying Information
Date 01/30/13
Client Name: Jane Pony a.k.a. "Screw Loose"
DOB: 06/06/2573
Age:40
Gender:P
DOA:01/30/13
Time: 11:00PM
II: Primary Condition as described in "specific observable behavior" requiring acute hospital care
Recent rehabilitation into societal norms through healing. Appearances normal. Resident nurse saw her home on the 26th of this month and instructed her on continued effort. Complaints regarding hallucinations, including several charging domesticated animals, later confirmed real event. Patient returned to self-inflicting attitude after complaints from local neighbors. Condition is labeled unstable, including several bursts of rage. Main behavior included vandalism of own home with several writing utensils (phrases included "THE END" and "COMING AGAIN"), ranting about "imminence". Physical altercation led to hospitalization on January 30th of this month for further review.
III: Clinical Information and Psychiatric Medications (including dosage)
Patient has had several therapy sessions regarding psychological issues.
Hiptotraphin: 100mg, 3x daily
Phenopyl G: 100mg, 3x daily
Hayseed Extract: 20mg, 3x daily
Redroot Stalk: 10mg, 1x daily
IV: Previous hospitalizations
Four months in 3611
Three months in 3612
One week in 3613
V: Further Information
Current Diagnosis: Psychotic Delusions, brought on by Stress Disorder.
Additional Diagnosis: Miscalculation by hospital staff on proper release date.
Scheduled treatment: Psychological evaluation sessions, homeopathic exposure, increased dosage or use of Koltorin 20cc, 2x daily.
No. of hospital days requested: 60
Projected discharge date (required): 03/28/13
Aftercare plan: Release and in-home care from attending nurse, continued medication, re-entry into society
Provider or Facility: Ponyville Hospital
Attending Doctor: Dr. Getbetter Date: 01/31/13
Signature: C