Ex Parte: KEITH MICHAEL STAUBIN

Clerk's Summary Sheet

VOLUME I OF II
Trial Court Writ No. 98CR0363-83
Application for Writ of Habeas Corpus
from 1OTH District Court of Galveston County
Applicant"s Name: KEITH MICHAEL STAUBIN
Offense: ASSAULT ON A PUBLIC SERVANT
Cause Number: 98CR0363

Sentence: TEN {10) YEARS INSTITUTIONAL DIVISION OF THE TE:XAS

DEPARTMENT OF CRIMINAL JUSTICE
Trial Date: NOVEMBER 13. 1998
Judge's Name: DAVID E. GARNER
Appeal Number: 01-98-01343-CR

This document contains some

pages that are of poor quality
at the time of imaging.

Citation To Opinion: NIA

Hearing Held: NO

RECE\VED

Findings & Conclusions Filed: YES

Recommendation:

DENY

JUL 2 7 2001

TEXASNACLO~~~E~~S

CR\\\1\\

Judge's Name: DAVID E. GARNER

POST CONVICTION HABEAS CORPUS

(ARTICLE 11.07, V.A.C. C. P.)
98CR0363-83 - lOTH

PETITIONER: KEITH MICHAEL ST. AUBIN #852112

ADDRESS:
C/0 GEORGE MCCALL SECREST, JR
BENNET & SECREST, JR
808 TRAVIS STREET, 24TH FLOOR
HOUSTON, TEXAS 77002
FROM:

EVELYN WELLS ROBISO~ District Clerk

Room 404 County Courthouse
Galveston, Texas 77550

JUDGE:

DAVID E. GARNER - lOTH JUDICIAL DISTRICT COURT

ATTORNEY FOR PETITIONER:

GEORGE MCCALL SECREST, JR
808 TRAIS STREET- 24TH FLOOR
HOUSTON, TEXAS 77002

ATTORNEY FOR STATE:

Michael J.Guarino
District Attorney
405 Galveston County Courthouse
Galveston, Texas 77550
INDEX
Page

Petition for Writ of Habeas Corpus

Notice to Petitioner of Filing

328

Waiver of Service by District Attorney

329

State's Answer to Application for Writ of Habeas Corpus .

330

Findings of Fact Without Evidentiary Hearing on Application for Writ of Habeas Corpus

335

Docket Sheet

336

Re-lndictment (Challenged Conviction)

337

Indictment (Challenged Conviction)

339

Judgment and Sentence (Challenged Conviction) .

341

Opinion (Challenged Conviction).

345

Mandate (Challenged Conviction)

350

Docket Sheet (Challenged Conviction)

352

Clerk's Certificate

356

".;

~~,1
..,!~

~
,.

_,)

Cause No.

984/(,L>&'a3-8'J 01 HAY 18

AH 9:20

(The Clerk of the convicting court will fill~h

line.) .",

COURT OF CRIMINAL APPEALS OF TE.

''-:Jf,-.,.1
i) ,rQd..'-- .
...-..--)L~~~

RICT cLERK .

GALVESTON CGU!'!TY. TX.

APPLICATION FOR A WRIT OF HABEAS CORPUS

SEEKING RELIEF FROM FINAL FELONY CONVICTION
UNDER CODE OF CRIMINAL PROCEDURE, ARTICLE 11.07

Keith Michael St. Aubin

NAME OF APPLICANT (Please print full name)
-Beto
PLACE OF CONFINEMENT
(1)

'

23 I 1978
DATE OF BIRTH

852112
TDCJ-ID NUMBER

What court entered the judgment of conviction you want relief from?
(Give the number and county of the court.)
1Oth Judicial District Court. Galveston Countv

(2)

What was the cause number in the trial court?

98CR0363

(3)

What was the trial judge's name?

(4)

What was the date of judgment?_____:...:N~o-'-ve=m=be=r-'1=3~19.::...:9~8,__ _ _ _ _ _ __

(5)

What was the length of sentence? ___.,.,_,te=n._y._,e=a~rs~-----------------------

(6)

\Vho assessed punishment? (Check one)

(7)

What offense or offenses were you were convicted of (all counts)?

--~====~~--------------

Judge Garner

(a) Judge (

); (b) Jury (X)

Assault on a Public Servant

./'

(8)

What was your plea? (Check one)

(a)
(b)
(c)

(X)

Not guilty
Guilty
Nolo Contendere

( )
( )

If you entered a guilty plea to one count or indictment, and a not guilty plea
to another count or indictment, give details:

(9)

Did you have a jury trial?( check one)

(a)
(b)

(X)

Jury
Judge only .

( )

(10)

Did you testify at the guilt/innocence phase of trial?

Yes ( )

No (X)

(11)

Did you testify at the sentencing phase of trial?

Yes ( )

No( X)

(12)

Did you appeal from the judgment of conviction?

Yes (X)

No( )

(13)

If you did appeal, answer the following questions:

(a)

Which court of appeals?_~F_..ir"""s"'-t_ _ _ _ _ _ _ _ _ _ _ _...;..__ __

(b)
(c)

What was the cause Number? --'0""'1,_--<-9~8-..,!,0~1..=.3__!.4=...3-~C~R~-------What was the decision? ----~af~fi!..!.lr.!..!.m!..__ _ _ _ _ _ _ _ _ _ __

(d)

What was the date of the decision?_--'5~/-=2.:::.c5/c.,:2~0~0~0-----------

(e)

. Did you file a petition for discretionary review? Yes ( )

(t)

If your answer to (e) was "yes," answer the following questions:

(g)

What was the cause number in the Court of Criminal Appeals?

No (X)

')
.-.'

(14)

(h)

What was the decision? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

(i)

What was the date of decision? _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Have you previously filed an application for writ of habeas corpus under
Article 11.07 for relief from this conviction?
Yes

(15)

( )

(X )

No

If your answer to (14) was "yes," answer the following questions:

(a)

What was the Court of Criminal Appeals writ number?-------

(b)

What was the d e c i s i o n ? - - - - - - - - - - - - - - - - - - -

(c)

What was the date of decision? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

(d)

What is the reason the current claims were not presented and
could not have been presented in an earlier application?

.. >,,

,
-'

-
(16)

Do you have any petition or appeal pending in any court, either state or
federal, attacking the same conviction?
Yes ( )

(17)

No (X)

If you are presenting a claim for time credit, have you presented the claim to
the time credit resolution system of the Texas Department of Criminal
Justice--Institutional Division?

Yes ( )
(a)

No ( )

If your answer to (17) was "yes," answer the following questions:

What was the date of d e c i s i o n ? - - - - - - - - - - - - - - - Why are you not satisfied with the decision? _ _ _ _ _ _ _ _ __

(b)

(18)

If your answer to (17) was "no," why have you not presented
the claim to the time credit resolution system of the Texas
Department of Criminal Justice--Institutional Division?

State concisely every ground on which you claim that you are being
unlawfully confined. Summarize briefly the facts supporting each ground.
If necessary, you may attach pages stating additional grounds and facts
supporting the grounds.
For your information, the following is a list of the most frequently raised
grounds for relief in habeas corpus proceedings. Each statement preceded
by a letter constitutes a separate ground for possible relief. The grounds you
4

k,

.J

may raise are not limited to those listed below. However; you should raise in
this application all available grounds (relating to this conviction) on which
you base your allegations that you are being unlawfully confined.

If you claim one or more of these grounds for relief, you must allege facts in

support of the ground or grounds which you choose. Do not simply check
any of the grounds listed below.

(a)

Conviction obtained by plea of guilty which was unlawfully

induced or not made voluntarily with understanding of the
nature of the charge and the consequences of the plea.

(b)

Conviction obtained by use of coerced confession.

(c)

Conviction obtained by use of evidence gained pursuant to an

unconstitutional search and seizure.

(d)

Conviction obtained by use of evidence obtained pursuant to

an unlawful arrest.

(e)

Convictionobtained by a violation of the privilege against selfincrimination.

(f)

Conviction obtained by the unconstitutional failure of the

prosecution to disclose to the defendant evidence favorable to
the defendant.

(g)

Conviction obtained by a violation of the protection against

double jeopardy.

(h)

Conviction obtained by action of a grand or petit jury which

was unconstitutionally selected and empaneled.

(i)

Denial of effective assistance of counsel.

(j)

Denial of right of appeal.

(k)

Denial of time credits on sentence.

(I)

Improper revocation of parole or mandatory supervision.

(m)

Illegal sentence.

(n)

Invalid or defective indictment.

~-

(o)

(A)

No evidence or insufficient evidence.

What is your Ground Number One: Applicant was denied effective assistance of

counsel, as guaranteed by the Sixth Amendment to the United States Constitution and
Article 1, Section 10 of the Texas Constitution, when his attorney failed to investigate the
psvchiatric historv of applicant.
What are the FACTS (tell your story briefly without citing cases or law): Applicant has an

extensive psvchiatric historv including previous diagnoses of psychoses and paranoidal

'

delusional behavior. In spite ofthe magnitude of applicant's mental illness. his trial
counsel failed to not only investigate his psvchiatric background but also failed to even
have him evaluated by a psychiatrist. See attached for additional information.
(B)

What is your Ground Number Two: Applicant was denied effective assistance of

counsel. as guaranteed by the Sixth Amendment to the United States Constitution and
Article 1, Section 10 of the Texas Constitution, when his attorney failed to prepare or
present anv evidence in mitigation of punishment during the sentencing phase of the trial.
What are the FACTS (tell your story briefly without citing cases or law): Applicant suffers

from severe mental illness. Psychiatric testimony vvas available regarding how
applicant's conduct could be explained bv his severe mental illness. Furthermore, the
jurv was deprived of any evidence or testimonv regarding the applicant's psychiatric
history which was mitigating. Additionallv. applicant has an extremelv loving and

6
.:

supporting family along with a host of friends who all would have testified regarding the
good in him, despite engaging in the conduct that resulted in his conviction. Defense counsel
presented absolutely no mitigating evidence - nothing during the punishment phase of the trial.
See attached supplement for additional facts.
Wherefore, applicant prays that the Court grant applicant relief to which he may be
entitled in this proceeding.

VERIFICATION
(Complete either the Oath Before Notary Public or the Inmate's Declaration)
Oath Before Notary Public
STATE OF TEXAS, COUNTY O F - - - - - - - - . '

- - - - - - - - - - - - - - - - - - - - - ' being first duly sworn, under

oath, says: that

h~

is the applicant in this action and knows the content of the above

application and according to the applicant's belief, the foregoing allegations of the application
are true.

Signature of applicant

SUBSCRIBED AND SWORN TO BEFORE ME this_ day o f - - - - - - - -

Notary Public
Inmate's Declaration
I,

Keith Michael St. Aubin

(inmate's name)

_ _ _ _,.,:.8""5~2""'"1~12=----------------' being presently incarcerated in

(inmate's identifying number from TDCJ or county jail)
Be to
(name of TDCJ unit or county jail)
declare under penalty of perjury that according to my belief the foregoing information and
allegations of the application are true and correct.

}:...L..-1\1.,;~;....\~--

Signed on _ _5-+-\. .;. .\

(date)

SignatJre of applicant

. '.~.

,f"

'

ture of att neys (if any)

GEORGE M ALL SECREST, JR.
BENNETT & SECREST, L.L.P.
State Bar No. 17973900
808 Travis Street, 24'h Floor
Houston, TX 77002
713.757.0679

Sig~fany)

JANI J. MASELLI
State Bar No. 00791195
808 Travis Street, 24'h Floor
Houston, TX 77002
713.757.0684

: .. 1

...;

IN THE lOTH DISTRICT COURT

OF GALVESTON COUNTY, TEXAS
NO.
NO.
NO.
NO.
NO.
NO.

EX PARTE
KEITH ST. AUBIN

98-CR-0358
98-CR-0359
98-CR-0360
98-CR-0361
98-CR-0362
98-CR-0363
'

SUPPLEMENT TO QUESTION #18

TO THE HONORABLE QAVID E. GARNER, DISTRICT JUDGE:

STATEMENT OF FACTS RELATIVE TO
ISSUES ONE AND TWO

In the writ form, Applicant very briefly explained why trial

counsel

was

ineffective.

To

put

trial

counsel's

actions

in

context, a complete review of the evidence is necessary.

Overview of the Evidence

The prosecution, in a single proceeding, tried the applicant

for the offense of murder, four cases of attempted capital murder,
and two cases of assault on a public servant, all arising out of
the same transaction.

The applicant was convicted in all of the

cases, except for being acquitted of one of the assault of a public

servant accusations--Cause No.

98-CR-0364.

Life sentences were

assessed in the murder and attempted capital murder cases.

Ten

years confinement was assessed in the assault on a public servant

conviction.
As the record reflects, in the trial of the murder case and
the

four

cases

of

attempted

capital

murder,

the

prosecution

contended that the shooting of the complainants by the applicant

were

wanton and without

legal. justification.

Defense

counsel

,..,;"'

1.0

countered that the shootings were justified in that the applicant

had acted in self-defense.
Jury Selection

During voir

dire

examination

of

the

venire 1

Penal

Code 1

section 9.32 (deadly force in defense of person) was discussed by

both sides and the
defense)

and

jury was qualified on sections

9.32.

The

defense

did

not

9.31

conduct

(self-

voir

dire

examination with respect to any mental health issues.

Opening Statement

The

prosecution

asserted

in

opening

statement

that

the

applicant carne to Galveston's annual Mardi Gras street festival

February 21, 1998, armed with a semi-automatic 9rnrn handgun loaded
with hollow point bullets.
the

jury that there was

(RR

3 - 26-27) .

The prosecution told

"some type of argument,

confrontation,

disagreement (between) some people who were out there, the victims
in this case" and the applicant; what started out as a disagreement
evolved into a shoving match.

(RR

3 - 27-28) .

According to the

prosecution, the applicant's friend, Enrique Fuente, tried to get

the applicant to walk away from the confrontation but the argument
continued.

(RR

28) .

None

of

the

victims

in

this

case

displayed any weapons to the applicant, nor did they make any lifethreatening gestures

toward him.

aggressive action on the part of

(RR

any of

28-29).

The

most

the victims was

Luis

Martinez's shoving of the applicant in the chest area.

29).

(RR

The applicant "whipped out a 9rnrn handgun with a 15-round clip

2
~; .

.~ ..

'.

... with little or no warning that this was going to happen ... and
fire (d) into the crowd."

(RR 3 - 29-30).

The prosecution. told the jury that

unprovoked,

legally unprovoked shots

"after the violent and

the

stick around at all but took off."

(applicant)

(RR 3 - 31) .

didn't

He got a ride

with two men (Don Mouton and Wilton Thomas) who were not involved
in the earlier confrontation; he showed them the gun and said,
"some guys surrounded me.
31-32).

At that time,

I busted a fool in the chest."

the applicant did not appear to have any

signs of physical harm or injury.

in which the

(RR 3-

applicant

was

(RR 3 - 27).

riding got

After the vehicle

stuck

in

the

mud,

the

applicant went into a beach house and asked to use the telephone
and purportedly appeared "cool as a cucumber," he was "callous,"
"wasn't concerned about the victim$, " and went around asking people
in the house,

"how their Mardi Gras was."

(RR 3- 32-33).

The prosecution concluded its opening statement by telling the

jury how.the applicant fought violently with the police and that he
was so much out of control that one of the men who had given the
applicant a ride, Don Mouton, told one of the officers ''to uncuff
him

so

defendant

doesn't

come

at

him. "

(RR

3 5) .

The

prosecutor stated that there was "no legal justification for any
type of self-defense argument."
The defense,

in

(RR 3 - 37).

its opening statement,

asserted that

the

applicant had run into a

"group of people who were looking for

trouble."

This group,

except

(RR 3 - 3 9)

for Michael

Lopez,

who was
3

an

the victims in this case,

innocent bystander,

were

acting crazy and wanted to fight .

white boy

( Id. )

They said,

we're going to kick his ass"

applicant.

(RR 3 - 40).

"fuck the

and surrounded the

While conceding that the applicant should

not have had a gun that night, defense counsel contended that the
applicant was "scared to death" and believed "this gang meant what
they said."

(RR 3 - 44).

Defense counsel concluded by~elling the

jury that "[t]he evidence will show he was scared to death and did
what he thought he had to do and he ran like hell because he was
afraid.

He was scared."

( Id.)

Testimony of Witnesses for the Prosecution

Complainant Juan Garcia testified that while walking down The

Strand in Galveston, with several of his friends, he was pushed in
the back of his shoulder blade; when he turned around he saw the
applicant.

(RR 3 - 54).

Their eyes met and the applicant appeared

to be moving his mouth and doing something with his hands.

55)

(RR 3 -

Garcia interpreted this as meaning that the applicant wanted

to "start something"; Garcia had turned around at this point and

was facing the applicant.

(RR 3 - 56).

Garcia admitted that he

did not know whether it was the applicant who had pushed him, but,
in any event, he was getting angry.
Luis Martinez,

(RR 3 - 57).

who were with Garcia that

Oscar Nava and

evening,

came

Garcia, who told them that the applicant was "talking shit. "
The applicant was by himself,

facing the. three men,

Nava, and Martinez confronted him.

(RR 3 - 58).

toward
( Id.)

as Garcia,

The complainant

Christina Gonzales, who was with the men, told Garcia to "leave it
alone."

(!d.)

4
/.

1.3

When

the

applicant's

friend,

Enrique

Fuente,

tried

to

intercede and break up the confrontation, Garcia told him "you need
to get your friend away from here or he's going to get his ass
kicked."

(RR 3 - 61) .

As the applicant was being pulled away by

Fuente and Garcia was being pulled away by Christina Gonzales,

Garcia heard someone say in a voice he did not recognize,
up, bitch?"

(Id.)

"What's

Garcia, who had his back to the applicant, took

off his jacket because "you know, we were going to go ahead and
fight, "

turned around and saw that

backwards.

(RR

the applicant

had stumbled

As Garcia made his way next to Luis

63) .

Martinez, who was four to six feet from the applicant, he saw fire
coming

from

knowledge,

the

applicant's

gun.

( Id.)

To

the

witness's

none of the individuals that were in his group were

carrying any weapons.

(RR -

53)

On cross-examination, Garcia conceded that he did not know who

had

bumped

into

him

confrontation began.

earlier
( RR 3

because he had decided to

in
-

the

81 - 8 2 ) .

~kick

evening

before

He took off his

(applicant's)

that he was a tough guy and no stranger to

85).

just

the

jacket

ass" and admitted

fighting~

(RR 3 - 84-

Garcia acknowledged that someone was saying, "fuck the white

boy," and that someone "could have been him."

(RR 3 - 91) .

Complainant Christina Gonzales actually saw Luis Martinez push

or shove the applicant.

(RR 3 - 103, 121).

When Juan Garcia took

off his jacket and handed it to her to hold, she told him "that was
stupid," but he kept on walking toward the applicant anyway.

1<. 1

(RR

3 - 104)

She could not see the hands of Oscar, Luis, or Juan, but

did not think they had any weapons.

(RR 3 - 106).

On cross-examination, Gonzales confirmed that the group had

been

drinking

that

night and

that

she

"was

getting

little

concerned that the guys (in her group) were getting kind of crazy."
(RR 3- 113).
114).

She described her friends as being "hyper."

(RR 3-

Clearly, Juan Garcia was "pissed off" when he took off his

jacket and went towards the applicant.

(RR 3 - 119)

Tellingly, complainant Luis Martinez, testified that while on

The Strand, he was standing behind Juan Garcia when Garcia turned
around "with a grin on his face," and said that someone had just
pushed him.

(RR 3 - 136) .

Martinez saw Garcia and the applicant

staring at each other and while he was not close enough to hear
what they were saying, he heard the applicant "talking shit--saying
fuck you."

(RR 3 - 138).

Garcia was upset and Martinez saw the

applicant lift his arms up, which meant to Martinez "what's up?" or
"what's your problem?"

(RR 3 - 140) .

Martinez viewed applicant's conduct as "a challenge" and he

and Garcia went toward the applicant.
was

saying,

(RR 3 - 141).

The applicant

"fuck the mother fucker"--which prompted Garcia to

remove his jacket.

(RR 3 - 142).

The applicant's friend (Fuente)

was telling the applicant to "get out of there" and Garcia told the
applicant he had better listen to his friend "before you get your
ass whipped."

(RR 3- 144).

According to Martinez, he

tired of the argument and pushed the applicant back.

~as

getting

(RR3- 145).

1.5

At this point,

the witness saw fire coming from the applicant's

hand in their direction; he never saw a gun.

(RR 3 - 146) .

Enrique Fuente, who was 20 years old at the time of the trial,
testified that he had known the applicant for approximately 12
years and

t~ey

were like brothers.

(RR 3 - 196)

When he picked

up the applicant earlier in the evening to drive to Galveston's

Mardi Gras,

the applicant had. the pistol with him at that time.

(RR 3 - 200) .

They drank beer on the way down to Galveston and

more when they got there.

(RR 3 - 203-204).

Fuente recounted that

as he and the applicant were walking west on The Strand, a group of

individuals were yelling at them using threatening words.
219) .

Fuente was

scared and told the

applicant did not want

to fight

group

that

he

(RR 3 -.
and

the

and did not want any trouble.

( Id.)

Fuente did not believe that the applicant was saying anything
to the group; in any event, one of the members of the group pushed
the applicant and he fell back a few steps.

(RR 3 - 220).

The

applicant was shoved hard--" it was a shove to provoke a fight."

(RR 3 - 246).
to fight.

Fuente, again, told the group that they did not want

(RR 3

220).

After the shoving of the applicant, two

men in the group "got in Keith's face."

(RR 3 - 246)

The next

thing that happened was the applicant started shooting towards the
group that was threatening them.
any of the group with weapons.

(RR 3 - 221)

Fuente did not see

(RR 3 - 223).

Before Fuente heard

the first shot fired, he did not know that the

to pull out the pistol.

(RR 3 - 225) .

app~icant

was going

Fuente was trying to get

7
'r

-:.

t6

away from the area after the shooting; he was scared and concerned
that someone in the group would try to retaliate against him.
3 -

232-233)

He thought about calling the police but was too

scared and did not want to get involved.

The

(RR

next

day

Fuente

received

(RR 3 - 234) .
telephone

applicant who wanted him to page his lawyer.

call

from

(RR 3 -, 23 6) .

the
The

applicant told Fuente that he did not have to talk to the police if
they called.

(RR 3 - 239-240).

Steve Romero did not know the complainants or the applicant.

He testified that he saw the applicant pushed by one of the men and
that when this occurred, the applicant began firing hitting Nava in
the head.

(RR 3 - 252).

Romero did not see Nava or the other two

men in his group do anything with their hands before Nava was shot.
(RR 3

255-256).

running backwards.

The applicant continued shooting as he was

(RR 3 - 258).

him that the applicant

11

He confirmed that it appeared to

backed up like he didn't want to fight.

11

(RR 3- 261).
Michael Lopez, a nephew of Steve Romero, testified he observed
11

three Mexican guys arguing with a white guy 11 and that he saw the

applicant walk up to a

11

Short Mexican guy 11 and the

guy 11 pushed the applicant.

falling,

11

(RR 3 - 284).

short Mexican

As the applicant was

the taller Mexican guy 11 came towards the applicant and

this is when the applicant started shooting.

Melvin Boone,
Department

11

(RR 3 - 284, 293).

a deputy with the Fort Bend County Sheriff's

testified

that

he

was

attending

the

Mardi

Gras

festivities off-duty and at approximately 10:00 p.m. on the date in

.8

1.7

question noticed a white male--later identified as the applicant-arguing with a Hispanic male.

(RR 4 - 5).

He could not hear what

was being said between the men and saw no weapons in the Hispanic
male 1 s hands.

(RR 4 - 6-7).

He observed one Hispanic male leaving

the applicant 1 s presence and another approaching the applicant-- 11 it

looked like they were going to fight.

(RR 4 - 8).

11

Boone opined

that based on his training, he got the feeling that the applicant
11

was on the offensive 11 because

(RR 4

9) .

11

he had a cold look about him ....

As Boone turned to his right

11

to alert uniformed

officers in the area that there was going to be a fight, he heard

shots being fired--more than five but less than ten.
From what

Boone observed,

shooting.

(RR 4 - 12) .

11

11

there was no

(RR 4 - 10) .

justification for

the

On cross-examination, Boone acknowledged that in his written

statement he had told authorities that
was walking away 11 when
(RR 4

16)

11

11

Renaldo

it appeared the white kid

another Hispanic male got in his face.

Boone confirmed that he,

spoken during the confrontation like

white boy.

11

11

too,

11

heard words being

we 1 re going to kick your ass,

(RR 4 - 1 7) .
Jimenez,

who

had accompanied Melvin Boone

to

The

Strand that evening, saw the confrontation between the applicant

and the Hispanic males.

He observed the applicant turn his back to

the group momentarily,

grab a

gun

from

his

front

pants,

turn

around, and start shooting into the crowd and at the Hispanic men.
( RR 4 - 3 8 - 4 0 ) .
make

11

Jimenez donfirmed that he saw the Hispanic men

some gestures with their hands,

11

but he did not know what

.- -

..

that meant.
hands

of

the

(RR 4 - 42).
Hispanics,

Jimenez did not see any weapons in the

any bulges

in their clothing,

movements to indicate they were reaching for a weapon.

or any
(RR 4 -

43) .

On cross-examination,

it was established that Jimenez had

previously indicated in the written statement he gave the police

that he saw the Hispanic men display gang signs.

(RR 4 - 48).

He

had also previously described the encounter between the applicant

and the Hispanic men as "a gang ganging up against a white guy."
(RR 4 - 52) .
Don Mouton was with Wilton J. Thomas on the night in question
and testified that he was approached by the applicant while parked
at a McDonald's restaurant.

(RR 4 - 90-91).

The applicant gave

Mouton $60 in exchange for a ride ostensibly to a beach house where

the

applicant's

brother was

having a

party.

(RR

92) .

The

applicant did not have any abrasions or injuries to his face and
did not appear to be intoxicated.

(RR 4 - 95-96) .

Once in the car while driving toward the beach house,

the

applicant told Mouton to slow down and stop speeding "because there
were a lot of cops in the area."

(RR 4 - 96).

The applicant then

asked Mouton and Thomas whether they wanted to buy a "9mm police
edition gun" and later stated that if he didn't buy the gun that he
(the applicant) would have to throw it in the ocean.

(RR 4 - 100) .

According to Mouton, the applicant made a statement that "he had

tried to talk with a Mexican girl and a bunch of Mexican dudes
surrounded him and he pulled out his 9 and started busting them and
10

1.9

busted one of the fools in the chest."

(RR

4 - 101-102) .

The

applicant was described as being calm as he was telling this to

Mouton and did not appear nervous or afraid; he "never mentioned
being in fear for his life or that the others had weapons."

(RR 4

- 102-103).
Mouton recounted the arrival of police officers,

after his

vehicle became mired in the mud and the fight that ensued between
the officers and the applicant.

( RR

4 - 11 7

12 4 ) . 1

Peter Contenta, a Galveston police officer, testified that he

was assigned to "secure as much evidence as possible'' at the scene
of the shooting.

(RR

hands or on his body.

Dr. William

4 - 210)
(RR

No weapons were found in Nava's

4 - 212-214).

Korndorffer~

the medical examiner for Galveston

County, testified that complainant, Nava, was shot three times; one
of the bullets entered the left side of his head and went all the
way across the brain--this was the fatal injury.
Two other bullets entered the complainant's neck.
deceased had

. 095 percent alcohol in his blood.

(RR

(RR 5 - 6)
(RR

6-8) .
The
10) .

Although the witness could not determine how far away the weapon
was when fired,

it had to have

have been further than that.

bee~at

(RR 5

least two feet and could

- 12) .

Vivian Clark, a guest at the beach house where the applicant

had been permitted to use the telephone after Mouton's vehicle got
Galveston County Sheriff's Deputies Bob Batten,
a
complainant, his brother Clyde Batten, also a complainant, and W.
Durand Fooks, testified concerning the struggle and fight that took
place with the applicant in an effort to place him under. arrest.
(RR 4 - 149-154, 162-165; 174-179, 182; 194-199, 203-204).
11

stuck in the mud,

described the applicant as appearing "to be a

very nice young man," "very talkative," and he "shook their hands,
said thank you," and asked the witness what she was watching on TV.
(RR 5 - 31) .

He did not appear to be intoxicated, he smiled, "was

very pleasant," and "never appeared upset."

(RR 5 - 31, 33) . 2

The prosecution ended its case on a low point by calling the

ubiquitous
alleged

jailhouse

snitch,

conversations

that

Marc
he

Crichlow,

and

incarcerated in Galveston County Jail.

the

to

testify

applicant

about

had

while

According to Crichlow--who

was testifying without receiving any promises from the state except
for "protection"--the applicant told him that he had "got a rush
out of the shooting" and did not say he was in fear of his life or
that the Hispanic men who were shot had any weapons or "had reached
for anything."

(RR 5 - 136-138) .

The applicant was "smiling--had

a grin on his face" as he told Crichlow this story and did not
express any remorse for the killings.
supposedly came

forward because the applicant

"going to free on this case."

On

(RR 5 - 139-140) .

cross-examination,

Crichlow had been in

probation and was

j~il

"hoping

Crichlow

told him he was

(RR 5 - 150) .
defense

counsel

established

for two months on a motion to revoke

(his)

lawyer can negotiate a deal so

(his) probation won't be yanked and (he) won't be sent away."

5

that

(RR

142) . 3

The witness's description of the applicant's demeanor was

confirmed by Judith Quance.
(RR 5 - 52-53).
Imagine that!
12
.. /'

Testimony of Witnesses for the Defense

Several individuals were called by the defense in an effort to

shore up

its

claim that

the

shootings were

legally justified.

Cindy Ahme confirmed that in the written statement she gave to the
police she h?,d said that "a Mexican guy kept going up to the white
guy, and the white guy kept backing up" and that "it looked like
they were trying t:o surround the white guy."

(RR 5 - 176-177).

Anthony Funts testified that he saw a group of.Hispanic men

and one of them was yelling "fuck this white boy, I'm going to whip
his fucking ass."

(RR 5 - 188).

In all, there were four Hispanic

males who were ''kind of in a semi-circle near the (applicant)" in

a threatening manner.

(RR 5 - 192).

back" when he pulled out the gun.

not

se~

The applicant was "falling

(RR 5 - 203).

the Hispanic men with any weapons.

The witness did

(RR 5 - 196)

Final Arguments of Counsel at the Guilt/Innocence Stage

Predictably, the prosecution seized on the reality that the

facts simply did not support a claim of self-defense:
I don't think they are going to have much in the way of
a defense ... [W]hat doesn't belong in this courtroom is
an allegation that this was a racial matter.
It was
words between two young men.
Don't let him because he
has so very little to argue, don't let him throw that in
your face.
(RR 6 - 15-16).
you

The prosecutor continued, "[w]hat they won't show

what they .can't show you is weapons on anybody else other

than this violent human being.

on The Strand"
weapon).

We had 11 witnesses that were out

(and no one saw the complainants with any kind of

No one saw "them reach into their pocket to try to get

13
'..

any kind of weapon" or "reach behind their belt to try to get any
weapons."

( RR 6

21- 22 ) .

Defense counsel is "not going to be

able to bring you one justificati6n for this killing,

injuries."

(RR 6

for these

22) .

Beyond arguing that the evidence did not fairly support selfdefense as a legal justification for the shootings in the case at
bar, the prosecutor focused on the applicant:
why did it happen, ladies and gentlemen?
It happened
because this fellow is just plain mean.
He's bad
and he's mean and (defense counsel) are going to get up
here and tell you that he was in fear of his life.
You know, he is an extremely dangerous person. He
can kill and maim in one minute and in the next minute he
can go to Pirate's Beach and charm some women and then
the following minute he can fight police officers. And
you have just seen two hours, just two hours, out of this
man's life.
Two hours, ladies and gentlemen, and that
should give you a very good insight into how dangerous,
irresponsible, and mean this man is.
All of these people afterwards that saw him said he
was calm, cool, and collected. He's a manipulator, he's
a dangerous manipulator without a conscience.
(RR 6

92) .

Sentencing Evidence Adduced by the State

At the sentencing phase,

the state offered evidence of bad

character and reputation and several extraneous offenses.

Deputy

Greg Bryan of the Harris County Sheriff's Department testified that

the applicant's character and reputation were not good in Harris
County prior to February 21, 1998.

(RR 7 -

7)

Derrick Coffman, another incarcerated scofflaw, who had prior

convictions for,

among other things,

making a false report to a

peace officer, testified that the applicant had approached him with
14

a scheme.
head

Supposedly, the applicant wanted Coffman to shave his

(apparently

appearances)
out of

applicant

and

the

witness . had

(RR 7

22,

The applicant,

28).

was going to head to Mexico with his

released.

similar

and let him use the witness's identification to get

jail.

Coffman,

the

(RR 7 - 24).

according to

"old lady"

once

Coffman, whose liberty was also imperiled

due to a pending motion to revoke probation, did not know whether

the applicant was even serious in his suggestion.
Sergeant

Thomas

Derry

of

the

Galveston

(RR

32) .

County

Sheriff's

Department testified that he entered the applicant's

jail cell

after the applicant had attempted to commit suicide by slicing open

(RR

his forearm with a razor blade.

43) .

The applicant was

bleeding and was covered in blood and as he was being escorted to

the medical clinic reportedly was calling the deputies "pussies"
and saying that he was "going to kill you pussies."
~pplicant

48) .

The

pen.

(RR 7 - 49) .

watch.

(RR

48)

(RR 7 - 47-

was found to be in possession of a sharpened

Thereafter, the applicant was placed on suicide

4

Doug Perry, a teacher at Lee High School, testified that in

his opinion, the applicant was not a peaceful, law abiding citizen
and that his reputation was not good.

(RR 7 - 64-65) .

Simon Geller, a correctional officer with the Galveston

County Sheriff's Department, confirmed Derry's testimony.
(RR 55-61) .
The applicant was upset when he made the aforementioned
statements and had blood all over him.
(RR 7 - 61) .
15

,Deputy

John

Fernandez

of

the

Galveston

County

Sheriff's

Department testified that he found a sharpened piece of wire and a

razor

blad~

in the applicant's cell.

Deputy
Department

Mark' Hinson

t~stified

of

the

(RR

7 - 68-69) .

Galveston

County

Sheriff's

that he found a sharpened piece of wire inside

a book in a cell occupied by the applicant.

(RR

7- 76).

Deputy Constable John Causey with Harris County Precinct 5,

testified that he knew the applicant in 1996 and 1997 and, in his
opinion,

he had a bad reputation and was not a peaceful and law

abiding citizen.

(RR 7

80) .

The State offered evidence that the Applicant had previously

been convicted for carrying a weapon (a club) and evading arrest,
both misdemeanors, and sentenced to thirty (30) days in jail.

See

State's Exhibits 36 and 37.

Sentencing Evidence Adduced by the Defense

The state and defense entered into a stipulation that the

applicant had never been convicted of a crime.
evidence

or

testimony

of

any

kind,

(RR 7

however,

was

83) .

adduced

No
~n

mitigation of punishment.
Final Arguments of Counsel at the Sentencing Phase

At

the

sent,encing phase,

defense

counsel

argued

that

the

applicant was eligible for probation and that he had never before
been convicted of a felony in this or any other state or been on
adult probation.

(RR 8

7) .

Defense counsel asserted that the

shootings were not done in a premeditated fashion,

16

"[a]nd whether

rightly or wrongly, Keith was afraid.

He was in fear, and, yes, he

overreacted," (RR 8- 9), the applicant was scared, afraid, but was
"a human being.

He's from a good family, " (RR 8 - 12-13) , the fact

that the applicant panicked and that "[i] t was terrible judgment by
a

19-year-o~d.

And a 19-year-old panics, how do you punish a 19-

year-old who panics who was in fear?"

(RR - 8 -

'

13) .

Defense

concluded his remarks by stating "don't punish a young man for the
rest of his l1fe, a 19-year-old who acted out of fear, a 19-yearold who panicked and acted impulsively.

A 19-year-old who acted

very immaturely because he was afraid."

(RR 8 - 25).

The prosecution, in turn, responded by arguing that

did you hear one person, did you hear one person come
into this courtroom, ladies and gentlemen, did you hear
any of these people out here come into this courtroom
that say that this is a good man?
Did you hear one
person other than his lawyer that likes to go over and
hug him and calls him a friend, did you hear one person
say he was a good man? No.
And the reason you didn't
hear that, and the reason you didn't hear that is because
he's not. Because he's mean. . . . The reason you didn't
hear them get on the stand when they were here throughout
this trial, the reason you didn't get to hear anything
nice about this person is because this person is not
nice. It is because this person is bad and it is because
this person is mean. Mr. Nugent, one of the best lawyers
in the State of Texas, don't you know he could have
brought you somebody, a preacher, a psychologist ... if
he could have brought you one human soul, they would have
been here .... he's violent, he's dangerous . . . . Did you
hear one person from the witness stand testify that the
defendant told them that he was remorseful?
( RR 8 - 2 6 - 2 7

35) .

17

Z6

IN THE lOTH DISTRICT COURT

OF GALVESTON COUNTY, TEXAS

EX PARTE
KEITH ST. AUBIN

NO.
NO.
NO.
NO.
NO.
NO.

98-CR-0358
98-CR-0359
98-CR-0360
98-CR-0361
98-CR-0362
98-CR-0363

LEGAL MEMORANDUM
AND BRIEF IN SUPPORT

TO THE HONORABLE DAVID E. GARNER, DISTRICT JUDGE:

ISSUES NUMBER ONE AND TWO
ISSUE ONE: APPLICANT WAS DENIED EFFECTIVE ASSISTANCE OF COUNSEL,
AS GUARANTEED BY THE SIXTH AMENDMENT TO THE UNITED STATES
CONSTITUTION AND ARTICLE 1, SECTION 10 OF THE TEXAS CONSTITUTION,
WHEN HIS ATTORNEY FAILED TO INVESTIGATE THE PSYCHIATRIC HISTORY OF
APPLICANT.
ISSUE TWO: APPLICANT WAS DENIED EFFECTIVE ASSISTANCE OF COUNSEL,
AS GUARANTEED BY THE SIXTH AMENDMENT TO THE UNITED STATES
CONSTITUTION AND ARTICLE 1, SECTION 10 OF THE TEXAS CONSTITUTION,
WHEN HIS ATTORNEY FAILED TO PREPARE OR PRESENT ANY EVIDENCE IN
MITIGATION OF PUNISHMENT DURING THE SENTENCING PHASE OF THE TRIAL.

The two-step analysis set out by the United States Supreme

Court in Strickland v. Washington, 466 U.S. 668, 104 S.Ct. 2052, 80
L.Ed.2d 674 (1984), and adopted by the Court of Criminal Appeals in

Hernandez

v~

State, 726 S.W.2d 53, 57 (Tex.Crim.App.1986), is the

standard for appellate review of counsel's effectiveness during

trial.

The Court of Criminal Appeals has also determined that this

standard is applicable to a review of counsel's performance at the

sentencing stage as well.

Hernandez v.

State,

988

S.W.2d 770

(Tex.Crim.App. 1999).
First, applicant must show that counsel's performance was so
deficient as not to function as the "counsel" guaranteed by the

Sixth Amendment to the United States Constitution.

amend.

at

693;

Jackson

(Tex.Crim.App.1994)
guar~ntee

Canst.

see Strickland, 466 U.S. at 687, 104 S.Ct. at 2064, 80

VI;

L.Ed.2d

U.S.

v.

State,

877

S.W.2d

768,

771

The constitutional right to counsel does not

etrorless

counsel,

therefore,

the

effectiveness

counsel must be determined by the entire representation.

of

However,

the "severity of the sentence" should "be considered in determining

whether

counsel's

performance

meets

this

standard. "

Vela

v.

Estelle, 708 F. 2d 954, 965 (5th Cir. 1983) .

The second prong of Strickland requires applicant to establish

"that there is a reasonable probability that,

but for counsel's

unprofessional errors, the result of the proceeding would have been

different."
L.Ed.2d

at

Strickland,

693.

466 U.S. at 687,

reasonable

104 S.Ct. at 2064,

probability

is

sufficient to undermine confidence in the outcome.

U.S. at 694.

80

probability

Strickland, 466

In determining prejudice in the context of deficient

performance at the sentencing phase, the question becomes "whether

there is a reasonable probability that the jury's assessment of
punishment in the case would have been less severe in the absence

Although the entire representation must be reviewed, "the

right to effective assistance of counsel ... may in a particular
case be violated by even an isolated error of counsel if that error
is sufficiently egregious and prejudicial." Murray v. Carrier, 477
u.s. 478, 106 s. Ct. 2639, 2649-2650, 91 L. Ed. 2d 397 (1986). II
Citing, United States v. Cronic, 466 U.S. 648, 657, n.20, 104 S.
Ct. 2039, 2046, n.20, 80 L. Ed. 2d 657 (1984)
See also, May v.
State, 722 S.W.2d 699 (Tex. Crim. App. 1989).
2

of counsel's deficient performance."

Milburn v. State, 15 S.W.3d

267, 270 (Tex. App. -Houston [14th Dist.] 2000)

In Moore v.

Johnson,

194 F.3d 586,

604

(5th Cir. 1999),

the

Fifth Circuit explained that even a deferential review is subject

to limitatidns:
The Court is,
therefore, not required to condone
unreasonable decisions parading under the umbrella of
strategy, or -to fabricate tactical decisions on behalf of
counsel when it appears on the face of the record that
counsel made no strategic decision at all. Compare Mann
v. Scott, 41 F.3d 968, 983-84 (5th Cir.l994) (citing
record evidence for the proposition that counsel made a
strategic decision not to offer mitigating evidence
during the punishment phase of a capital trial) , with
Whitley, 977 F.2d at 157-58, (concluding from the record
that counsel's failure to offer mitigating evidence
during the punishment phase of habeas petitioner's
capital trial was not the result of a considered
strategic decision,
and therefore not entitled to
deference), and Wilson, 813 F.2d at 672, (concluding that
the existing record was inadequate for purposes of
determining whether counsel made a strategic decision not
to offer mitigating evidence during the punishment phase
of a capital trial or whether that decision was
professionally reasonable) ; see also Whitley, 977 F. 2d at
158 ("The crucial distinction between strategic judgment
calls and plain omissions has echoed in the judgments of
this court.") ; Profitt v. Waldron, 831 F. 2d 1245, 1248
(5th Cir.l987) (Strickland 's measure of deference "must
not
be
watered
down
into
a
disguised
form
of
acquiescence.");
id. at 1249
(refusing to indulge
presumption of reasonableness a9 to "tactical" decision
that afforded no advantage to the defense). Rather, the
fundamental legal question is whether, viewed with the
proper amount of deference, counsel's perform~nc~ was
professionally
reasonable
in
light
of
all
the
circumstances. Strickland, 104 S.Ct. at 2066.
The question becomes did the Applicant receive a

fair sentence

resulting in a punishment verdict worthy of confidence.

v. Whitley,

514 U.S. 419 (1995)

3

cf. Kyles

Failure to Investigate Psychiatric History

In order to be constitutionally effective,

defense counsel

has a general "duty to make reasonable investigations or to make a

decision

reasonable
unnecessary."

that

particular

investigations

Strickland, 466 U.S. at 691, 104 S.Ct. at 2052.

In Seidel v. Merkle,
c~nsidered

makes

146 F.3d 750

(9th Cir. 1998), the Court

whether the petitioner was denied effective assistance

of counsel by his attorney's failure to conduct any investigation

into the petitioner's psychiatric background and subsequent failure
to present any evidence to the jury regarding his mental health.
Seidel,

146 F.3d at 752.

In a case similar to the case at bar,

Seidel was convicted of second degree murder, and contended that he

was

"scared for

[his]

life"

at

the

time of

resulted in the killing of the complainant.

751, 755.

the

incident

Seidel,

that

146 F.3d at

In finding deficient performance, the Court held:

In general, "counsel has a duty to make reasonable

investigations or to make a reasonable decision that
makes particular investigations unnecessary." Strickland,
466 U.S. at 691, 104 S.Ct. 2052. In the instant case,
there were abundant signs in the record that Seidel
suffered from mental illness. Nevertheless, trial counsel
failed to condu'ct any investigation at all into his
client's psychiatric history and therefore neglected to
pursue a potentially successful defense. See Sanders v.
Ratelle, 21 F.3d 1446, 1456 (9th Cir.1994) (" [C]ounsel
must, at a minimum, conduct a reasonable investigation
enabling him to make informed decisions about how best to
represent his client."); Evans v. Lewis, 855 F.2d 631,
637 (9th Cir.1988) (" [C]ounsel'-s failure to pursue the
possibility of establishing
[his client's]
mental
instability constituted deficient performance.").
It was clear from the ~vidence available to counsel
at the time of trial that Seidel has_ an extensive history
4

~-0

of mental problems. The pre-trial record included the

following factual items: {1) Seidel had been treated with
medication by a prison psychiatrist while awaiting trial;
(2) Seidel's jail medical record indicated that he had
been treated at a V.A. hospital for a mental disorder;
and (3) Seidel's Own Recognizance Report, prepared for
his bail hearing, documented prior hospitalization at a
V.A.
hospital for symptoms related to his mental
condition.
In addition to the evidence in the pre-trial record
that should have alerted trial counsel to the possibility
Of using Seidel's mental illness as a defense, there is
also evidence in the record that counsel actually was
aware of the-mental problems that his client suffered
Seidel, 146 F.3d at

755-56.

{Emphasis added) .

The Court determined that Seidel's trial counsel had

... conducted no investigation to ascertain the extent or
possible ramifications of his client's psychiatric
impairment. Counsel did not obtain Seidel's military,
prison, or medical records, which obviously would have
provided a full account of his mental health history. He
failed to interview any witnesses regarding Seidel's
mental state. Counsel never requested that any mental or
psychiatric evaluations be performed on his client to
assess his condition. In sum, counsel failed to conduct
any research at all into the possibility of presenting a
defense related to his client's obviously impaired mental
state. Counsel's disregard for conspicuous pieces of
evidence that pointed to a potentially fruitful trial
strategy cannot be described as anything short of
defective representation.
Seidel,

146 F.3d at 756.

(Emphasis added) .

What is especially compelling and applicable to the instant

case is the fact that Seidel's attorney utilized a theory of selfdefense.

Id.

In Seidel,

the State argued that the self-defense

was the only feasible defense based upon the evidence.

Id.

The

Court of Appeals disagreed with that proposition noting that:

While the police statement, indicating that Seidel was
"scared for [his] life" at the time of the incident and
5

'l"'
..'\.
.. _......

only attacked the victim after receiving a punch to the

head, is consistent with a theory of self-defense, there
is nothing in the statement that precluded a second
defense based on Seidel's psychiatric problems. The State
has been unable to explain why self-defense and a defense
based on mental illness were mutually exclusive under the
existing circumstances. Indeed, the two defenses were
quite l~kely to be complementary: Seidel's fear for his
own safety during the fight with Bucholz could have been
exacerbated by his psychological history of multiple
trauma. As Dr. Paul Koller, the expert psychologist
appointed by-the state trial court to examine Seidel,
explained:
Typically, such a combination of multiple
traumas tends to leave victims excessively
fearful
and
psychologically
primed
to
over-react to perceived threats ... It is thus
quite
possible
that
the
combination
of
situational factors, Mr. Seidel's PTSD, 2 and
his organic brain damage helped create an
excessive
fear
for
his
well-being
and
subsequent
impulsive,
poorly thought
out
over-reaction with the knife.
Dr. Koller's report simply confirms that trial
counsel's "strategic" decision to rely exclusively on a
theory of self-defense could not have been the product of
reasonable professional judgment.
Seidel, 146 F.3d at 756-57.

Additionally,

(Emphasis added) .

the State asserted that if the psychological

evidence had been presented there would have been vigorous negative
cross examination.

Seidel, 146 F.3d at 757.

Again, the Court of

Appeals discounted this based upon the clear facts of Seidel's

mental

illness and determined that he had received ineffective

assistance

of

counsel

when

his

attorney

failed

investigate Seidel's psychological background.

Post-traumatic stress disorder.

6

Id.

to

properly

Lambright v.

241 F.3d 1201

Stewart,

(9th Cir. 2001),

is yet

another case where the Court of Appeals considered whether defense

counsel's failure to investigate or present any evidence of the
defendant's

mental

disability

deficient representation.

or

social

history

resulted

Lambright, 241 F.3d at 1204.

in

The Court

held:
Lambright argues that an extensive series of "red flags"
should have motivated counsel to investigate his
psychiatric
condition
and
to
present
mitigating
psychiatric
testimony
at
sentencing.
Lambright's
presentence Psychological Evaluation told of his service
in Vietnam, during which he witnessed the violent death
of friends, and the mental breakdown that he suffered
after returning to this country. It described some of the
hallucinations he had experienced and his subsequent need
for hospitalization in a mental facility. The report also
mentioned two of Lambright's attempts to commit suicide.
In an affidavit before the district court, moreover,
Lambright wrote that he had "discussed his past mental
problems and drug use with his trial counsel. " There can
be no doubt that Lambright has raised a colorable claim
of deficient performance. Counsel's alleged failure to
obtain a psychiatric evaluation of Lambright, despite
knowing of his wartime experience and extensive drug
abuse, is the type of performance courts have labeled
deficient under Strickland. See Williams, 120 S.Ct. at
1514
(holding
that
the
failure
to
"conduct
an
investigation that would have uncovered extensive records
graphically describing [the petitioner's] nightmarish
childhood" constituted deficient performance); Turner v.
Duncan, 158 F. 3d 449, 456 (9th Cir .1998) ("[Counsel's]
failure to arrange a psychiatric examination or utilize
available psychiatric information also falls below
acceptable performance standards.") ...
(Emphasis added)

Lambright, 241 F.3d at 1206-07.

In Ex Parte Duffy, 607 S.W.2d 507, 525 (Tex. Crim. App. 1980),
overruled on other grounds,

Hernandez v.

State,

988 S. W. 2d 770

33

(Tex. Crim. App. 1999), the Court found a deprivation of effective

representation holding that
[w]hether counsel's failure
to assert psychiatric
defenses was a strategic decision begs the question. It
may not be argued that a given course of conduct was
within the realm of trial strategy unless and until the
trial attorney has conducted the necessary legal and
factual investigation which would enable him to make an
informed,
rational decision.
(Citation omitted).
Abdication of basic threshold responsibility is the
antithesis of a considered strategy to assert or withhold
possible defenses.
Thus, (defense counsel) withdrew
psychiatric
defenses
and mitigating
testimony
of
punishment before he had even examined them.
In Ex parte Kunkle,
Court

of

Criminal

852 S.W.2d 499

Appeals

(Tex.Crim.App.

considered

whether

1993),

counsel

the
was

ineffective for deciding not to present evidence of the defendant's

abuse and behavioral problems, as well as evidence of his parents'
mental histories at the punishment phase of a capital proceeding.
Kunkle, 852 S.W.2d at 506.

The Court held that:

Applicant's trial counsel, however, made a tactical

decision to neither present nor proffer this evidence at
the punishment stage. Applicant would have this Court,
using hindsight--i.e., considering his trial counsel's
trial tactics in light of the subsequent decision in
Penry- -hold
that
trial
counsel
did
not
perform
reasonably. But this Court previously held that counsel's
performance is to be evaluated at the time of trial.
Butler v. State, 716 S.W.2d 48, 54 (Tex.Crim.App.1986).
We are unable to conclude that such a deliberate
decision, under the circumstances and after a thorough
investigation of available mitigating evidence, rendered
applicant's trial counsel unreasonable at the time of

trial. May v. Collins, 904 F.2d 228, 232 (5th Cir.1990).

Relief is therefore denied on applicant's fifth claim. 3 , 4

Kunkle,

852 S.W.2d at 506.

decision in Kunkle,

(Emphasis added) :

The premise of the

is that a valid strategy must be based upon

adequate inv.estigation.

While the Courts will not use hindsight in

gauging counsel's effectiveness, the decisions made by counsel will

be evaluated based upon the investigation utilized to determine the
best possible strategy.

"A conscious and informed decision on

trial tactics and strategy cannot be the basis for constitutionally

ineffective assistance of counsel unless it is so ill chosen that
it permeates the entire trial with obvious unfairness."

Crane v.

Johnson, 178 F.3d 309, 314 (5th Cir. 1999) (citing Garland v. Maggio,

717 F.2d 199, 206 (5th Cir. 1983) (on rehearing))

In Crane, the petitioner raised several issues of ineffective
assistance of counsel based upon the failure to investigate.

One

All emphasis supplied unless otherwise indicated.

It is imperative to note that at the time of Kunkle's

trial the jury was not provided with a "Penry" or mitigation of
evidence instruction as is now mandated by Article 37.07, section
2(e) (1), V.A.C.C.P.
Counsel made the strategic decision at that
time to offer, among other things, evidence of his client's
behavioral and mental problems and psychiatric evaluations because
"(he) did not want to give the State anymore evidence for the jury
to
use
against
(Kunkle)
in
answering"
(the
special
issues)-deliberateness and probability of committing acts of
violence in the future).
Id. at 504.
In the case sub judice, counsel, of course, was not hampered
with special issues that are only applicable to capital cases.
Even if the jury believed that there was a probabiliti that the
applicant would commit acts of violence in the future, that belief
would not automatically or necessarily result in the imposition of
a life sentence.
9

35

issue was whether counsel had properly considered Crane's mental

impairment.

Crane,

178 F.3d at 314.

The Court held that it was

not ineffective to fail to present evidence of mental impairment

because along with numerous affidavits

"demonstrating that

the

insanity defense was investigated by defense counsel, and that any

such insanity defense would have been spurious," 178 F.3d. at 313,
the attorneys also made a strategic decision based upon the fact
that

quite

possibly the

evidence

"would have been aggravating

because it would have necessarily revealed Crane's

~blackouts'

Crane,

178

that

accompanied

F.3d at

314. 5

the

alleged

The Court

mental

noted that

~rages'

and

impairment."
" [a] 11 of

the

evidence that Crane contends should have been presented at the

punishment phase of his. trial had a double-edged quality.
counsel decided the evidence was potentially more harmful
helpful."

Crane, 178 F.3d at 315.

Trial
than

The reasoning of the Court is

instructive: "Crane ... failed to overcome the strong presumption

that these informed tactical decisions were reasonable under the
circumstances."

Crane,

178 F.3d at 315.

(Emphasis added) .

Again, it is critical to note that Crane was tried for capital

murder and strategic decisions made by trial counsel were no doubt
fueled by the belief that Crane's "best chance of prevailing at the
penalty phase was to obtain a favorable jury response on the future

Crane's attorneys actually consulted two psychiatrists

and had their client evaluated. Id., at 314. Crane suffered from
persistent headaches due to a motorcycle accident; no abnormality
or mental illness was detected.
Id.
10

dangerousness

issue. "

Id.

at 314.

With the issue of

"future

dangerousness" being very much in play and with no prospect of

receiving a mitigation of punishment instruction to counterbalance
the

special

issue

unconstitutionally

submission,
deprive

which,
defendant

consideration of mitigating evidence,

~isk

in

some

of

the

cases,
jury's

would
fair

defense counsel could not

delving into_Crane's psychological past.

In the case sub judice, there is simply no doubt that defense

counsel was on notice regarding applicant's psychiatric past and
history of mental disease.
confirms,

As Elizabeth St.

Aubin's affidavit

on numerous occasions she spoke with defense counsel

regarding her son's emotional and mental difficulties and sent

defense counsel numerous articles addressing the mental illness
issues in this case.
working

files

(Appendix 5).

reveals

that

A review of defense counsel's

virtually

no

investigation

was

undertaken with respect to the Applicant's mental state; moreover,

defense

counsel

never

had

mental

or

psychiatric

evaluation

Judge Reavley, in his concurring opinion in May v.

Collins, 904 F.2d 228, 233 (5th Cir. 1990), ably explained the
constitutional dilemma presented in a capital murder punishment
proceeding, conducted pursuant to Texas's old death penalty special
issue regimen, as to "double edged" evidence: "a juror who
concludes that the evidence requires affirmative answers to
questions on deliberateness and future dangerousness, but who also
concludes that the defendant's character, moral culpability, or
social worth mitigates against a death sentence, may not (and
should not) feel at liberty to express her ultimate conclusion,
since it requires nullification of one of the statutory questions.
We can never be certain under this statutory scheme that a juror in
this predicament will not be silenced by the need to comply with
the law's facial requirement.~'
11

performed on

the Applicant

condition before,
Appendix 2).

during,

in an effort

to

assess

or after the shootings.

his

mental

(Appendix 5,

"As the exclusiop of mitigating evidence potentially

undermines the reliability of sentencing determinations, the burden

is on the state to prove that the error was harmless beyond a
reasonable doubt . "

Carter v.

Bell,

218 F.3d 581,

594

(6th Cir.

2000).

Preparation and Presentment of Mitigating Evidence

Factors
culpability

that
"ste [m]

mitigate
from

the

an

individual

diverse

defendant's

frail ties

of

moral

humankind. "

Woodson v. North Carolina, 428 U.S. 280, 304, 96 S.Ct. 2978, 2991,

49 L.Ed.2d 944
Stevens,_ _JJ.
--.---

(1976) (plurality opinion of Stewart,

) ,:' -- As---trre-:~-s-up~me
~:-.

.-:--.

- -

--

Powell,

and

Court reasoned:

"For the determination of sentences, justice generally

requires consideration of more than the particular acts
by which the crime was committed and that there be taken
into account the circumstances of the offense together
with the character and propensities of the offender."
Pennsylvania ex rel. Sullivan v. Ashe, 302 U.S. 51, 55,
58 S.Ct. 59, 61, 82 L.Ed. 43 (1937). Consideration of
both the offender and the offense in order to arrive at
a just and appropriate sentence has been viewed as a
progressive and humanizing development. See Williams v.
New York, 337 U.S., at 247-249, 69 S.Ct., at 1083-1084;

Applicant acknowledges that although some of the

jurisprudence quoted herein deals with sentencing in a capital
context, it is applicable in the instant case due to the gravity of
the offenses charged and the fact that the maximum punishment of
five life sentences and a ten year sentence were handed out.
See
Milburn v. State, 15 S.W.3d 267 (Tex. App.-Houston [14th Dist.]
2000), and discussion infra at 17-20.
12
~.tO

- !,;)

Furman v.
2810-2811

Georgia, 408 U.S., at 402-403,

(Burger, C. J., dissenting).

92 S.Ct.,

at

Woodson, 428 U.S. at 304, 96 S.Ct. at 2991.

In the instant case, no evidence of mitigation, whatsoever,

was presented by defense counsel for the jury's consideration in
explaining
individuals;

the

Applicant's

moreover,

conduct

1n

shooting

nothing was presented at

five

unarmed

the sentencing

phase by the defense in an effort to obtain less than the maximum

punishment

authorized by

law.

None

of

this

was

lost

on

prosecution when it acknowledged this shortcoming in its

the

final

argument at the sentencing phase of the trial:

Did you hear one person, did you hear one person
come into this courtroom, ladies and gentlemen, did you
hear any of these people out here come into this
courtroom and say that this is a good man? Did you hear
one person other than his lawyer that likes to go over
and hug him and calls him a friend, did you hear one
person say he was a good man? No.
And the reason you
didn't hear that, and the reason you didn't hear that is
because he's not. Because he's mean. I'm not picking on
these folks.
These folks are all here to support his
parents.
The reason you didn't hear them get on the
stand and they were here throughout the trial, the reason
you didn't get to hear them say anything nice about this
person is because this person is not nice. It's because
this person is bad.
And it is because this person is
mean. Mr. Nugent, one of the best lawyers in the Sate of
Texas, don't you know if he could have brought you
somebody, a preacher, a psychologist - ...
Don't you know if he could have brought you one
human sole they would have been here.
( RR 8

26- 27) .

Predictably,

1n answering this habeas petition,

the State's

response will surely be, as it was in its brief on direct appeal,

that evidence of mitigation can be a double edged sword and in the
case sub judice,

evidence of the Applicant's mental history was

13
.~9.
. ~..-

,'

,.,...

more harmful than helpful.

reasons.

First,

That argument fails for at least two

Applicant

examined in context,

had available

evidence

which,

when

presented a compelling justification for a

sentence less than the maximum authorized by law and far outweighed
negativ~.

the

Second,

the

United

States

Supreme

Court

has

confirmed that when considering whether defense counsel provided

effective

assistance

of

counsel

in

not

presenting

relevant evidence in mitigation of punishment,

available,

"not all of the

additional evidence need be favorable to the petitioner."

Williams

529 U.S. 362, 396, 120 S.Ct. 1495, 1513, 146 L. Ed. 2d

v; Taylor,

389 (2000) .
In the case at bar,

'' ... it is undisputed that [applicant] ...

had a right--indeed, a constitutionally protected right--to provide

the jury with the mitigating evidence that his trial counsel either
failed to discover or failed to offer."
393,

120

S.Ct.

at

1513.

Williams,

529 U.S.

The United States. Supreme

Court

at
has

clearly held that mental illness should militate in favor of a

lesser penalty.
2733

See Zant v. Stephens, 462 U.S. 862, 885, 103 S.Ct.

2 7 4 7 7 7 L. Ed. 2 d 2 3 5

( 19 8 3 ) .

Additionally, evidence about

the defendant's background is relevant because of the belief, long

held by this society, that defendants who commit criminal acts that
are attributable to a disadvantaged background; or to emotional and
mental. problems, may be less culpable than defendants who have no
such excuse.

Penry v. Lynaugh , 492 U.S. 302, 322-327, 109 S.Ct.

2934, 2948-52, 106 L.Ed.2d 256

(1989).
14

':.,.

40
:.

. :

In Austin v. Bell, 126 F. 3d 843, 848-849 (6th Cir. 1997), the

Court held
that the failure of trial counsel "to investigate and
present any mitigating evidence during the sentencing
phase so undermined the adversarial process that
[defendant's] death sentence was not reliable .... [G) iven
that several of [defendant's] relatives, friends, .death
penalty experts, and a minister were available and
willing to testify on his behalf, failure to present any
mitigating evidence does not reflect a
strategic
decision, but rather an abdication of advocacy.
In Moore v.
Dist.]

State,

983 S.W.2d 15

(Tex.App.

- Houston

[14th

1998), the Court of Appeals determined that the defendant

had received ineffective assistance of counsel at sentencing when

no mitigation testimony was offered on behalf of the defendant.
Moore, 983 S.W.2d at 22.

The Court of Appeals reasoned as follows:

This court has recently held counsel is ineffective when

he fails to seek out,
investigate,
and interview
available witnesses during the punishment phase. See
Milburn v. State, 973 S.W.2d 337 (Tex.App. --Houston [14th
Dist.] 1998) . Likewise, other courts have held trial
counsel is ineffective when he fails to investigate and
present available mitigating evidence at punishment. See,
e.g., Austin v. Warden, 126 F.3d 843, 848 (6th Cir.1997)
(the failure to present mitigation evidence when several
relatives, friends, death penalty experts, and a minister
were available to testify was an abdication of advocacy) ;
Hall v. Washington, 106 F. 3d at 749 (holding defense
counsel was ineffective at sentencing when he failed to
make
a
significant
effort,
based
on
reasonable
investigation and logical argument, to ably present the
defendant's fate to the jury and to focus the attention
of the jury on any mitigating factors) ; Glenn v. Tate, 71
F.3d 1204, 1207 (6th Cir.1995) (defendant's lawyers were
inadequately prepared for sentencing phase when they did
not acquaint themselves with defendant's social history,
never spoke to any of his numerous brothers and sisters,
never examined his medical records, or talked to his
probation officer); Tucker v. Day, 969 F.2d 155, 159 (5th
Cir .1992) (counsel was ineffective when he failed to
provide any assistance at a sentencing hearing, stating,
. -'f

15

...
!.

4:1

"I'm just standing in for this one"); Kubat v. Thieret,

867
F. 2d
at
367
(substandard
argument
and
the
presentation of no evidence, despite the availability of
fifteen character witnesses at sentencing, amounted to no
representation at all); People v. Ruiz, 177 Ill.2d 368,
2 2 6 Ill. Dec . 7 91 ,
6 8 6 N. E . 2 d . 57 4 ,
58 2
( Ill. 19 9 7)
(counsel's failure to investigate and present mitigating
evidence, which a research of defendant's background
would have revealed, was representation which fell below
objective standards of reasonableness under prevailing
professional norms) .
In sum, we believe trial counsel failed to render
"reasonably -effective assistance" because he did not
investigate any poss~ble mitigation evidence,
and
therefore,_ rendered the adversarial process presumptively
unreliable at punishment. The jury had no character
evidence before it which would have humanized appellant
and offset the State's recommendation of punishment.

Moore v. State,

Case

law

investigate

983 at 23-24. 8
is

replete

and present

(Emphasis added) .

with

instances

mitigation

evidence

render counsel's performance deficient.

F.2d 351,

367

available

witnesses

where

the

at

failure

sentencing

to
can

In Kubat v. Thieret, 867

(7th Cir. 1989), defense counsel's failure to call

at

sentencing

deprived

the

defendant

of

effective assistance of counsel:

At
the post-conviction hearing,
fifteen character
witnesses testified on Kubat's behalf. None of the
witnesses were members of Kubat's family; most were
neighbors and coworkers; all were well-respected citizens
in their community; one was a deputy sheriff; and all
stated that they would have testified on Kubat's behalf
at the sentencing hearing if they had been asked. Despite

The Moore case was decided under the Ex parte Duffy

standard, which did not require a showing of prejudice. Cf.
Hernandez v. State, 988 S.W.2d 770, 772-773 (Tex.Crim.App. 1999).
However, the reasoning of the court clearly found that counsel's
representation was prejudicial and indeed,
many of the decisions
relied upon by the Court utilized the Strickland standard.
16

the availability of this impressive array of character

witnesses, Kubat's counsel contacted only two of the
fifteen before trial and called none of the fifteen to
testify at the sentencing hearing.
Kubat, 867 F.2d at 366-67.
As the instant case demonstrates, Applicant's mother had an
army of witnesses willing and able and actually

pres~nt

in the

courtroom to testify on Applicant's behalf; defense counsel told

her to pick the best six, which she did.

(Appendix 5) .

Then,

without any explanation whatsoever, after the State finished the

presentation of its punishment evidence, defense counsel rested and
presented no witnesses.
In Milburn
Houston

[14th

considered

the

v,

Dist.]

State,

15

2000),

failure

to

S.W.3d
the

present

267,

267-70

Fourteenth
any

(Tex.App.

Court

mitigation

of

Appeals

evidence

at

punishment under the Strickland standard 9 in a case involving a

defendant who was convicted of the first degree felony offense of

Milburn had originally been decided under the Duffy

standard, See Milburn v. State, 973 S.W.2d 337 (Tex.App. -- Houston
[14th Dist.] 1998), but was vacated and remanded in part, Milburn
v. State, 3 S.W.3d 918 (Tex.Crim.App. 1999), and on remand the
Court of Appeals considered the ineffectiveness claim under the
Strickland standard.
Applicant would also note, as Justice Marshall pointed out in
his dissent in Strickland, that failure to provide effective
assistance could constitute an independent due process violation,
with or without prejudice to the defendant.
See Strickland, 466
U.S. at 711, 104 S. Ct. at. 2077 (Marshall, J., dissenting) ("Every
defendant is entitled to a trial in which his interests are
vigorously . and conscientiously advocated by an able lawyer. A
proceeding in which the defendant does not receive meaningful
assistance in meeting the forces of the State does not, in my
opinion, constitute due process.")
... :.;; ..
~

17

... -.

possession of 400 grams or more of cocaine, with intent to deliver.

To begin its discussion of ineffective assistance at the punishment
phase, the Court noted:
"The sentencing stage of any case, regardless of the
potential punishment, is 'the time at which for many
defendants the most important services of the entire
proceeding can be performed.'" Vela v. Estelle, 708 F.2d
954, 964 (5th Cir.1983), cert. denied, 464 U.S. 1053, 104
S.Ct. 736, 79 L.Ed.2d 195 (1984). Where the potential
punishment is life imprisonment, as in the instant
matter,
the
sentencing proceeding takes
on added
importance. See id.
Milburn,

15 S.W.3d at 269.

(Emphasis added) .

The Court noted that in Milburn's case,

"appellant's trial

counsel was ineffective by .failing to investigate and interview

potential

punishment

willingness

of

witnesses,

several

of

despite

appellant's

co-workers to testify on his behalf."

the

availability

relatives,

Milburn,

friends

and
and

15 S.W.3d at 269.

This determination was made notwithstanding the fact that trial

counsel alleged his failure

to interview or call any witnesses

during the punishment stage was

"trial strategy. "

Milburn,

S.W.3d at 270:
He attributed his failure to interview or call any
witnesses during the punishment stage to trial strategy.
Counsel explained that in his experience juries don't
generally place much weight on the testimony of family
members. We rejected the argument that, in this case, the
failure to call witnesses at the punishment stage could
be considered sound trial strategy. See Milburn, 973
S.W.2d at 344. We noted that counsel can only make a
reasonable decision to forego presentation of mitigating
evidence after evaluating available
testimony and
determining that it would not be helpful. See id. at
.,. ,',i-''f-..

18
,I

15

345-46.

Here,
counsel
admitted
he
had
neither
investigated nor evaluated available punishment evidence.
As a result of counsel's lack of preparation, we
concluded that the jury had no mitigation evidence before
it
to
offset
appellant's
probation
record,
the

prosecutor's argument that appellant had abused the legal

system and had not
been rehabilitated,
and his
recomm~ndation of thirty years' imprisonment. See jd. at
346. Accordingly, we held that the first prong of
Strickland had been met by showing that trial counsel's
performance at the punishment phase of appellant's trial
fell below the professional norm of reasonableness. See
id.
Milburn, 15 S.W.3d at 270.

(Emphasis added).

In undertaking its Strickland evaluation, the Court of Appeals

then considered the second prong--the prejudicial impact of the
deficient performance received by Milburn.

As the Court stated,

"we must determine whether there is a reasonable probability that

the jury's assessment of punishment in this case would have been
less severe in the absence of- counsel's deficient performance."
Milburn,

15 S.W.3d at 270.

The Court further noted:

The sentencing process consists of weighing mitigating

and aggravating factors, and making adjustments in the
severity of the sentence consistent with this calculus.
See Vela, 708 F. 2d at 965. In this case, appellant's
trial counsel presented no evidence of mitigating factors
for the jury to balance against the aggravating factors
presented by the State. Indeed, appellant's trial counsel
performed no investigation into any possible mitigating
factors and failed to contact even a single family member
or friend, despite the availability of such mitigation
evidence. As noted in our discussion of the first prong
of Strickland in our previous opinion, there were no
fewer than twenty witnesses available to testify on
appellant's behalf. These witnesses would have testified
that, inter alia, appellant was a good father to a child
of special needs and that he was an outstanding employee.
See Milburn, 973 S.W.2d at 343. This evidence would have
provided some counterweight to evidence of bad character
19

......r

4-5

which was in fact received by the jury See Blake v. Kemp,

758 F.2d 523, 535 (11th
Cir.1985), cert. denied, 474
u. s . 9 9 8 1 0 6 s . Ct . 3 7 4 8 8 L . Ed . 2 d 3 6 7 ( 19 8 5 ) .
I

Milburn, 15 S.W.3d at 270-71.

In

reaching

counsel's

tailure

its
to

decision
present

that
any

Milburn
mitigation

was

prejudiced

evidence

at

by
the

sentencing phase, the Court held:

We find that appellant has demonstrated prejudice in this
case, even though it is sheer speculation that character
witnesses in mitigation would have in fact favorably
influenced the jury's assessment of punishment. See
Pickens v. Lockhart, 714 F.2d 1455, 1467 (8th Cir.1983).
Counsel 's lack of effort at the punishment phase of trial
deprived appellant of the possibility of bringing out
even a single mitigating factor. Mitigating evidence
clearly would have been admissible. The jury would have
considered it and possibly been influenced by it. See id.
We conclude that a reasonable probability exists
that appellant's sentence would have been less severe had
the
jury balanced the aggravating and mitigating
circumstances, particularly in light of the fact that the
jury ultimately sentenced appellant to a term of
imprisonment in excess of that requested by the State.
[footnote 1 below in footnote J].
Therefore, appellant
has shown that he was actually and substantially
prejudiced by his trial counsel's complete failure to
search out and present any mitigating character evidence.
See, e.g., Blake, 758 F.2d at 534-35; Ex parte Felton,
815 S.W.2d 733, 737 n. 4 (Tex.Crim.App.1991)
Milburn, 15 S. W. 3d at 271. 10

(Emphasis added) .

10

The Court of Appeals relied upon a wealth of precedent 1n

reaching its decision, which is recounted here:
Several courts have reached the same result under similar
circumstances. See Dobbs v. Turpin, 142 F. 3d 1383,
1389-91 (11th Cir .1998) (counsel's complete failure to
investigate and present any mitigating evidence at the
punishment phase was prejudicial where such evidence was
available) ; Smith v.
Stewart,
14 0 F. 3d 12 6 3,
(9th
Cir.1998) 1 cert. denied, 525 U.S. 929, 119 S.Ct. 336, 142
L.Ed.2d 277
(1998)
(counsel's complete failure to
investigate and present any mitigating evidence at the
20
\~;

In the case sub judice, although defense counsel attempted to

raise the specter of

self~defense

in an effort to convince the jury

that the shootings were legally justified, that strategy, with all
respect, was doomed from its inception because of the absence of
credible evidence establishing that the use of deadly_force was
legally warranted.

No one testified that the complainants were in

possession of weapons of any kind or that any one of them made a

furtive movement which could reasonably suggest that a weapon was

punishment phase was prejudicial where such evidence was

available); Austin v. Bell, 126 F.3d 843, 848 (6th
Cir.1997), cert. denied, 523 U.S. 1079, 118 S.Ct. 1526,
140 L.Ed.2d 677 (1998) (failure to present mitigation
evidence where several relatives, friends, death penalty
experts, and a minister were available to testify was an
abdication of advocacy) ; Hall v. Washington, 106 F. 3d
742, 749 (7th Cir.1997), cert. denied, 522 U.S. 907, 118
S.Ct. 264, 139 L.Ed.2d 190 (1997)
(holding defense
counsel s performance ineffective and prejudicial at
sentencing where he failed to make a significant effort,
based on reasonable investigation and logical argument,
to ably present the defendants fate to the jury and to
focus the attention of the jury on any mitigating
factors);
Glenn v. Tate,
71 F.3d 1204,
1207
(6th
Cir.1995), cert. denied, 519 U.S. 910, 117 S.Ct. 273, 136
L.Ed.2d
196
(1996)
(defense
counsels
inadequate
preparation for sentencing phase was prejudicial where
they did not acquaint themselves with defendants social
history, never spoke to any of his numerous brothers and
sisters, never examined his medical records, or talked to
his probation officer); Tucker v. Day, 969 F.2d 155, 159
(5th Cir .1992) (prejudicial impact where counsel failed
to provide any assistance at a sentencing hearing,
stating, 11 I 1 m just standing in for this one 11 ) ; Kubat v.
Thieret, 867 F.2d 351, 367 (7th Cir.1989), cert. denied,
493 U.S. 874, 110 S.Ct. 206, 107 L.Ed.2d 159 (1989)
(substandard argument and the presentation of no evidence
was prejudicial where fifteen character witnesses were
available to testify at the sentencing hearing; and it
amounted to no representation at all) .
Milburn, 15 S.W.3d at 271,n. 1.
21

being

reached

for

moments

before

the

Applicant

opened

fire.

Although the Applicant had the benefit of an "apparent danger"

instruction in the court's charge to the jury with respect to the
use of deadly force
therefore,

~he

in self -defense,

he did not

testify,

and,

jury did not hear any testimony or receive-evidence

from any source relative to his thought process and perception of

the events
With

up to the very moment the trigger was pulled.

leadin~

defense

counsel

evidence of any kind at

deciding

to

refrain

from

adducing

the sentencing phase in mitigation of

punishment, the jury was deprived of a. context in which to judge

the Applicant's conduct in shooting five unarmed people.

Once the

jury rejected the defense's claim that the Applicant had acted in
self-defense--as it was surely destined to do--no information of
any kind was provided at the sentencing phase to help explain why
the

Applicant

complainants,

responded
in

to

the

threatening

the manner in which he

did.

conduct
As

of

result,

the
no

evidence or testimony of any nature was offered in support of a

lesser sentence.
The Applicant,
shootings,

had a

who was 19 years of age at the time of the

history of mental

illness and had been under

psychiatric care for a number of years.

(Appendix 1, 2, 3, and 5).

He had been hospitalized on two separate occasions for psychiatric

reasons and had been prescribed a host of medications most of which
were anti-psychotic.
Medical

and

(Appendix 1, 2, 3, and 5).

hospital

records

in

the

possession

of

the

prosecution--which were ultimately tendered to defense counsel-22

confirmed the two psychiatric hospitalizations and treatment by Dr.

Garb.

In addition, Elizabeth St. Aubin was exceedingly well versed

in the history of her son's mental illness and the corresponding

psychiatric and behavioral issues that she and her family had been
dealing witq.

(Appendix 5).

She provided defense counsel with a

host of documents, including copies of the aforementioned hospital

recor~s,

and medical

as well as pertinent information chronicling

the mental disintegration of a young man who, for most of his life,
excelled as an athlete,

made good grades,

people, and did good deeds.

got

along well with

(Appendix 5) .

While it is true that included in the medical and psychiatric

records

were

aggression,

entries

addressing

misbehavior,

isolated acts of violence,

acting

out,

and other indications of

anti-social behavior on the part of the Applicant,

it is equally

true that these same records irrefutably revealed the presence of

severe mental illness.

The Applicant had a documented history of

paranoia and psychosis.

As Dr. Ronald Garb,

treated the Applicant confirms,

to

such

an

extent

that

he

a psychiatrist who

"[a]t times, Keith's paranoia was

became

delusional. "

(Appendix

2) .

Furthermore, Dr. Garb is of the opinion that evidence of "sporadic

family violence in (applicant's) past is easily explained by his
severe mental illness."

(Appendix 2) .

Dr. Seth Silverman, a forensic psychiatrist who has examined

and evaluated the Applicant, is of the opinion that the Applicant
was suffering from paranoid delusions shortly before the shootings;
moreover,.

he

believes

that

the
23

Applicant's

"reality

testing

deteriorated

to

the

point

where

his

perceptions

impaired and he was intermittently psychotic."

were

grossly

(Appendix 3).

Dr.

Silverman is further of the view that the Applicant's conduct would

not have occurred on February 21, 1998, had his mental state not
been

influen~ed

Garb and Dr.

by his severe psychiatric illness.

(Id.)

Both Dr.

Silverman are of the opinion that evidence of the

Applicant's

documented

paranoia

and

underlying

severe

mental

illness would have been helpful to the jury at the punishment phase
in understanding the Applicant's mind set and why he acted the way
he did with respect to the events

for which he was convicted.

(Appendix 2 and 3).

As the affidavit of Mr.

Richard

H~

Burr,Esq.,

a nationally

renowned expert in penalty phase representation attests, with the

defense resting behind the state and presenting no evidence at
sentencing,

"[t] he jury could not have known that Mr.

perceived the

St. Aubin

situation in Galveston life threatening-which no

reasonable person would have seen that way-because he was mentally

ill.

Thus,

the

jury could not have known that mental

illness,

rather than a defect in character, was behind this tragic event."

(Appendix 4) .
For

defense

counsel

to

conclude,

especially

without

the

benefit of a psychiatric evaluation, that there was nothing to be

gained by delving into the Applicant's psychiatric past, "does not
reflect

advocacy."

strategic

decision,

but

rather

an

abdication

of

Austin v. Bell, 126 F.3d 848-849.

,..-,.,.

24

so

In light of applicant

receiving ineffective assistance of

counsel, he is entitled to relief.

ISSUE NUMBER THREE
THE JURY INSTRUCTION AT THE PUNISHMENT PHASE OF APPLICANT'S TRIAL
VIOLATED DUE PROCESS OF LAW, AS GUARANTEED BY THE FIFTH AMENDMENT
TO THE UNITED STATES CONSTITUTION, . AND DUE COURSE QF LAW, AS
GUARANTEED BY ARTICLE I, SECTIONS 13 AND 19 OF THE TEXAS
CONSTITUTION, BECAUSE CONTRARY TO WHAT THE JURY WAS TOLD, 11 GOOD
CONDUCT TIME 11 CANNOT BE COUNTED TOWARDS PAROLE ELIGIBILITY OR A
RELEASE DATE FOR THE OFFENSE THAT THE APPLICANT WAS CONVICTED OF
AND CONSTITUTED AN INCORRECT STATEMENT OF THE LAW THEREBY
MISLEADING THE JURY.
The jury charge in applicant's case contained the following
instruction, pursuant to Tex. Crim. Proc. art. 37.07 4(a):
In the penalty phase of the trial of a felony case in
which the punishment is to be assessed by the jury rather
than the court, if the offense of which the jury has
found the defendant guilty is listed in Section 3g (a) (1},
Article 42.12, of this code or if the judgment contains
an affirmative finding under Section 3g(a) (2), Article
42 .12, of this code, unless the defendant has been
convicted of a capital felony the court shall charge the
jury in writing as follows:
Under the law applicable in this case, the defendant, if
sentenced to a term of imprisonment, may earn time off
the period of incarceration imposed through the award of
good conduct time. Prison authorities may award good
conduct time to a prisoner who exhibits good behavior,
diligence in carrying out prison work assignments, and
attempts at rehabilitation. If a prisoner engages in
misconduct, prison authorities may also take away all or
part of any good conduct time earned by the prisoner.
It is also possible that the length of time for which the
defendant will be imprisoned might be reduced by the
award of parole.
Under the law applicable in this case, if the defendant
is sentenced to a term of imprisonment, he will not
become eligible for parole until the actual time served
equals one-half of the sentence imposed or 30 years,
whichever is less, without consideration of any gopd
conduct time he may earn. If the defendant is sentenced
25

51

...
to a term of less than four years, he must serve at least
two years before he is eligible for parole. Eligibility
for parole does not guarantee that parole will be
granted. It cannot accurately be predicted how the parole
law and good conduct time might be applied to this
defendant if he is sentenced to a term of imprisonment,
because the application of these laws will depend on
decisions made by prison and parole authorities.
You may consider the existence of the parole law and good
conduct time. However, you are not to consider the xtent
to which good conduct time may be awarded to or forfeited
by this particular defendant. You are not to consider the
manner in w~ich the parole law may be applied to this
particular defendant.
(CR - 98CR0358 - 267; CR - 98CR0359 - 118; CR- 98CR0360 - 121; CR
98CR0361

111;

CR -

98CR0362

12 0 ;

CR -

9 8 CR 0 3 6 3

109) .

(Emphasis added) .
In Jimenez v. State, 32 S.W.3d 233

(Tex.Crim.App. 2000), the

Court of Criminal Appeals considered the identical instruction and

the issue of whether the
charge was erroneous, since an award of good conduct time
would not count toward his release on mandatory
supervision because his offense is listed in former
Article 42 .18, section 8 (c) of the Code of Criminal
Procedure. The First Court of Appeals agreed 'that the
charge on the accumulation of good-conduct time, as given
in this case, was error.' See Jimenez v. State, 992
S.W.2d 633, 638 (Tex.App.--Houston [1st Dist.] 1999).
Jimenez,

32 S.W.3d at 234-35.

mandatory
convicted.

supervision

due

Applicant is also ineligible for

to

See Tex.Gov't Code

the

offense

for

which

he

was

508.149.

In Jimenez, the Court did not reach the 1ssue of whether this
was an erroneous instruction, instead determining that the Court of
Appeals had applied the appropriate harm analysis.

However, former

26

52

Presiding

Judge

McCormick

addressed

the

due

process

problem

presented by such an instruction:

The trial court submitted the statutorily mandated
parole charge without any objection from appellant. This
charge generally instructs a jury on parole matters but
also instructs the jury not to consider "the manner in
which the parole law may be applied to this particular
defendant."

This parole charge, among other things, instructs

the jury that a defendant could earn good conduct time
off the periqd of his incarceration. This portion of the
parole charge, however, is misleading with respect to
defendants such as appellant because they are ineligible
to earn good conduct time off the period of their
incarceration

****

This Court has held that an accurate parole charge does

not violate separation of powers or due process and due
course of law constitutional guarantees. See Muhammad v.
State, 830 S.W.2d 953, 955-56 (Tex.Crim.App.1992); Oakley
v. State, 830 S.W.2d 107, 109- 112 (Tex.Crim.App.1992).
These cases do not dispose of the constitutional issues
presented here since a portion of the parole charge
provides the jury with inaccurate information with
respect to defendants such as appellant.
Jimenez,

32

S.W.3d

at

239-40,

and

3.

(McCormick,

P.J.

concurring) .
Presiding Judge McCormick was prescient in his declaration
that'' [t]he Court's opinion merely postpones deciding this issue."
Jimenez, 32 S.W.3d at 239.

In Luquis v. State, 997 S.W.2d 442, 443

(Tex.App. - Beaumont 1999), the Court of Appeals considered whether

the parole charge was unconstitutional
it was not.

Luquis,

ultimately determining that

997 S.W.2d at 443.

On June 28,

2000,

the

Court of Criminal Appeals granted the petition for discretionary

review filed by Luquis on the following grounds:
.,..;r..

27

S3

--

1. Is it Error to Instruct the Jury on the Effect of

Good-conduct Time on the Amount of Time That Will Be
Served in Prison, as Required by Article 37.07, Section
4(a), Code of Criminal Procedure, When Appellant Is Not
Eligible to Have Good-conduct Time Counted Toward.His
Parole Eligibility Date or Release Date?
2.

Is Article 37.07, Section 4 (a}, Code of Criminal

Unconstitutional under the Due Course of Law
Provisions of the Texas Constitution as Appl:bkd to
Appellant, in That it Requires Instruction on Goodconduct Time That Could Be Misleading to the Jury in a
Case in Which Good-conduct Time Does Not Affect Parole
Eligibility or Release Date?
Proced~re,

3. Is Article 37.07, Section 4 (a), Code of Criminal

Procedure, Unconstitutional under the Due Process Clause
of the Fourteenth Amendment to the U.S. Constitution as
Applied to Appellant, in That it Requires Instruction on
Good-conduct Time That Could Be Misleading to the Jury in
a Case in Which Good-conduct Time Does Not Affect Parole
Eligibility or Release Date?
4. What Is the "Law Applicable to the Case" That Is
Required to Be in the Jury Charge by Article 36.14, Code
of Criminal Procedure: Does Article 37.07, Section 4 (A)
Make Good-conduct Time and Parole Part of the Law
Applicable to the Case?
5. If it Is Error to Charge the Jury as Required by
Article 37.07, Section 4(a), Code of Criminal Procedure,
in a Case. Where Good-conduct Time Does Not Count Toward
Parole Eligibility or Release Date, What Harm Analysis
Applies?
In the instant case, Applicant's right to due process and due
course of law was violated by a misleading and inaccurate
the

effect

of

good conduct

time

toward

jury

instruction as

to

sentence, when,

in fact, Applicant was not eligible to have good

conduct time effect parole eligibility or his. release date.

his

The

Applicant suffered egregious error due to the assessment of maximum

sentences by the jury.
Relief should be granted.

28

S4

'

WHEREFORE, PREMISES CONSIDERED, it is respectfully requested

that all relief be granted and specifically, that an evidentiary
hearing be conducted and that findings of fact and conclusions of
law be entered recommending that the Applicant be afforded a new
trial.
Respectfully submitted,

'

~ ~=T-,-=J=R:-.----00
/___./

BE)mETT & SECREST, L.L.P.

-8'68 Travis Street, 24th Floor
Houston, Texas 77002
(713)

757-0679

J~LLI

State Bar No. 00791195

808 Travis Street, 24th Floor
Houston, Texas 77002
(713)

757-0684

Attorneys for Applicant,

KEITH MICHAEL ST. AUBIN

29

-t:"s
...':

. ~

IN THE lOTH DISTRICT COURT

OF GALVESTON COUNTY, TEXAS
EX PARTE
KEITH ST. AUBIN

NO.
NO.
NO.
NO.
NO.
NO.

98-CR-0358
98-CR-0359
98-CR-0360
98-CR-0361
98-CR-0362
98-CR-0363

ORDER

'

Applicant's request for an evidentiary hearing is GRANTED.

It

is hereby ordered that a hearing will be conducted on

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

2001.

SIGNED this ___ day of

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

2001.

HON. DAVID E. GARNER

District Judge

30

,...- ~ ;

~.

56

r--- .

r----

r---- ..

r--

r-

APPENDIX TO
APPLICATION FOR WRIT OF HABEAS CORPUS
EX PARTE KEITH ST. AUBIN
TRIAL CAUSE NO. 98CR0358
TRIAL CAUSE NO. 98CR0359
TRIAL CAUSE NO. 98CR0360
TRIAL CAUSE NO. 98CR0361
TRIAL CAUSE NO. 98CR0362
TRIAL CAUSE NO. 98CR0363
GALVESTON COUNTY, TEXAS
FIRST COURT OF APPEALS
CASE NO. 01-98-01318-CR
CASE NO. 01-98-01339-CR
CASE NO. 01-98-01340-CR
CASE NO. 01-98-01341-CR
CASE NO. 01-98-01342-CR
CASE NO. 01-98-01343-CR
HOUSTON, TEXAS ;

57

APPLICATION FOR WRIT OF HABEAS CORPUS

EX PARTE KEITH ST. AUBIN

TABLE OF CONTENTS
.APPENDIX

Medical Records
Medical Records of Jail
Medical Records of West Oaks Hospital
Medical Records of Ronald Garb, M.D.

Affidavit of Ronald Garb, M.D.

Affidavit of Seth W. Silverman, M.D., P.A.

Affidavit of Richard H. Burr, III

Affidavit of Elizabeth St. Aubin

58

'

:,

59

':- ..,

,(:

CORRECTION.-\L 1VJEDICAL SERVICES

BEHAVIOR-\L OBSER\'ATIO~ A;\0 REFERR-\L

Inmatt: s name!

:)..\::

~-_L~:..=...c=-

OBSERVATION REPORT: (circle)

Inmatt: is:
0iot t:ating
Not kaving cell

Nor skeping

Appearance:

Speech:

Dressed inappropriately

Loud
Over-talkative

Screaming
Talks to self
~
Makes little sense
Talks about mutilating or killing self

Behavior:

Inappropriate
Sexual Behavior
Attitude:

~
Pacing :....

Threatt:ning staff & inmates

Tt:nse
Non-responsive
Rigid
Not enting
Not skcping normally
~laking threats
Not cooperative
Self harm
Suicidal
Crvino
Weird
. "'
Smenring feces l)f urinating on sdf. staff or t11JOr

Exposing self

Other sexual i.nvolvement

Aggressive
Bc:lligerl!nt

Assaultive
Negative

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

1~
II

Reron<J b

tv: C2!~ ~ .=:;;;D~ate~d~~~l8_=4=~~J==="=T~im~e~I~==3=0====il

Rcvir,;\\cU tn

.,~~~=---~-==~=~"-=-

Date
.

T1mc

1~2

R. H. Mond,hine. M.D.
8300 Wateka
Houston, Texas 77036
713-771- H1J

September i 6, 1998

Dr. Hutton
.\1:edical Unit
Galveston County Jail
715 19u. Street
Galveston, Texas 77550

Dear Dr. Hunor._

r have been Keith St. Aubin. s physician since his birth 5-23-78. He is allergic to
Pecicillin and Erythromycin. lt is my understanding that he currently has a :>evere case of
acnt which ha:s not responded to topical treatment. I have found in the past that acne
responds weil to antibiotics in th~Tetracycline family. Your consideration ofthis matter
in regard to Keith wculd be greatly appreciated
Your truly.

k-fL. rv-~~
R. H. Ylondshine M.D.

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.
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COMMENTS:

---------

129

_______r--

--.. -----I

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=
CORRECTIONAL MEDICAL SERVICES
HEALTH SERVICES REQVEST FORivi
Prine Name: ST. tJ..U. ~10,

K<i.\ \1\

Date of Request:

1,

l~

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. Locauon:.-,,-=.
3~
Date o fB .1rth: - - - - - - - Housmg
...- - - Narure of problem-or request: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

I consent to be treated by health staff for the condition described.

'\?~I ~?-,.._~.-.-' ~
-SkiN A TIJRE

PLACE THIS SLIP IN MEDICAL BOX OR DESIGNATED AREA

DO NOT WRITE BELOW THIS AREA
*****************************************************************

HEALTH CARE DOCUMENTATION

Subjective:

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130

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SIGNATURE
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****************************
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SIGN'ATURE

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DO NOT WRITE BELOW THIS AREA

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SIGNATURE
PLACE THIS SLIP IN MEDICAL BOX OR DESIGNATED AREA
DO NOT WRITE BELOW THIS AREA

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r

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WEST OAIS PSYCHIATRIC HOSPITAL

6500 HORW~OOD DRIVE
HOUSTON, TX
UEN'T .'tAUE
S! AUBIN, H:ITH
75SBOO
;JATIE.NT

AMBULATORY REGISTRATION
7707+- 0000

A HEALTHCARE INTERNATIONAL FACILITY

TELEPHONE

~,

~IUUS~R

AFC

CFC

sao sao

HJ-771-HH
I.ITY

COUNTY

5T CNTR'f'

HOUSTOH

6Zll LUGARY
Y

18Y

TX

JA fE C' BIRTH

:OF.!

SQCIAL SEr.uR!TY ',Q

05/ZJ/1978

~lEAAEST

RELA fiVE .,u,l

ST AUBIN, lEN
ST AUBIN, lEN
AOORESS

6Z11 LUGARY

ADM OR NO

713- Z7~- ZOOO

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J.Qt.UIT:NGTII.IE

03/11/97

8:00

713- ZH 3566
Zl

77036-

TX

GARB KD, RONALD

TELEP>!ONE

GARB KD, RONALD

.t.OM t.AST 60 OAVS

TAAHSFEA~O

AR

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~ITENOINGOOCTOANAME

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TEXAS INSTRUMENTS

77035-

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" GUARANTOR TELEPHONE

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FAT Z66-8Z-ZS6Z 7,.t3-771-HH
CITY
HOUSTON

GUARANTOR NAME

oooaaJ

1tP

::>l TIF..H OCCUP.HION

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CODE NO.
DSM Ill

(FIRST DIAGNOSIS PRIMARY UNLESS NOTED)

CODE NO .
lCD -9

-dYJ.-36

AXIS 1:

~()(3. q~

,3\\
AXIS II:

AXIS Ill:.

(PHYSICAL)

AXIS IV:

AXIS V:

LEVEL OF FUNCTIONING

PROCEDURES:

; JISCMA!JG.:: :)15P0Sf7"10N

CONDITIO~!

ON DISCHARGE

IMPROVED
NOT TREATED

NOT IMPROVED
AMA YES
NO

TRANSFERRED:
OTHER HOSPITAL
OTHER

EXPIRED

-48HR
48 HR

CORONER .
AUTOPSY YES

NO

I CERTIFY THAT THE NARRATIVE DESCRIPTION OF THE PRINCIPAL AND SECONDARY DIAGNOSIS AND THE MAJOR PROCEDURES PERFORMED ARE ACCURATE
COMPLETE TO THE BEST OF MY KNOWLEDGE.

DATE

AITE~OING PHYSICIAN SIGNA TUAE

,,-_

89

WEST OAKS HOSPITAL

PATIENT NAMEs

ST. AUBIN, KEITH

MRf: 88-43

ATTENDING PHYSICIAN: RONALD GARB, M.D.

AUTHOR 01' REPORT:

JULIE SENGSTACKEN, R.N.

DATB OF ADMISSION:

3-11-97

DATB 01' DISCHARGE:

3-13-97

CLINICAL RESUME:_
REASON FOR ADMISSION:
This 18 year old, white male was admitted
to West Oaks Hospital inpatient unit for increasing agitated and
aggressive behavior along with marijuana and alcohol abuse. He was
initially treated on the inpatient unit and was transitioned to the
residential program and at this time is transitioned to the day
treatment program to continue treatment in a lower level of care.
SIGNIFICANT FINDINGS:
The patient had a history and physical as
well as laboratory studies done during the inpatient stay. Please
see previous chart for details.
COURSE AND PRQGRESS OF TREATMENT: The patient was admitted to the
day treatment program and oriented to unit guidelines and treatment
components. The patient was involved in family therapy during this
stay, at which time he argued with his parents about wanting to
visit a friend.
Their wishes for patient to continue at Lifeway
and intensive outpatient program were discussed and were acceptable
to both patient and parents. His mood was irritable and he had
oppositional defiant behavior on the unit. He was guarded but less
explosive. On 3-14-97, the patient's mother called to. state that
patient got into an argument with his father at the home and ended
up pushing the father into the wall, causing holes in the wall. The
mother and the youngest child fled the house for safety and
patient's parents were worried and ambivalent about his discharge
status. On 3-14-97, the patient was discharged due to noncompliance
with the treatment program. Patient agreed to stay at his aunt's
house temporarily and was negative upon discharge and denied the
seriousness of his issues.
FINAL ASSESSMENT:

As above.

RECOMMENQATIONS AND ARRANGEMENTS FOR fURTHER TREATMENT:

Patient
was discharged to the care of his aunt, Mary Jane, here in Houston.
He was to follow up in the office of Dr. Ron Garb for medication
management and to continue seeing his individual therapist. He was
discharged on Depakote 250 mg. 2 at bedtime, Effexor 75 mg. b.i.d.
~nd Risperdal 1 mg.
each morning and 2 mg. at night. He was
discharged on a regular diet. The patient's parents were encouraged
PAGE 1 of 2
DIS~GB

S~Y

WEST OAKS HOSPITAL

MRf: 88-43

ST. AUBIN, KEITH

to attend Alanon and were invited the parents' support .group at

West Oaks Hospital. Patient stated that if his muscles got sense,
he had thoughts of frustration and irritability, he would call his
father or.his therapist.
FINAL DIAGNOSES:
AXIS I

AXIS
AXIS
AXIS
AXIS

II
III
IV
V

Marijuana dependence
Alcohol dependence
Depressive disorder, NOS
Oppositional defiant disorder
Sociopathic traits
None
Moderate
Discharge GAF.: 48

RG/js:sj
D: 5-4-97
T: 5-9-97

PAGE 2 of 2
DISCHARGE

SUMMARY

91
f.

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' z.l"ospital
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AFTERCARE HOSPITAf,

PATIENT NAME

3 1

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orscHARGE DATE: __~~--~----~(--~-------------------

social)

E.

Discharge Medications/Patient Instructions: (May attach a copy of medication

side effect stickers and inc~ude dietary considerations)
Comments/Side Effects

H:

Date
Original to be placed in chart, copy to be given to patient.
Fonn #178

REV. 6/94

"Subsidiary ofHcalthcare America, Inc. Affiliated with The Brown Schools"

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DESCRIPTIVE CHARTING INCLUDES IN BEHAVIORAl.. TEAMS .THE PATIENTS STATUS. THERAPEUTICINTEAVENTION,

INTERVENTIO~ AND PlAN, NURSING NOTES MUST AEI'LECT THE NURSING PAOOAESS (ASSESSUENT; PLANS. INTERVENTION
EVAlUA TIONI
.

q9

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1419&000 ARE,:tl~rOPiii'-~1
WEST.OAKS
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SB

Sm1thKI1ne Beecham
Clinical Laboratories

CENTRAL
.TIME
EPORT STATUS

JG ABUSE PANEL
t-:THANOL

*
*
*

10-50 +

IF

SPECIMEN WAS RECEIVED WITHOUT .CHAIN OF CUSTODY AND MAY NOT

HAVE BEEN HANDLED AS A LEGAL SPECIMEN.
RESULTS SHOULD BE
USED FOR MEDICAL PURPOSES ON~,:\AND NOT FOR ANY LEGAL OR
EMPLOY.MENT EVAL-uAT-IVE PURPOS~..:.,;

AMPHETAMINE&-- -
(1000 ng/mL SCREEN>
BARBITURATES
-~
~ENZODIAZEPINES

METABOLITES
MARIJUANA METABOLITES
C50 ng/mL SCREEN!
1"1ETHADONE
METHAQUALONE
OPIATES
PHENCYCLIDINE
J:.'ROPOXYPHENE
qLCOHOL, ETHYL <U>
~OCAINE

~:~W:~
NEGA:fu'116~
NEGATIVE
NEGA.TIV.E
NEGATI.VE
NEGATIVE
NEGATIVE.

NEGA:Ti.V~>
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NEGA'h.:<)it

NE~T,t~.

*
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REPOfH CONTINUED ON

R~f~~ence
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P;AGE

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footnote #1

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14196000 AREfiJ.*titlfe/STOP: 8031000

WEST OAKSHO~STON
6500 H
HOUSTON~

GINGER
.
FAX # 7

~, Sm1thKI1ne Beecham
~U Clinical Laboratories

NAME

CENTRAL
TIME
REPORTSTATUS

i".ootnote

Iii-

THE SUBMITTED URINE SPECIMEN WAS,TESTED AT THE LISTED CUTOFFS &

CONF I R~1ED BY A SECOND I NDEPENDENJ: CHEMICAL METHOD .
.. .:~i::::/>

DRUG CI:.:ASS---

INIT:i.'A'(' Tt!ST

. LEi.i.EL
. ..
.

..

----~----

i~tfi~~i~~L

AMPHETAMINES
BARB I TURA'fES: BENZODIAZEPINES
COCAINE METABOLITES
MARIJUANA METABOLITES
METHADONE
METHAQUALONE
OPIATES
PHENCYCL I 0 I NE
PROPOXYPHENE
ETHANOL
> > END OF REPORT

'

30'~:~~~~iJL

~00

ng/mL

300 riQ/~L

50

n~/mL

300 DQ/mL
300 ng/mL
300 h~/~L

25 ng.{mL
300 li:Q/mL
.02. gYd
<<

,---I

WEST OAKS HOSPITAL, INC.

CHILD - ADOLESCENT

PATIENT NAME___LK..l._.e::......:.,

~-L-h-L..-~3.L.:...t_~_A~u_~b__;_l_n_ __

.l-!i

STATEMENT BY PHYSICIAN
[hereby admit the above named patient to West Oaks Hospital Unit/Program _ _ _ _ _ _ _ __
on the basis of __ my preliminary examination/
transfer from _ _ _ _ __
hospitaL
Date

Physician Signature

Time

APPLICATION OR VOLUNTARY ADMISSION

I hereby file with t e administrator of the above name hospital this request to be admitted as a
voluntary patient and a ee to submit to the custody of the hospital for diagnosis, observation, care
and treatment until discH ged.

Patient Signature (Required fo patient 16 years

of age and over)
Date

Date

Witness Signature
STATEMENT OF
[ hereby accept t

Approv

CCEPTANCE
patient admission to West Oaks HospitaL

or Designated Employee

Time

RELEASE OF RESPONSIBILITY FOR VALU

I. the above named patient, hereby release West oaks Hospital from any responsibility for any
monies, jewelry and other items of value.
AUTHORIZATION FOR EMERGENCY MEDICAL AND DENTAL TREATMENT
L the above named patient, hereby authorize West Oaks Hospital to secure necessary emergency
medical and dental treatment. I authorize the administration of the anesthetic prescribed to carry out
the necessary emergency medical and/or dental treatment. I further authorize West Oaks Hospital
to release medical information necessary for treatment and information necessary forthe emergency
facility to file insurance or Medicare claims. This authorization shall remain in force from the date
indicated below until such time as the above named is withdrawn from West Oaks HospitaL [
understand that I an responsible for anv charges for em7,.gencv services.

>/fL/1?

Date
Sworn to me and s bscribed
before me this -::-.-""--:::-day
of
,

Patient Signature

19{(]

Notary Signature

- r:.~c 54 ~

""'

Parent/Guardian Signature
Relationship
My Commission Expires:

I)

c-2t9SQ6

,:to7
j.

r---t

i''"
!

,.----.

CONSENT FOR DAY TREATMENT

I here~y agree to be admitted to the above named hospital program for assessment, diagnosis, and
treatment until discharged.
} G
Date of Admisson
c3-:l ... (

CV0

Patie t tgnature (required for patients 16

years of age and older)

Date

Date
'

Date
CONSENT FOR OUTPATIENT TREATMENT
I hereby agree to be admitted to the above named hospital program for assessment, diagnosis, and
treatment until discharged.
Date of Admission _ _ _ _ _ _ _ _ __

Patient Signature (Required for patients 16

years of age and older.)

Date

Parent/LegaL.Guardian Signature

Date

Witness Signarure

Date

CONSENT FOR WEST OAKS ACHIEVEMENT PLACE

I hereby agree to be admitted to the above named hospital program for assessment, diagnosis. and
treatment until discharge.
Date of Admission

----------

Patient Signature (Required for patients 16

of age and older)

Date

Parent/Legal Guardian Signature

Date

Witness Signature

Date

.I have read. understand, and agree with the consents in this document and give my consent to them
from the date of each signing until final discharge from West Oaks HospitaL

c:\wp51 \forms\adoladm.frm jlw

1J~B

r--

r-1

WEST OAKS PSYCHIATRIC KOSPITAL

6500 HOHNVOOD DRIVi
HOUSTON, TX

GUEST REGISTRATION
7707+-0000

PA.TIEHT NAME

~.I,TIENT-...JMB!:R

fElEPHQ:O.E

ST AUBIH,

503084&

J1J-771-31H

lEITH

.no11;ss

A HEALTHCARE INTERNATIONAL FACILITY

...,

(.IT'

KOUSTOI~
l~l.

TX

~.\:~ (JF 31~TH

Y
18T
M ~
05/ZJ/1978
Z66-8Z-ZS6Z
~,~~S~~S~"~"E~------------------------~,~Af~HE~RS~N~A~~~------~----~~~~~~~TN<HS~RS~"WAIOOoE~N,~,.U.~F.~~~~-----------,~1

ST ,,UBIN, KEil
~EAREST REL~TIVE ~AME

ST AUBIN, [EH

q{)()U-9EO

10

RELATION

T!:LEPHONE

FAT

"713-771-9144

::MC:RGEt..C'I'

77036-

::;o:1.:.l :~f.C.:.JIIIr, ',()

~TIFICATI()I>,

NAUE

FAT

""Gu"'"'"'r"'o'"""""'u"'"e-'-------------.,.----------------....::...-,,Eo,CA;;;,oo;;;;---;:-G"'SOCJAt.=o.se""cu'"o'"'rv"'""ii-----,G"-u"""'AN""ro'"o"re"Le'"'PMON;;;;;;;e__.__________...:...____--, t.,.ERG "<!TlF Pf<!NE

ST AUB!Il, lEil
6211 LUGA!lY

FAT 266-82-2562 7)3-771-914+

CITY
HOUSTON

o\QORESS

GU-'.RAI'JTQR EMPlOY~~

;:uptQY.ER TELEPHONE

TEXAS INSTRUMEilTS
',.l.,.tE
AETNA (!X INSTRUMENTS CLAIKSJ

:::::~1',\"RY

AOt.l 0A NO

713-27+-ZOOO

AiT

0~.

"ii

J13-ZH-JS56

't13-771-91+j
SU. _COUNTY

TX

.I.OUITT!NQ DOCTOR NAME

713-ZH-3S6E
ll~

77036-

TELEPHONE

GARB MD, RONALD

708

::t...,.Q.:J

ISOLA'

EMERG ~TIF ~El

ST AUBHl, KEN

713-ZH-3566

SWK

1008

J.TTCNDtt:i DOCTOR NAWE

GARB MD, RONALD

708

.,=lEV l()f.l Cl.TE

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11.

~INAL

l.CI.'Jir.:-..o Cl7:;

l.O/)IT":'I~ ~t\:::

03/06/97

DIAGNOSIS

16:00

lS

::g:CE~71F.CJ.:;~l

',C

10\liT!~.C

C.l.:....CS.S

COMB DRUG DEP

NEC- UUSn:c

CODE NO.
DSMIII

(FIRST DIAGNOSIS PRIMARY UNLESS NOTED)

CODE NO.
lCD- 9

AXIS 1:

AXIS II:

AXIS Ill:

(PHYSICAL)

AXIS IV:

AXIS V:

LEVEL OF FUNCTIONING

PROCEDURES:

CONDITIO~!

JN DISCHARGE

I CERTIFY

IMPROVED
NOT TREATED

NOT IMPROVED
AMA YES
NO

TRANSFERRED:
OTHER HOSPITAL
OTHER

EXPIRED

~81-'R

CORONER
AUTOPSY YES

-481;1R

~0

fHAT THE NARRATIVE DESCRIPTION OF THE PRINCIPAL AND SECONDARY DIAGNOSIS AND THE MAJOR PROCEDURES PERFORMED ARE ACCURATE .A
COMPLETE TO THE BEST OF MY KNOWLEDGE
I

__ _j

~ '7E~DING PHYSICIAN SIGNATURE

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. WEST 0.\.-.:5 HOSPtTA.L

CHE:'tIC\L DEPE:'fDE::;Ct. 5.C:RHCE5
PRTR..~ T:HL'IT

PXriENt0iA..\IE;

k~\L...

CHD fiC\L 0 P. L.';D r:-:sey ASSESSi'rCD

!..

..,.CZ,~\.Q~AL,~- ~T A~.d.a\.Y)

l~'\~s DATEOFE[Rcd: 51;?.1.)1)'

rooo~.noxr:: ~f(ojq"]
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RCOV"ERY/REL!._?S HI.STOR\'

Ere.viaus .A....~AiC.~:.l..l... ar Ot.her t:-:e;J Pragr-clil Hi:::ror:;: (circle pragra.rn:i)

I ye::.. pl~e nate:

Pre~.ri=:t!S ~~o~~:-::: ::~i~~cies

Frcr::

Tc

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~

cl'-Al-4-' 0\_dcL...~.

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3 ErL~ \10 R..l...L '"P~SOlYALITY:':'.rOO OtT:IO UGHT CH_~.\GES

/.~sc:::t: from w;:r~.:::chool

7 .-l.b-ci~ lies. e..~=.::~s re~arcii!!g ~ing

~flmily/frie.'ld conric:
Ge:1e:a! artirude cha.!!g!
Dange:- to oche.r-s (hcr.iC:::W)

Loss of c::mtrd
.:l.r!e:n;Jt:S co ~;::p fui
A...-.e-~cs m .:-..::~~de fuil
..l "':"':-"if C:JrL.-7~r::~~ lOOUC using
Gtci~ ave:- y~::.: :.:.::ing behu..~ar

o~!~ons
De::r~ssiort

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Si.::;: proal~=:
.~...!:.v_! e!:\'

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Irriciii!ry
y[e:::cr: lc::i.5

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::;OCL.l..L'FA.}CTL Y CONCER"'fS
Describe:
Job/school loss or jeJ~a.~y
!?roble:ns ""ith fu.m.i1y. frie~cis
or cc-worke.--s

\Vno is impaaeci by you: usc

S'...!.~ ~ :: r! s:-:!!e!:l ava!l!b i~

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Hospital
AFTERCARE HOSPITAL

'~tiC A

PATIENT NAME:

/{e.& Sf-. CluJ.~

SO 3 OBlf- b

Addressograp~ 0 0 8 Sl I 0

s;, frMIY:N. n: r Tfl

~~~~~~~--~~~~~------~--6~Ana

DISCHARGE DATE :_---J\._3""---..-~1_I_-_'J~"J~-------wS

00 0 0
7'";

tro, RONAlD

-23-78 DOB IBY

"'"'
A.

Follow-up Treatment (Specify type, with whom, and frequency)

B.

Living Arrangements:

C.

Support

'

{Mf TA c~~~,L--"JMYr
(specify vocational, educational, social)

otr'Z

~
applicable) _____________________________________

D.

Agency/Resource

E.

Discharge Medications/Patient Instructions: (May attach a copy of medication

side effect stickers and inc~ude dietary considerations)
Effects

H:

S' aff Signature

3-1!-?7
Date
Original to be placed in chart, copy to be given to patient.
Form #178
"Subsidiary of Healthcare America, Inc. Affilialcd with The Brown Schools"

REV. 6/94

1.18

WEST OAKS HOSPITJ\t:t- b

IOQS SL

Orders For Transition To Lower Level Of Care

S':'

.. PATlENT'SNAME

~/

2. TRANSITION FROM LEVEL

J. DIET:
~-

UJJ\1{, I(1TH
G~~B HD, RO:OLD

REGULAR

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MEDICATIONS:

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AXIS II---..-..1..-------

'l&s v--H&+f-------

AXIS III-f---.:l~,;.t::=~----

Z. MENTAL STATUS EXAM (SIGNJFICt:INGS ONLY):

~~~

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,....---.

f
rml 0004

PHYSICIAN'S ORDER
ORDERED

{.

WE5T UAK.5
The Psychiatric Institute of Houston
Houston, Texas

AFTER PHYSICIAN WRITES A MEDICATION ORDER

1.
REMOVE YELLOW AND PINK COPIES
SENO YELLOW COPY TO PHARMACY PINK TO MEDICATION NURSE.
3. USE ORDERS IN SEQUENCE

2:

ORDERS

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rml 0004

The Psychiatric Institute of Houston

Houston, Texas

PHYSICIAN'S ORDER
ORDERED
DATE
TIME

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~;i-1:1

ORDERS

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AFTER PHYSICIAN WRITES A MEDICA TIDN ORDER

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REMOVE YELLOW AND PtNK COPIES
2.
SEND YELLOW COPY TO PHARMACY -PINK TO MEDICATION NURSE.
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DESCRIPTIVE CHARTING INCLUDES IN IIEHA~ORAL TERMS THe PA TII!N\"S ~TATUs\. THERAPEUTIC INTERtENTION, RESPONSE TO
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Refer.ence

> > REPORT CONTINUED ON NEXT. PAGE

<<

r-
WEST OAKS HOSPITAL, INC.

yi

PATIENT

CHILD- ADOLES::'

NAME-~~e~il~b-\-,---:::~=-..t.f---=..._____..!..lli~=b.:::..:...~t\._: ; ,._

STATEMENT BY PHYSICIA~
l hereby admit the above named patient to West Oaks Hospital Unit/Program
----------------~
on the basis of __ my preliminary examination/
transfer from -----------hospital.
Date

Physician Signature

Time

APPLICATION FOR VOLUNTARY ADMISSION

l hereby file '..vith the administrator of the above name hospital th. request to be admitted as a
voluntary patient and agree to submit to the custody of the hospita or diagnosis, observation, care
and treatm
until discharged.
-....

quired for patient 16 years

Date

of age and over)

Date

Witness Signature

Date

STATE:VIENT OF ACCEPTA.'iCE
l hereby accept the patient named above fo

Approved or Designated Employee

Date

Time

RELEASE OF RESPONSIBILI
FOR VALUABLES
l. the above named patient, here .. release West oaks Hospital from any responsibility for any
monies, jewelry and other items of value.
AUTHORIZATION FOR EMERGENCY MEDICAL Al'JD DENTAL TREATMENT
I, the above named patient, hereby authorize West Oaks Hospital to secure necessary emergency
medical and dental treatment. I authorize the administration of the anesthetic prescribed to cany out
the necessary emergency medical and/or dental treatment. I further authorize West Oaks Hospital
to release medical infonnation necessary for treatment and infonnation necessary for the eme1:1~~-_,
facility to file insurance or Medicare claims. This authorization shall remain in force from t
.,~
indicated below until such time as the above named is withdrawn from \Vest Oaks Hos
understand that I an responsible for any charges for emer~cy se~es. ~
fit_~~

im:
lta::I:re

) ]ll ~ 1

Date
"Sworn to me and subscribed

=-kelltJ,..
~
atient Signature

ci~ ~3

~~ 7Q

~_..,__da~
--t-...___...-"""'-'""+"--'\-'

M.

3~ 0~

Relationship
~~t
My Commission Expires bL"---'----~--'-(..;;_f

Notary Signature
...
": . ~9

#~,

rCONSENT FOR DAY TREATMENT

l hereby agree to be admitted to the above named hospital program for assessment, diagnosis, and
treatment until discharged.
Date of Admission

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

Patient Signature (required for patients 16

years of age and older)

Date

Parent/LegalGuardian Signature

Date

Witness Signature

Date

CONSENT FOR OUTPATIENT TREATMENT

l hereby agree to be admitted to the above named hospital program for assessment, diagnosis, and
treatment until discharged.
Date of Admission

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

Patient Signature (Required for patients 16

years of age and older.)

Date

Parent/LegarGuardian Signature

Date

Witness Signature

Date

CONSENT FOR WEST OAKS ACHIEVEMENT PLACE

I hereby agree to be admitted to the above named hospital program for assessment, diagnosis, and
treatment until discharge.
G
Date of Admission
-L_p _. 1
.

U:: 1t. LLJL

itness Signature

ate

[have read. understand, and agree with the consents in this document and give my consent
from the date of each signing until final discharge from West Oaks Hospital.

c:\v-.rp5l \forms\adoladm.frrn jlw

to them

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rWEST OAIS PSYCHIATRIC HOSPITAL

6500 KORNVOOD DRIVE
HOUSTON, TX
.,.. neNT NUMSE.A
PA.TtEHTNMII
ST AUBIN, UITH
1155118

GUEST REGISTRATION
A HEALTHCARE INTERNATIONAL FACILITY

7707+-0000
MAIDEN NAME

TEI.E-

~~~I(JT"N~&Tr'Qur,rqv

.aGE

SEX

18Y

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RELATION

ST AUBIN, KEN

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ST AUBIN, UN

0703

GSOClAl SECURITY NO.

EMEAG IIIOT1F CIEL

ST AUBIN, Wl

713-Z74-3S66

FAT

GUARANTOR TELEPHONE

FAT Z66-8Z-ZS6Z --cni

7,.13-771-91++
l13~Z7+-3566
.. ---HOUSTON
.. eMPlOY"eA
-ADM. OR NO. AOUITTING OOCTOR NAME
708
GAiB MD, RONALD
713-27+-2000
POt.JCY
lTT OR. NO. in'eNCIHG OOCTOR " 708
GARB KD, RONALD
Z668ZZS6Z

oo~w

6211 LUGAR!

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77036-

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aU.lRAHTOA EMPLOYER ..

TEXAS INSTRUMENTS
AETNA <TX INSTRUMENTS CLAIMSJ

~ULIBEA-fl,.

PRIMARY OA,YOR N.WE

.MEO SEA

SECONOAFiY PAYOR NAME

COL

.\Of,l

SAC

0 .:.'1"

')j:IC

l~.' :;::-

L::::> SU

LOS

l.C'.tiTTING Tlt.IE

o\OI.UmNG DATE

03/0S/97

'i=INAL DIAGNOSIS

13:00

~0

'II

TElEI>!<ONE

ADM LAST600AYS

TRAN$FERFIE0 FRQlt FACiliTY NAll.lf

TRANSF'ER"'EO IN

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EMERGENCY NOTtFICA T10N NAWE

"713-771- 9144
RELATON

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77036-

07

reLiPHONe

GUARANTOR NAME

00CSS43

'if CNTAY

Poi.TlENT OCClJPATION

STAUBIN, UN

NEAREST REL.A nVE N.u.IE

tQ\1 - .. ~

t..!F.OIC.Al ~ECORQ PJ

TX
)OCIAI. SECURIT'V NO

DATE OF SIFHH

FATHERSN.tJ.IE

SPOUSES NAME

;:1A,T rv~~

CFC

500

HOUSTON

6211 LUGARY
US CITZ

AfC

500

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AOORESS

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]13-771-HH

DAECERTifiC._.TON ~

40tATTING OlAGNOSIS

COMB DRUG DEP

KECu~SPEC

CODE NO.
DSM Ill

(FIRST DIAGNOSIS PRIMARY UNLESS NOTED)

CODE NO.
lCD -9

AXIS 1:

AXIS II:

AXIS Ill: (PHYSICAL)

AXIS IV:

AXIS V:

LEVEL OF FUNCTIONING

PROCEDURES:

[ iJISC~ARG

OAG

CONDITION
)N DISCHARGE

IMPROVED
NOTTREATED

NOT IMPROVED
AMA YES: NO

TRANSFERRED:
OTHER HOSPITAL :.
OTHER .

s A7US

EXPIRED:

LOS

48HR
+48 HR

CORONER
AUTOPSY YES

NO

CAUSE Or OEA TH

I CERTIFY THAT THE NARRATIVE DESCRIPTION OF THE PRINCIPAL AND SECONDARY DIAGNOSIS AND THE MAJOR PROCEDURES PERFORMED ARE 1\CCURA TE A

COMPLETE TO THE BEST OF MY KNOWLEDGE.

TTENOING PHYSICIAN NAME
DATE

ATTENDING rHYSICIAN SIG~A lURE

1(

j.._/.~.1

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A-RG.l
WEST OAKS HOSPITAL
PATIEH'l' DME:

ST. AUBIN, KEITH

MRf: 88-43

ATTENDING PHYSICIAN: RONALD GARB, M.D.

AO'l'BOR 01' REPORT :

JULIE SENGSTACKEN, R.N.

DATE 01' ADMcrSSION:

3-5-97

DATE 01' DISCHARGE:

3-6-97

CLINICAL RESUME:
REASON FOR ADMISSION:
This 18 year old, white male was admitted
to West Oaks Hospital after a failed attempt at outpatient. Patient
has been increasingly violent and in more assaults with other young
men. He was recently kicked off the baseball team after being
assaultive in public and has had other assaults with the ex-girl
friend's boy friend in which he "broke up a truck".
Patient has
been using marijuana and drinking alcohol on a daily basis.
He
also has been terrorizing his family. He has become increasingly
aloof, suspicious and hostile. He denies suicidal ideation.
SIGNIFICANT FINDINGS:
The patient had a history and physical
done by Dr. Eugene Degner and was found to be medically stable. on
3-7-97, the patient had a urinalysis which was within normal limits
except for 1+ mucus threads. He had a CBC done on 3-6-97 which was
within normal limits and a chemistry profile on the same day which
was within normal limits. The RPR was nonreactive.
COURSE AND PROGRESS OF TREATMENT: The patient was admitted to the
inpatient unit and oriented to unit guidelines and treatment
components. His behavior was demanding and angry. His mood was
irritable and his affect was flat. He denied any suicidal or
homicidal ideation.
However, he exhibited no impulsive or
aggressive behavior and on 3-6-97 was ready to be transitioned to
day treatment to continue treatment in a lower level of care.
FINAL ASSESSMENT:

As above.

RECOMMENDATIONS AND ARRANGEMENTS FOR fURTHER TREATMENT:

The
patient was discharged to home. Patient and father verbalized an
understanding of the discharge aftercare plan and intention to
finish treatment in the day treatment program.
FINAL DIAGNOSES:
AXIS I

Marijuana dependence
Alcohol dependence
Depressive disorder, NOS

PAGE 1 of 2
DISCHARGE SUMMARY

,--

r. . .

r--

WEST OAKS HOSPITAL

ST. AUBIN, KEITH

MRI: 8843

Oppositional defiant disorder

AXIS
AXIS
AXIS
AXIS

Sociopathic traits
II
III None
IV Moderate
V
Discharge GAF: 45

RG/js:sj
0: 5-4-97
T: 5-9-97

PAGE 2 of 2
DISCHARGE

SUMMARY

r-

,.

j - --~

A-ED.1
WEST OAKS HOSPITAL
ST. AUBEN, KEITH

PATIENT !IAMB:

ATTEHDIBG PHYSICIAN: RONALD GARB, M.D.

AUTHOR 01' RBPORT:

EUGENE DEGNER, M. D.

DATB 01' ADMISSION:

03-05-97

KRf:SS-43

UNIT:

DATB 01' BXAMIHATIOB: 03-06-97

CHIEF COMPLAINT:

Violence.

HISTORY OF PRESENT ILLNESS: This is an 18 year old white male who

is very angry and minimally cooperative. He states he does have an
anger problem that bas become very violent. He has destroyed
property and injured others.
He was a day patient here for a
period of time and has continued to deteriorate.
He has been on
Risperdal and Effexor and believed he was slightly calmer than he
was prior to the medications.
He states his sleep is fine. His
appetite_ is good.
PAST MEDICAL HISTORY: Patient's general health has been excellent.
He has ha~no serious illnesses, surgery. He had a fractured left
wrist about 2 years ago which gives him no trouble at this time
which is essentially his only serious injury.
He is allergic to
Penicillin and Erythromycin. He smokes about \ pack of cigarettes
a day. He states he has drank "a little bit." He usually drinks
about every other weekend. He denies a problem with alcohol. He
had a history of rather heavy marijuana use. He states he has not
used any marijuana since this summer.
REVIEW OF SYSTEMS:
Denies itching or rashes.
SKIN:
Denies headaches,
dizziness,
HEENT:
sore throats or ear
problems.
RESPIRATORY:
Denies cough, cold or wheezing.
CARDIAC: Denies shortness of breath, heavy chest pain or ankle
edema.
GI:
Denies vomiting, diarrhea, constipation or GI bleeding.
GU:
Denies dysuria, frequency or nocturia.
REPRODUCTIVE: No sexually transmitted diseases.
MUSCULOSKELETAL:
Denies joint complaints.
PSYCHIATRIC:
Denies suicidal or homicidal ideation.
FAMILY HISTORY:
Noncontributory. His parents are well. He has
2_brothers. Everyone is in good health as far as he knows.
EDUCATION:

He is in the 12th grade.

PHYSICAL EXAMINATION:

Well-developed, well-nourished white male

who appears in no acute distress.

viTAL SIGNS:

Temperature 98.6 degrees. Pulse 88.

Respirations

16.

SKIN:
Clear.
HEAD:
Normocephalic.
EYES:
Pupils are equal and react to light and accommodation.
Extraocular muscles are intact. Funduscopic is normal.
EARS:
"Tympanic membranes visualized and intact.
NOSE:
No discharge.
THROAT:
No evidence of inflammation.
DENTAL:
Good dental hygiene.
NECK:
Supple. No masses are palpable. Thyroid nonpalpable.
CHEST:
Breath sounds are heard bilaterally. Equal bilateral
excursion. No rales or rhonchi are heard.
HEART:
There is normal sinus rhythm. PMI is the 5th intercostal
space in the mid clavicular line. No murmurs are heard.
BREASTS: Appear to be symmetrical. No masses palpable.
BACK:
Symmetrical without deformities.
ABDOMEN: Soft and flat. Liver, spleen, kidneys not palpable. No
other masses palpable.
EXTREMITIES:
No deformities or edema.
GENITAL!~:
No hernias, testicular masses or penile lesions.
RECTAL:
Prostate is small, smooth and symmetrical.
NEUROLOGIC:
Cranial nerves I through XII appear to be intact.
These inciude I - ability to smell cotton ball, II - peripheral
fields equalto examiner, III, IV and VI- extraocular musclesare
intact, symmetrical bilaterally, V - no loss of sensation in the
face, VII - grimaces and frowns symmetrically, VIII -hearing test
okay by tuning fork, IX - has gag and swallow reflex, X - able to
make guttural sounds, XI - shrugs symmetrically, XII - no tongue
deviation. There is no motor or sensory loss noted. There are no
pathologic reflexes noted. The deep tendon reflexes are equal and
symmetrical. Gait, balance and coordination are normal.
MENTAL STATUS EXAM: Patient is oriented to time, place and person.
Appears to be average intelligence. Memory appears to be intact.
His mood is angry and defiant. His affect is flattened.
His
thoughts are clear without signs of delusions or hallucinations.
IMPRESSION:
1.
2.
3.
4.

Explosive Disorder
Oppositional Defiant Disorder
Rule out major depression
Rule out schizo-affective disorder

ADMISSION NOTE:
18 year old is admitted for stabilization.
is a danger to self and others.

He

PAGE 2 of 3

HISTORY AND PHYSICAL

1../J.S
" -

ST. AUBEN I

MR#: 88-43

KEITH

ED:jc

D: 03-06-97
T: 03-06-97

J?AGE 3 of 3

HISTORY AND PHYSICAL

(
I

A-RG.l
WEST OAKS HOSPITAL
ST. AUBIN, KEITH

PATIENT NAME:

ATTENDING PHYSICIAN: RONALD GARB, M.D.

DATE OF ADMISSION:

3-5-97

DATE OF EVALUATION:

3-5-97

LEVEL OF CARE:
LEGAL STATUS:

MRf: 88-43
UNIT: 7

Inpatient
Voluntary

This 18 year old is being admitted because of

CHIEF COMPLAINT:
failed outpatient treatment. He has been increasingly violent with
more and more assaults on other young men. Recently, he even began
to become assaultive in public while playing baseball and was
ordered off the team by the coach.
He has behaved in other
obnoxious ways such as spitting. He was recently jailed for a short
period of time because of assaulting his ex-girl friend's boy
friend, breaking up the truck. He has also been increasingly using
marijuana and drinking increasing quantities of alcohol in amounts
unspecified, but every single day and more and more. He has also
been terrorizing his family, threatening them and his brothers and
has become increasingly aloof and suspicious and hostile. He has
not been reported and denies having suicidal ideation. In parallel
with the above, his mother has discovered burglary paraphernalia
including a ski mask and other peripheral evidence that he was
involved in robberies.
HISTORY OF PRESENT ILLNESS: He was seen by the undersigned about
a year ago for irritability and assaultive and hostile attitude.
He was placed on Effexor 75 mg. b.i.d. and Risperdal up to 3 mg. at
h. s. with initial very good result.
However, he relapsed and
became noncompliant with treatment after about 3 months of improved
behavior. He lied about his relapse and has gradually become very
involved in the drug scene together with a worsening in his already
very prominent mood disturbance.
PAST PSYCHIATRIC HISTORY: The patient has never been treated as an
inpatient. However, he had a very brief day patient stay at West
Oaks Hospital for about a week in 1996.
Since then, he has b~en
seeing the undersigned for medication management but has refused
any AA or any other attempts to engage in a 12 step program.
FAMILY PSYCHIATRIC HISTORY: Relevant in the sense that his mother
has been depressed and she reports 2 successful suicides in close
relatives in her family. His father al.so reports a positive family
diathesis for depression, in particular references one extremely
depressed aunt who has been repeatedly hospitalized. Father works.
PAGE 1 of 4
PSYCHIATRIC HISTORY AND MENTAL STATUS EXAMINATION

I"""

WEST OAKS.HOSPITAL
ST. AUBIN, KEITH

MR#: 88-43

for Texas Instruments and is a fairly emotionally aloof and

detached person. Keith has 2 brothers, Brian, age 17, and Chris,
age 8, who apparently are fairly stable children.
PAST MEDICAL HISTORY:
The patient denies systemic inquiry
difficulties
with
cardiac,
cardiovascular,
respirator,
gastrointestinal, and neurological problems.
PSYCHOSOCIAL HISTORY:
Parents report that Keith has always been
"strong-willed". He was a fairly complaint child until about the
age of 14, although he was irritable always and very much insisted
on getting his own way. At the age of 14, things became worse when
he moved to strake School where his prior academic performance,
which was good because it required little effort, began to be
prominently below standard at that school. However, he compensated
by the fact that he is a highly talented baseball player and has
been on the baseball track ever since. He is about 1 credit short
of graduating from high school but his general behavior and
demeanor has been very close to that of being an emancipated minor.
He is about a couple of months short of his 19th birthday. He has
a long h!,st<;?ry of assaults and some police attention both for
assaultiveness and for traffic violations and some legal charges
are still pending.
STRENGTHS:
WEAKNESSES:
MENTAL STATUS EXAMINATION:
He is a thin, wiry, very intense
looking, 18 year old with a guarded and hostile demeanor. His motoractivity is normal. His speech is terse.
His mood is angry,
irritable. His affect is appropriate. He denies suicidal ideation
and is denying homicidal ideation. His thought processes include
the fact that he is very quick to take offense. He ha.s delusionlike ideation that people are against him. He has been known in the
past to assault people for even looking at him, although at this
point, he is not quite so hostile and the above behavior may have
to do with drug intoxication. He has no fixed delusional beliefs.
He denies any auditory or visual hallucinations.
He is very
concrete and has a degree of thought poverty and poverty of
expression. His orientation is full in all 3 realms. He is alert
and his intelligence is average. His memory for immediate, shortterm and long-term is good. Judgment should be considered fairly
poor and his insight is equally poor. Reliability is poor.
He
should be regarded as impulsive.
REASON FOR ADMISSION:
PROVISIONAL DIAGNOSTIC PROFILE:
PAGE 2 of 4
PSYCHIATRIC HISTORY AND MENTAL STATUS EXAMINATION

rI

T .. -

'

WEST OAKS HOSPITAL

ST. AUBIN, KEITH

MRI: 88-43

Marijuana dependence
Alcohol dependence
Depressive disorder, NOS
Psychotic disorder, NOS
Oppositional defiant disorder
Sociopathic traits
II
III None
IV
Moder~te
V
CUrrent GAF: 45 Past year: SO

AXIS I

AXIS
AXIS
AXIS
AXIS

BEHAVIORAL INDICATORS THAT PATIENT IS READY FOR NEXT LEVEL OF CARE:

IMPRESSION/TREATMENT PLAH: This 18 year old is being hospitalized
for failed outpatient treatment of an irritable and explosive
disorder which is fairly enduring and may constitute an ongoing
depressive disorder of an atypical fashion.
Clouding the picture
is substantial ongoing drug dependence, mainly marijuana and
alcohol . He has shown some antisocial behavior, stealing, lying,
assaultiveness. He is superficially fairly charming according to
his parents, stating that he has always had no difficulty in making
friends. ~:tt- is not clear whether he has been cruel to animals and
it is not clear just how long his stealing and lying have been
prominent, certainly from the age of 14. He has criminal charges
pending. He therefore will be admitted to the acute inpatient unit
where he will commence with detox as well as having his vitals
monitored. He will have some baseline lab work and physical workup.
He will then be introduced to the 12 step precepts, individual,
group and educare. At the same time, he will be maintained on his
antidepressants, Effexor 75 mg. b.i.d. and Risperdal 2 to 3 mq. at.
h.s. which have been helpful in the past and which may still be
useful, although these may be changed for other antipsychotic or
antidepressant combinations. He remains a diagnostic difficulty
since the drug overlay, but it seems clear that he has very severe
Axis II difficulties. The big question is just what kind of Axis I
problems he has and the differential is uplined above.
DISCHARGE PLAN: He will be stepped down to residential treatment
when the initial detox phase is over.
PROJECTED LENGTH OF STAY:

PAGE 3 of 4
PSYCHIATRIC HISTORY AND MENTAL STATUS EXAMINATION

WEST OAKS HOSPITAL

ST. AUBIN, KEITH

MR#.:

88-43

RG:sj
-

0: 3-6-97
T: 3-6-97

PAGE 4 of 4
_ _ _ _P_B_Y_C_H_I_A_T_R_I_C_H_I_S_TO_R_Y_AND
_ _ME_NT_A_L
__
B_T_A_T_u_s_E_XAM
__
I_N_A_T_I_O_N_..~-.__

__;j. 50

.,...__ ..........
i

''"

WEST OARS,HOSP!D~
SELF-.ASSESS,!S!tT R!!PORT

or entsr

11

~/A"

i::::

:::.c~

',11'~ ~ii

S-! -

Name:

'yvltc_ ~c.e \.

A-V\.\:,,'r-0

( ~~iC.C.l e)

(Las~)

_::!._ddrass:
Zio:

City:

(/05(p

Name you wish to go by: _ _J..:I.(:::..k~l.!.ho......_ ___:__ _ _ _ _ _ _ _ _.:..___ _ _ _ __

Date of Birth:
Marital Status:

C)

I~

s/ 16

p._ga: _j_Q

Sex:

YV1

__, Si.i1gle _ _ Widowed _ _ Divc::-ce-:i

Married
Separated
"M-neelc::air _ _ J._r.iliulance _ _ Police
Othe:::-

no

Did anyor.e accompany you?

If yes, w-hom?

Do you have a legal guardian? __.:Yes ~ Nc

If l"'es, n~e:
If a child or adolescent, who has custcC.y?
Copy of custody papers obtaine~? _ _ Yes
If no, explain arrangement for securL-:g:

]._re you presently e:n:QJ.oyed? , ___:::_ Yes _ _

Job/Profession:
---.g. SC'\..V'lu_.:::r

1Io.

No

If an adult, what is your highest level of education?

If a child or adolescent, presently iri school?
J Yes
No
Grade L-evel:
~ "JNa::ile of 'school:
K~-l
~. '-a.
Type of classes: ~Regular ____:::_ !:or.ors _ _ S9ecial Education

Accitic~al

cc~ents:

Re:ie.;eci wit"n patient by: Na"e

Date

A04 ~

~j/:ZJ..S

:: =~i!le

-1-

.1.51

r---..., ....

II.

"PRESENTING

1.

How

PRUl;L.t:;L1.

ar~

~ ~

J ;

n~w?

you feeling right

Frustrated
Hopeless
~.ngry

Trusting
Rejected

(Check all that may apply):

Sad
Suicidal
Scared
Worried
Peaceful

Calm
_ .._ Indifferent
Isolated
Anxious
Desperate
Helpless
Nervous
Abandcne-:..
Curious
Other

If ether, please d e s c r i b e ) : - - - - - - - - - - - - - - - - - - - -

2.

Ecw long have you felt like this?

~r.a~

1
4.

is your reason for seeking treatment at this

o

~~.-. \

iN4

~;rvc1

ti~e?

wlwrt :.Pqd=~

Desc:::-ibe current problems in daily functioning (e.g., ;.;ork, school,

social,. family andjor interpersonal relationships):

'-O).h'Ylldttd 'YY!a.kQ

Ylt.L Cl M

cr'u1

PREVIOUS TREATHE~~ (outnatient t=eatment and hospitalizations)

WhenHonth/Year

5 {j k

Problem/Treatment outcome
)Cvnul. ( iV o/V-

Has a fa:nily member had psychiatric treatment? _ _ Yes

If yes, ,.;hom and describe history and treatment:

No
(')

DO NOT WRITE IN THIS AREA-STAPP USE ONLY

Additional C=ouents:

.....

r
Iv.

HISTORY OF SUBSTANCE USE

Alcohol:
Yes

Do ycu drink alcohol?

~rnat

2.

Nc

Ho. tines per week:

kL::d cf alcohol do you drin}:'?

..,

F.lllCU.:!t per day:

...,

..

Eo,.,. lcr:s; have you been drinking in this ~attern?

5.

"rtr..er: C.iC. you have you.:r last C.rin:-:?

6.

Please c!).eck if you na.re had any cf the: fcllc,.;inc syr;:;.pto::::1s ,.;nc::-1 ycu
sto? drinking:
Blackouts
Vc:::uiting
Loss of Memory
~a~y

i-..i.

~ ~~)

cA~<, ~~ no~

Tremors
Constipation

much?

~\,uft'~

Sweatincr
Nausaa
Diarrhe~ _____ Headaches
P.apid F.eart Beat

7.

How

times have you tried to stop drinking?

8.

Have you ever attended 1--..J....?

..:/Yes __ No

s:

D~

1--~

sponsor?

2...

Do you use drugs?

First use:
"-\

Yes

Ho

vou currently have an

../

If yes, when and whe:re?

Yes

No

No. ti::::1e.s;week?

;;..v~ ''~

2.

Wnat kind of drugs do you use?

3.

1-..nc"J.nt per day:

~.

Ec. -i long have you been using in thls pattern? -~?-___::yr-~:::::::::....:....!.-------

5.

Wnen C.id you last use? i,.\

6.

Please check if you have had any of the following symptoms when you
st.cp using:

...

Blackouts
Vomiting
Loss of Me!!l.orf

J.,-,.;;h e--1,;~

Sweating
Nausea
Diarrhea
HeaC.aches
RapidHeart Beat

Tremors
Constipation

-r:c. ;

s.

Ec-..; you every attsnC.ed NA/0.?

~any

F.ow much? _ .....~~~<..:...--------

"";
""'es ;..,.~c::.- ve you tried to _c:tc'"'..,_ ,.""' c:__; nq'.
'--""
_
Yes

lio

If yes, when and.

"-Hr~e.=e?

9.

De vcu currently have an Nil./CA. sponsor?

-3-

Yes

No

'.l.'ODilCCO:

1.

Descri~e

usage:

Caffeine: ____ Yes

l.

v.

No

Describe usage:

ALCOEOL/DROG
hospitalizations)
P?~VIOGS

TP3ATHENT

c:.
__
-,......:

(outpatient

i'lnen-

HherejHith 'I-Inam

MonthjYear

Proble~/Treatnent Out=o~e

Yes

Has a family member had alcohol/drug treatment?

If yes, whom and describe history and treatment:

VI.

___..

No

LEGAL EISTORY
1.

Are you currently on probation or parole? ____ Yes ~ No

2.

Present legal involvement:

3.

Past legal involvement:

4.

Eave you ever ben convicted ,of a DWI, DUI or PI?

j
_ _ Yes

v'

No

-~-~~

IV>\t><14f

---t~"'E: ~~)
~~~~'-

DO NOT WF.!TE IN TRIS AREA-STAFF USE ONLY

Additional comments:

Reviewed

~ith

patient by: Name

Date

~71~/M
.:3- .5- Cj 7
6Q
TlBe

-4-

)/:

r-

r----

CHILDRZN/AOOLESCEUTS
Special Considerations
Please complete if pote~t~al patie~t is unde::: age ~8.
(Co~plste in conjunction with ?:::e~:::aa~e~t Salf-Assesswe~t For=t)
of ?otential Patient:
I.

P~SENT!NG

\L (!...1~-v-\
t

~.

5.
6.
7.

Age:

PROBLE~(S):

Cruelty to animals
. , I.arug usa
.,..";
__ cone_
Self abuse/mutilation
P-ee
-~~-cksjaccression
_,c:....
c.".... c. .
... ...
.
Fire se-t-ting
Suicide-attemot
Hallucinations/delusions

l.
2.
3.

St. 4'-"-L,\.v

~
-./

Yes
Yes
Ys:s

..lL_

~io

Ho

-.~- He

Y::s

~io

Yes
Yes

_:L_
J
---1::.-

Yes

~ ~~0

No
lio

If yes to any of the above 1 describe ,;=.e:l a:ld ,;!J.s:::e it oc::u::::::ed and ho..., ofte:l
(please be specific with any details t~at could ~~lain the preble~):
\) \

,~'(_

8.
9.
10.
ll.
l2.

fN\c ~

S \{'tv~~\.~

Failure to thrive
Developmental delays
Difficulty with atten-tion
Denression
Eating/Sleeping problems

--

Yes
Yes
Y:s
Yes
Yes

Ho
l:io
Ho
-.~---::; No
j
Ho
J

If yes to any of t'!le above 1 desc:::i!:e (pleasa ::,e specific wi th any details
that could explain the preble~):

l3.
l4.

lS.
l6.
l7.
lo.

Trouble with authority

Learning disabilities
School phobia
Poor peer relationships
Suspensions from school
Grade retention

Please give soecific details that

there are any othe::: school-related

\'./

-j-

Yes
Yes
Yes
Yes
Yes

No
No
_;L_ No
_L_ No
Ho
..)

yes,

whic:::.

e~la:~ ~y ot~e::: sc~ccl proble~s

and if

V-e:.
-C:-

./

N8

(-""
..!..:..

qrc.ce?
~=~bl~

-5-

not stated:

Additional Comments:

Revie,;ed witil parentjpatient by' Nane

.

Data

~~ 7)~ ~
//.'10

..3 -;6'-:17

Tiwe.

r---

r-

r-

WEST OAKS HOSPITAL

REQUEST FOR CONSULT
Date:

!j'_s;.'f1.

Patient Name:

ljnit: . ' /

j}i.i.zl? ~~

Requesting Staff:

r~

~
.
~~
~~

Physician:

Anticipated Date of Discharge:

Type of consultation or service requested:
Department to provide the consult:

~4~ ~

Please indicate the assessment question (s) or the goaljissue

to be addressed.

To be
)

Received by: ________________________________

Date:

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

Assigned to: ________________________________________________________________

Action to be taken:

Note:

Consultant should provide documentation

for the chart as soon as availabl~. 1 S c l
l

.l.

Addressograph

l- 8

Original and two copies to the cortsul~in~. I(ITH

department.
Fourth copy remains 6rt th~' l
chart.
~ ~ .,
(:".-;'\-~~

FORM 072
.. Subsidiary of Healthcare America, Inc. Affiliated with The Brown Schools"

I8

703

88 4 s

.,". ,

70S

REV._6/94

1S?

r--

r
I

WEST OAKS HOSPITAL

REQUEST FOR CONSULT
Date:

1 ,
~.91,'--~

3-:-17

Patient Name:

qnit:

Anticipated Date of Discharge:

Requesting Staff:
Physician:

/J/, f~

------------:TL~~~-~~~~--------------------

(!, ,&c ~

Type of consultation or service requested:

Department to provide the consult:
Please indicate the ass
to be addressed.

/3-MA<.k, 3,Is

m~nt

~estio~

(s} or the goaljissue

~

~) ~

>?1 o.7 .3.'ItJ / ' /#,;

.YJif

&

r-

To be completed by consulting department:

Received by: _______________________________
Assigned

Date: ------'~=:;.......t....\_~.o_;;.\_~_1_ _ ___

to:~~~---~-~~~--~\~~~~~~~,~C~L_t~-----------------------

Action to be taken:

(_():.

_Q_;;

\>'\

Note:

OS.<: ..e..s<; ~~

flCJ\-

~\Ui:.

~(_~

~~~

C...(Qr_~\0~J

\?\-..

J~?e_~~-

~\.10-e..~

..---..
~ """""'

~Jl,

(__~

Consultant should provide docum~ntation

for the chart as soon as available ll 5 511- 8

Addressograph

7tJ

Original and two copies to the con~~~~H~H, lEI Tit

department.
Fourth copy remains OI1j ;tp& J. ' '
chart.
()~-ll-78
'-~-~>-~7

FORM 072
.. Suhsidiarv of Healthcare America. Inc. Affiliated with The Arnwn Sch(lllfs"

"

... ,,

, ,

roe

REV. 6/94

.....,1S8

':.
:~

r----

Reason for coming to the hospital:

I.

MEDICAL SCREENING
~-

_,;'

VITAL SIGNS: Terrp:

q1, .b

Pulse:

CO'

'I

Ileal:: _ _ __

Labore-d: _ __

Strong: ._,/

Unlabcre-d:

ReSj:l:_:._/_j!~!..__ 9/P:

Altered baseline may required medication and equiprent not usee at llest Oal:s Hospital; recent history of
abnormal vital si;ns/chest pains/temperature over 101 degr~s.

Explain=----~-----------------------------------------------1-..LLERGIES:

.:i!-;At:t:J,tt:KzjAutj'Wz.e1tr~~~ _j4!r&j~f1~~~~-~---"+-,'

circle correct resoonse

II.

Pm?ILS

size:

~m.mLeft~m~ight

Pupil size:
a:Oreviations:
D -dilated S sluggish
P - pir.;x>int F - fixed

Pu~il

"III.

-~!!!!e
;~

Reacticn:

~~l
~ac:ive
h~ - Nc~re:ctive

CONSCIOUSNESS
4.

~riented

Lethargic

~cnfused

5. Stuporous
6.

9.

Comatose

CCA!i:ative

An altered state of consciousness could be related to signs of intoxication, overccse,

~~ical condition.

re~e~t

or urdiagnosed

Conunents: ___________________________________________________________~______

IV.

MOVEXBNT

LHAND

1. Hand grip strong

R-HAND

___L

_j_

L-HAAO

R-HAAO

2. Hand grip weak

3. Leg iilOVement strong
4. Leg movement weak

NURSE SIGNATURE:

-:::3

/"'\ ' )

...!~~=......lo!Ooo....---n~~:::........:;::....!_.....:=-=..;~1____.:_A}.J__:___

0/<.TE::

"3- 0 - Cj

l of 13

,.--
!

V.

SPEECH

(;);~:;;..
1.
2.

3.
4.

5.

Carbled
Ra.Tblinc;

Hor.e

Severe ic;:.air.:letlt ~ir:ziu:ic:n o~ cx:veoe!lt

lr.ability to stard ~or.ral fU'1Ctlc:n

VII. U:aE:::::Pr.e.T5RI) OR. miDllG:BOSED EITSICL SY!!PTQ~:

_c~es: ~in

_~espiracort distress _A.b:!.:::r:linal pain _Blood less

_Pr::C:.:.c:ive, prolonged c::L:<;il (>3 ~l:.s)

_s::a

-._Hem:p~is

_Vcmiting

_llish:: S'oieats _cllills/Fever _Peer a~tite

_tJncrested !::rei:~ b:<'les _Oeliriln trener.s _Oia~cretic

I;:;-

A)

VIII. HtlT!U'TIOH:

_~alNJtriticn

_severe de:hyera:ic:n

.....

--y
~

O:::YGmrjXEDICAL
Oesc~ibe:

....
......

_H~ for IV fluies

EQUI~ 1{/I If

______________________________.._.._.._.._..-..-,-.~.-----------------------------

.ACTIVITTISS 0? DAILY I.I'VD'G

AJ/fr

l::a:.':ir.g are ~~la:ico.

:::rr.
I t p r e-;.-.ar:t, cile
'"Til

~--

If pes;: par:m, eate oi del ivert:. _____

ea :e: - - - - -

Las: me!"Ses:. - - - - -

TUBERCULOSIS aBSESSXE:BT

year:_Yes~/

'olit."lin the last year:

~
X-ray pas::'
Pas-: or present positive PPO test: _Yes _llo
. /
Result:_Pcs~tive_Megathe
Pas: or present dia;nosis of tt.bercJlosis: _Yes -'l!_.aa
If yes, when: ____________________________
T reg t::>ent:
llhen: ______________

:::III. l?OSI'OfJ.. 't'B HI'V"?

1ft-nen diagnosed:

Yes

When diagnosed:

-------~-----

--------~------

DIS~..SE (S) :--;'~;;-::::-:::;;7-::-;-------------

(Specify)

OT5.ER c:JHHUH'io.BU:
ASSESSH3~

Yes

FINDINGS:

Patient not -=::H=lly st.;Jble:

Patient ae::!i=lly ::'t.aCle:

Initiate ftr::::~ E:Cic::~l ezaa ;rd ::-eat::le':t

Initiate tl<lnSfer ~

_______

-7"

_v'
__

<tS~.,_.,t !:-y OO!l'

____________________________________________________

Ctel
esred fx
~er

ACOliiCWAL

12/5/96

~S/FI>D!XGS:

_________.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._..__

2 of l3
c:/reports\assess.nL:r

(Jill)

r.

,---

NURSING ASSESSMENT
PART II

t<-e;~

Patient name:
Last

First

Hho do you live -with:

Voluntary

Admission:

----~~--Involuntary

EDW

OPC

23

obs

'

lnforr.dticn from family or sisnificant ocher resar~~r aarnissicn with patient'~ pe~ission.

Family :may give information:

II.

Patient 1 s

(Mar.Cacory for adol. and child services)

(Any area c!'led:e-: r~.Jires explanaticn: onset, euratiC(I,

symptoms, severity)

CLINICAL INTAKE. ASSESSMENT

1.

31:

s~gnature

Depression/Affective Symptoms:

---,/None
_.L Crying
Guilt Feelings
-----~ecent/Past Losses
~ Sleep Disturbance
~Eating Disturbance
~ Threatening/Aggressive
Explanation;

e~r

2.

~Loss

of interest
Asitated/Hostile
- - Irritability
Regressive Behavior
Psychomotor Retardation

Xlthdra~oon

"~~/1.0

~Hood Swi_r~s ~ CC~ ' /

___;:::-Isola teo
(_"
___ Trouble c:ncentrating
_ _ Feelings cf worthlessness
___ Hopelessness/helplessness

ai:: 10lot) fa!.u1A !JJ~t:

_7UICIDAL ASSESSHENT

JOMICIDAL

~enies
--

~Ham a

~ luaJ?.;

~enies suicidal ideation

- - Ideation
Threats
Clear Intent
Past Att~t:
IJi ll contract for safety:
Explar.a::icn:

3.

~igue

_____ ac:ess

(Any area checked re-:;uires explanation:

symptoms, severity)

onset, duration,

'--,---=----

Plan: - - - - - - Access to method:

Current
Occasional
Persistent
Recent/Atte!T'Ct: - - - - - - - - - - - - - - - - Describe:

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

ASSESS~~NT

(Any area checked requires explanation:

Symptoms, Severity)

Onset, Duration,

Homicidal Ideation
Ideation
Plan: ---------'Access to method ~------Threats
Current
Persistent
Intent for whom: ________________________________

Clear Intent
___ Recent Atterrpc:
Threatening/Assaultive
_ _ _ Assaultive History ----------Describe
aocsive/ag;ressive behaviors:

Nurse signature:

~ 7}~ p} Date:
3 of 13

4.

PSYCHOTIC SYMPTOMS/IMPAIRED THOUGHT PROCESS

requires explanation:

5.

6.

(Any area checked

onset, duration, symptoms, severity)

(Any area checked requires explanation: onset, curation, s~toms,

severity)
/coherent _ _ Incoherent
Flight of Ideas _ _
. Tangential _ _ Circu::stantial
Loose
Racing thoughts
o;sCribe:

ASSOCIATIONS:

ANXIETY

SYMPTOMS'

(Any area checked requires explanation:

symptoms, severity)

onset, duration,

Marked Anxiety
_ _ Generali;:ed Anxiety _ _ Panic Attacks
Intense Fears/Phobias
_ _ _ Cbsessions/CCIT"",..Ulsior.s _ _ Separa:icn Anxiety
_ _ Sc.cnatio concerns - - - - Runinations
Avoidance Behavior
~ts=----~=-----~----------------------------------~

--~~=-~~~--------------~'o~H~~-~~~~~~ffi.,~
j;2- _
~~

MOOD/AFFECT:

7.

1.
2.

Hood:
Affect:

_ _.Angry

__

8.

Depressed _ _ Fearful
suspicious
Bl~.:nted
Irritable_ Harl:e<! rr.ood shifts
Inappropriate
Describe:

=::2"' Flat

__

OTHER DISORDERS: ,
# . a t i n g Disorders (describe): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

J!Jij'

Self Mutilation (describe):----------------------------,---,..-.

()

III. ~~NTAL STATUS ASSESSME~

1.

Race

APPEARANCE:

~'Jell
Nourished
Clean
.

~latory

Poorly Xourished
Unclean/Disheveled
Younger

.l /Appears Stated Age

sex

Older

Other: - - - - - - - - - - - - - - - - - - - - - - - - - - - -

2.

BEHAVIOR DURING INTERVIEW:

_/oistrus:ful
Defensive
Fri;ntene-: _ _ Tearfl.!l
Dis:racted
Catatonic
Oeoanding/Entitled--~ CollaborativeLC:ocoerativ~
ver:,ally Ag;ressive
_ _ Disoriented
/

Phy~ically Aggress~ve~~isint re~ted~

~tac:Alert
Attltude

Descr1be:

-8:a:t
3

______________ .

SPEECH PATTERN:

_________

d,d 7//1-r

-nr_ud._ .

Volune:
Ouiet _ _ Loud ___ Average _ _ Monotone
Rate:
~--~ow _ _ Rapid _ _ Pressured _ _ Averase
content: ~Conveys little information

Nurse Signature:

~ n~Jw Date:
,., ..,"'>
..,.,........
N

4 of

4.

sy.~-iUUM/ORIENTATION:
_ _ Person

5.

:'

~ce ~me ~Purpose

LEARN (On a scale of 1-10 describe your

cesire and motivation to learn:

MOTIVATION TO

'

IV.

CEILD ASSESSMENT
1.
2.
3.
4.
5.
6.
~ 7.
~
8.
~ 9.
10.
_ _ 11.
~ 12.
./ 13.
14.
~ 15.
16.
17.
~-

'

i8.

19.
20.
21.
22.
2:0.

(Any area checkeci r~ires eetails, 01'\Set, curation, severity)

Distractibility or attentionspan prcbl~.

Restless, always in motion.
Difficulty learning.
Doesn't like to follow directions.
Can't keep hands and feet to self.
Hood changes quickly and drastically.
T~r outbursts and unpredictable behavior.
Explosive.
Destructive, destroys property.
Problems ~~king or l:e~ping friends.
Disrespectful to others.
Fishts with others .
Suspended frcm school.
Cruel to animals or kills them.
Tells lies or stories that aren't true.
Steals.
Set fires
Picl:s at things (nails, fingers, hair, clothing, skin, s.ores, scabs).
Sucl:s or chews (thumb, finser, clothes, blankets, hair).
Problems with sle~p (can't fall asle~p, '-?too eJrly, up a: night).
Enuretic.
Encopretic, smears feces.
suspended from school.

ADDITIONAL FINDINGS/COMMENTS:

****
DISPOSITION:

1.

Admit to unit

2.

Admit to Program

Attending Physician
Attending Physician

Nurse sis-nature:

5 of 1::

12/5/96
/..

..

~------

WEST OAKS HOSPITAL

INITIAL NURSIN~ ASSESSMENT
PART III
/?

DATE:O-

Nl>-J1E:

I.

II.

5 --1{)....-;

TI11:E:

A.M. _ _ P.IL

Immunization Record on Chart (RN/CNS) Yes _ _ _ No

~ N/1-If no, explain !2:r;angement for_ securing or 3rd party verification of
record:
.C, j/V) Cit'i...Qv :tn br l ~

Measurements (RN/CNS) P::

HT :
5' q
w"T:
I , 'b
I'

Head Circumference:
(For children <7 y.o.)

III. Personal Belongings (RN/CNS)

Brouaht
Monev
Jewelrv
Glasses
Contacts
Hearincr Aid
Dentures
Cloth ina
Elec. Eauio.
Valuables
Other

Sent Home

Tvoe/AJnount

Personal Belongings
Contraband RemovW.
Disposition:
r1/:i
Belongings searched

Business Office

Room

Searched ~or Contraband: Yes

~
NO

1/-i /

. .~~Z!)
by whom?

z:r./0.

Zf )1f ff

[17 hiJ

(RN/CNS):

()

No

oriented to:
Room
Visitor Policy
Smoking Reg.
TV/Stereo
Phone
Patient Handbook
Exit Routes
Body Se~h Done:
(RN/CNS)
Yes
v
No,?".
::t;f rto 1 exp:(.ain:
By Hhom?
, f'/{'_ ?i )/u.fJ /)z di-..J

'\'I , .. nC~~~ JQ [0,,( ,\:#!_

i) .

RN/CNS

D.i\'I'E :

_,

L'5 -'--~-

C'!
I

TIME:
6 of 13

1. 84

IV.

Allergies: DRUGS (list):

FOODS (list):
OTHER (list) :

v.

Hedications Patient Has Taken in the Past:

Cortisone
Insulin
Dicritalis
B/P Medications
Tranquilizers

(RN)

Nitroglycerin
Other

------

Medications Patient is Currently Taking (RN)

crth

Were medications broucrht to unit? Yes

No
~ N/A
Disposition ~--~----~--~--~~~~~~------~----------------------Hedication consents signed and dated? Yes
::::;:::::-' No
N/A _ __
VI.

Nental Status Examination (RN)

1.

HEHORY (Give examples of 1. Remote, 2. Recent, 3. Immediate recall)

2.

INTELLECTUAL EVALUATION (Give examples of 1. General knowledge of

current events; 2. Calculations
serial 7's, note effort,
hesitation,
frustration;
3.
Concept formation
patient's
interpretation of a proverb)

t ': 1/##tl; :~?i:t'f:;;::::;;~

A.
B.

c.
D.

0uDG~N~.~ive examples of 1. Future plans; 2. Impulsiveness)

~A.
B.

!(' ~/ .
~ -~~

fijj},

--

.n:&xt-.!pLa./C
I

VII. Spiritual Assessment (RN)

~eligi~us

honorea:
2.

Py,fe:::ce~and

L)!f:~CI:c G

Customs

(religious or cultural)

to be

Spirituality (spiritual orientation, values, beliefs)

A.

Do you believe that you have a capacity for belief in a power

No ____
outsc'1fny~urse1l~? Yes
DATE: ::; -[)
TIME:

~~

RN:

c.:::JJ l~ Jttk 11~

t-----

-17

7 of 13

1l ~;,5
...,
~~-.-

If yes, what form might

B.

~hat

power take for

you?~~

VIII.nealth Patterns Assessment

l.

Coping/Stress

c.

2.

nave you had any recent changes in. your life (job,
divorce, death)? Yes
No
~
Describe:

Assistive Devices:

ADL:

(S=Self, A-Assisted)

Hearing impaired receiver

cane
Wheelchair
Walker
crutches
Prosthesis
Other, Describe:
....3.

_5

_s

Feeding
Toileting
Bathing
Dressing .
Grooming
Other, Describe:

None

Activity/Exercise:
Mobility:
Limitations:

. 4.

move,

Ambulatory
_ _ _ None
_ _ _ Weakness

_____ With assistance

Fatigue
_____ Other

Speech and Language Assessment

Visual Impairment:
/

None
Uncorrected
Contacts/Glasses
Blind

2earing

I~pairrnent:

~None

()

(Right=O.D., Left=O.S., Both=O.U.)

cataracts

6.u.

o.s.
o.s.

0.0.
0.0.

o.u.

Glaucoma _ __

Learning Disability:
Describe:

Uncorrected
Yes

Hardof hearing
Do you need assistance with reading?
Deaf.
.__ .. --No
Yes
Hearing aid
Describe:
Do you need assistance with writing?
/
No
Yes
Describe:
TIME:

(~{,.]C)

- _:6
A-

8 of

..

r--

r~

Speech Impairment:
~None

Language barrier
Slurred
Hute
stutters
cannot express
cannot understand
swallowing
Fluency
Voice; Describe:
Other; Describe:
5.

D~ you have a~guage barrier? If so

describe:

~~ ~

'"

Do you ne~d an interpreter?

____ Yes
~No

Sleep/Rest
Sleep:

~-No proble-ru
Difficulty falling asleep
Difficulty staying asleep
Does not,fe?l:rest~d after sleeo

wnat helps you sleep? ,,

J}&fft-<-t-J cf'_.--t-v.-;f ~00

~

IX.

Physical Assessment
1.

Medical
dates)
1.
2.

-(

History
.

(major

illnessesjoperationsj:major

injuries

and

')

'LI.&6-d

2.

Infection Control (List any infection control considerations)

1.

~A.kbl

,,

2.
3.
3.

Nutritional/Metabolic
No
Wt/Ht Plotted on Graph Sheet:
Yes
~No
Recent Weight Loss:
Yes
Describe:
Yes
~No
Recent Weight Gain:
Describe:
Sore mouth
Difficulty chewing
Indigestion
Difficulty swallowing _ __ Pancreatitis
Nausea
Cirrhosis
Vomiting
Describe:
,....---- No
Yes
Recent changes in appetitejeating patterns?
Describe::
Dietarj consult requested: -..,.-- Yes
__.-: No
Diabe:te:s:
Yes
v
No Type & Date Dx'd:
Soecial Diet:
Yes
Z No Describe:
D~ntures:
Z None
Partial
_ _ _ Upper
Upper
Lower
Lower

ruChm f1t k

{}!.

DATE:

TIME:

)</ )()
9 of 13

1. 67

,-

r--

X.

C~ildren's/Adolescent's

~----

......

Services History

Pediatrician:
Date of Last Physical: ~~+~~q~q~r~~----------------------------
Have you had any of the following:
* Psychological testing:
~Yes
No Date:
Ph. D.:
/
Neuropsychological testing:
V7 Yes
No Date:
Ph.D.:----~-~~~-----------------------

Educationa~sting:

,;;/'

~ Yes

.EKG:

No

Yes
Place:
Date:

11. D.:

EEG:

Yes

No

MRI:

/Yes

No

No

....,.,..,...,&tL-.~d/_..,......,@0.....,..,..,....,.,/.,.-----::

Place:
Date:
M.D.:

Place:
Date:
M.D.:

XI.

School Information

*
*
*

*
*

Grade:
Teacher:
School Nurse:
School C~lo~:
School:
~J
Address:
P.hone:
~-~aunt of ti~e needed each day for

home~orkjschool projec~s:

XII. Social Assessment

1.

sexual orientation
____ Asexual
_____ Homosexual

Heterosexual
N/A (due to age)

Bisexual

()

/Hobbies/Recreational Activities:

2.

3.

stren~t

4.

Role Relationship
A.

Who gives emotional support?

Spouse
other

RN:

---~----

~ Family ----~-Friend

Self

None

c.

If child, does hej~e cling to one parent and avoid the other?
Yes
No
/
If yes, describe:

c.

How d~es y~ur. c~nditionjhospitalizz:.tion at"fect yo:: tanilY.

guard1anjs1gn1f1cant others? Descr1be: J.5,t~UirC
.

(10,\rJi.. 1ffi tb ,W

DATE:

S-5-'il

TIME-,

;<Po-

10 of l3

,.-----

D.

E.

How does family/guardian/significant others

condition? Describe:
.
c
/1
Describe your.
friend
:'
''(!Jc.
?/!/:;.._.
,
a
.
.5.~ ,,
7

affect
,

t-V EA4

F.

Describe
etc.) :

G.

Describe social programs;activitie~ (Boy/Girl

sports, s~~~JP' volunteer work):

(AA,

your

Big Brother/Sister,

HHHR..\,

Scou~s,

s~hool

5.

6.

current_Livin Situation (includin

ethers, enviro~ent, dwelling :

7.

Childhood/family
extended fami y

History

.) :

8.

~~use

significant

immediate family members,

nificant others,

History
Abuse from
Type:

victimized)
other)

Hho abused patient?

lvnenjWhere abuse occurred:
Patient's age when abused:
CPS notified:
~.

~~use

Type:

Date:

to others (patient abused or victimized others):

;C)f;,ntu-

(sexual, physical, emotional, other)

2~il i tary

10.

Service Histo5(: -')/--'/-4:,...__-- - - - - - - - - - - - - - - - - _/ ~/] ,.,.- a rl

!~r. ,t, _I ..,
Financial Status: ___.,-~lUw~~~,~~~~l,Ji~S~~L:~tr~-~~Jv~c-~-~----------------

11.

Community resources currently used by individual are identified:

12.

Social, ethnic, cultural, e~otional and health factors that might

affect patient's response to illness, treatillent or health care
teaching:
C.frJ~Ud'L-(

9.

\ <17.. Qn ,( (

---;

- r-;
~; 1

DATE: :.J- ,) -

t/ I--..
TIME: /

7'Jj

ll of 13

r
Developmental Milestones and Current Level of Functioning

XIII.
L
2

1-/tt~ ~/~

3
4.

Bc.sed on the total nursing assessment, prioritize initial patient goals

according to the patient's needs.
(To be completed within S hours of
ad.rn.ission)

Problem:
Goal:
as evidenced by

n.e-vJ~
*

-Problem:
Goal:
as evidenced by:
Expected Achievement Date:

Problem:
Goal:
as evidencedby:
Expected Achievement Date:

Problem:
Goal:
as evidenced by:
Expected Achievement Date:

Problem:
Goal:
as evidenced by:
Expected Achievement Date:

()

Preliminary Discharge Criteria Plans

1Yftl'Af/1Yl};Jij;):J

criteria:
Plans.:
~ :_~- AE!._~

RN :

DATE :

TIME :

Criteria:
Plans:
Criteria:
Plans:

TI11E =

1 ~{?a
12 of l3

1. 70

~----

Initia~ PatientjFa~ily

A.
B.

c.
D.
E.

Educational Goals:

~14~f

Fa:uJily'sjguard'
Describe:

::
her's expectations for traatment.

Family'sjguardian'sjsignificant other's
involvement in patie ~'s initial~
Describe:

commitment

D.a.TE: ,

L2/5/96

J-5-97

for

'

expectations
care.

and

TI:H::E:

13 of 13

r---

r-'"''

"'"""

.I

West Oaks Hospital

Ph~sician Admit Note/Preliminary Treatment Plan
(Format for Psychiatric History and Mental Status E:tam)

Patient Name:

Ke_,Ab

.. lSSll-8
T.AUBtlf,
R. GARB

j- . AtA.bi /l

703

884]

l1TH
708

9ct

<5Z37&
c. 3-os.cn

Medical Record Number:

Unit:

ADDRESSOGRAPH

']

_(?:.; ; :d:. ~.G:>.<.>. ._t:_.b._._______

Dateffime of Admission/Exam: 3 - 5 - 9 ]

18

9q999

"

Attending Physician: _

L'd of C ' " (okcl o n ) , Q R"idenhal

Day T reatmonl

Legal Sta

Chief Complaint (please use patient's/parent's own words):

Telephone Dictation Instructions. \. Oia\995-5826. 2. Enter your !0~. ). Enter the work typ~ md press# (2:; = Psydtiatric History and :O.lmtal Stotu.~
E.\Jm). 4. Enterth~ ~ledical Record Number then#. 5. Press 2 to begin recording(l -R<eurdiPau~. 3. R~-view, 44 Fast Forward. 5 Disconnect. 77
R~wind). 6. Press 8to c:nd your dic-tation and begin dicr.otion on anotherpatirnt. 7. For Slats or Hdp CJII :\kdical R.:cords at778-5264.

r
2
Past Psychiatric History (include specific measures taken to mltintain this patient in a less restrictive treatment settin;;
or provide rationale this has not been don , past treatment
.'

Past Medical History (include medication allergies):

Psychosocial History (include currenl family dynamics):

~ ~
Weaknesses.-~~~12~'~....____.....'~==--i+--:;.L-;2.:::...t.__:_lfd?---=------

Strengths:

Telephone Dictation Instructions- I. Dial 995-5826. 2. Enter your ID#. 3. Enterth~ work type and press# (2# =Psychiatric History and :-.l<l1tal Status
Exam). 4. Enter the :-.ledical R=rd Number then II. 5. Press 2 to begin recording (2 -R<:eord/Pause, 3 Review. 44 Fast Forward. 5- Disconnect. 77 Rewind). 6. Press 8 to end your dictation and begin dic1ation on another patimt. 7. For Stats or Help call Medical Records at 778-5264.

r-
(

...
Mental Status Examination:

h!W:;g

-<l '
;JR:l4-;_~![

' ] LA..'~..__,:::L..Au,=------c;:;;ff

Appearance/General Behavior:

115511-8
S 7' 4 'J B I N ,
::;o
GAR'I

qqg

05-23-/8
03-05-97

Motor Activity:

703

K 1 TH

8843
70 8

t8

Speech:
Mood:
Affect:

Orientation:
Sensorium:

Memory - Iinmediate:
Memory - Short Term:
Memory - Long T
Judgment:
Iruight: ------~~~~~-------------------------------------------------------
Reliability:
Other:

----------------------------------------------------------------sion (please see hospital admission criteria which will be critical for development of treatment plan):

Telephone Dictation Instructions I. Dial 995-5826. 2. Enter your ID#. 3. Enter the work ~p.: Jnd press : (2.: = Psychiatric History and Mental Status
bam) . .J. Enter th" !\l<!dical Record Numb"f then#. 5. Pr= 2 to begin recording (2 Record:1'111s~ 3 . Re\i.:w. 44 Fast Forward, 5 Disconnect, 77R,wind). 6. Press 8 to end your dictation and begin dictation on anOiher patient. 7. For SUts or Htlp .::~II \ltdic:~l Records at 778-5264.

~-

,....---.~

r~-

Ax..is I:

A...:is II:
-

Axis III: _ _

--L-1\J---'-'~-'==._...._________

t_1_c~t;;<e'(,:..P.~~._-'-L-'----------

A...:is IV: _ _

A\:..is V: GAF (admission) _ _

..>.C"""'--...,S~#=-----------,'1

GAF (past year) _ _ _~_,L/"------------

Treatment Plan (include s

Discharge Plan (include next anticipated level of care and potential complicating factors): - - - - - - - - - - -

Elu.
Projected Length of Stay: - - - - : : : . ; ; : > - : : - - - - - - - - - - ' - - - - - - - - - - - - - - - - - - - -

Admitting Physician
Telephone Oktltion lntruction.s. l. Dial 995-5826. 2. Entc:r your 10#. J. Enter the work type and press< (2~ =Psychiatric Historv and ~(ental Status
Exam). 4. Entc:r the \l.:dical R<!COrd Number then::. 5. Press 2to begin recording (2 -Record/Pause, J- Review, 44. Fast Forward. 5 - Discormect_ 77.
R.:wind). 6. Press 8 to end your dictation and begin dictation on anoth.:r patient. 7. For Stats or Help call Medical Records at 778-5264.

r--

r\VEST OAKS HOSPITAL, INC.

lYIASTER TREA TlVlENT PLAJ.'f
A.

Patient Name _ ___.:,_ _ _ _ _ _ _ _ U n i t - - - - - - - D a t e - - - - - - - - - -

Re~onforAdmission '{~ C\ib~ f~rQr?S~

(1' d~

(;JJ(
All admissions must meet the following basic criteria:
I) A!te~arive rre:ume:lC hl!S be~:J tt'ied and has b~:t unsuc::!sful. 2) Alte:'7lative creJtme!'lt is nor aoorooriac:: (alte:'71Jtive
creatrne:Jt inc!ude:i, but is not limited co. reside:trial cre:trme:Jt, day crctme:Jt, on inre:tsive ourpacie~r- c:e). 3) Sig:;J.ificJnt
impairme:Jt in daily functioning in at le:lSt ;:wo ofche following major ue~ of life; a) sc~ool-or vocc.donJ.!, b) ~oc:al
situations, c) family relationships.

B.

CJ.Se

Manager----~--------

Famiiy The::~pisr

----------=-,...---

Individual Tne:-:~.pist - - - - + - - - - - - - Estim:lted

015

L~:tgth Of Stay: --'--'=-------

Admission Diag:;J.osis

A..'GS I:
A..'<IS II:
A..'<IS

[II:

AXIS IV:

S'lK.E:SSORS:

None

Miici

3
Mod.

E~e::1e

6
CJ.r.as;:ropnic

0
[nac:::_:.!ate [nfor.nation

H!~;,est G..l...F ?:!!t Yeu: --'-/...a..J{).L-------PA TEYI'S S'lR...~GTHS AMJ ASSEtS

./.
,../ vJ I JJ I I
(voc:!tionaL, social, family support, cog!litive,motivarion): _'):1-=,...,QO"'-"::..C::::....;\~!..ftth.!...4.u....flw(.._4r.~Jl~---------.-\XIS V:

c~:u GA..F: _ _____:.(Q~5=-------

C. NAMES OF FAMIL Y!OR SIGNIFiCANt Otr.:=:::tS:

L!?1!7.-\ TIONS OF T:~EIR fNVOL VE:VlBJT (financiai, legal commWlication. t:ran.spor..arion): - - - - - - - -

D. ?~:..IMrNAK y
~ Home

.VVork
~ Ourpacie:u

S ucoor: Groups:

DfSC:-!ARGC: PLAN/EX?~CTCQ DfS?OSiTiON:

._.--p!Jc!:n~:Jt
Ty-pe
S'~ool

Foifow-10 with:

-. . .:.A. !. :. . l~-+;.J..J..~.~~~Sk!U-1J~O{fl!--=Qu,p=p!-._

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PROBLEM#

oEFrNrnoN:

PROBLEM

DE?rNIT!ON: _______________________________________________

1:-

PROBLEM f:t.

-----

DE:~ITION:

____________________________________

~---------

Group Tne~pis-.:: - - - - - - - - - - - - - - - - - - - - - - - - - - -

r have discussed :his plan of c:u-e wirh the par:e:u ::nd/or family.

P:Ht:!:iC

S ig..r1arure

Guardi::n Si g!lar..:.:~

..l.Jmission Dace!

1]....
.1! (

Ocstnaclivc Bcbavior/Disruptivc Behavior

WEST OAKS HOSPITAL, INC.

PROBLEM STATEMENT SHEET

PROBLEM: Recent attempted suicide (within 72 hours) OR suicidal/homicidal ideation requiring suicidal/homicidal
precautionS OR assaultive/destructive behavior as a result of a mental disorder.
LONG TERM GOAL: Patient will learn to identify and express feelings without exhibiting destructive/dangerous behavior.
PROBLEM DESCRIPTION (complete those that apply):
Suicidal/homicidal ideation, as evidenced by:

Self-mutilative behavior, which includes: - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Unmanageable and/or uncontrollable anger, as evidenced by:

- -lQ . :z. . :=. .H"- 41Q. , t:.Jt~L" :.4:.V(!}:.J..f--------------

lmpulsive behavior, as evidenced by: - - - - - - - - - - - - ' - - - - - - - - - - - - - - - - - - - -

Other: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -ADDRESSOGRAPH
---------

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WEST OAKS HOSPITAL, INC.

PROBLEM
STATEMENT
SHEET
. -.
.
:
:
.

DATE:

PATIENT NAME:

_......S.~_-___;_G._--_)1_7
_ _ __

pROBLEM: Substance abuse of sufficient magnitUde that cessation of use results in physic:1! symptoms of
withdrawal or such ~rude that it cannot be managed in a less restrictive environmen~

of

LONG TERM GOAL: Com.mitment to sobriety through involvement in specific tre:mnent.

d~~=>-~Th~/"'---~(.f-51-'V'--~~4""=4Y:-J--

Alternative tre:ument has been tried and was unsuc::essful (be specific): _.l....
l_..JO'=""'fil-1-......

Significant impairment of daily function:

School0No~: _________________________________________________________________

Family: -------------------------------------------------------------------

Social: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Alte:-ed physical condirion_i.e., skin integrity, infection risks, poor nutritional status, he:J.d and body lice,
lab values (be specific): ___...;..____________________________________

Other: -----------------------------------------------------------------ADDRESSOGK..-\.PH

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PAillNT & F:\MTI.Y IE !CHING DOC!JJ\{ENT!IION

ADDRESSOGR4PH

Your signature below indicates that you have received

che patient education documented.

PatientTeachinc;.

Taaghr ro:

Wlf Qll!l o/Dufl {Jp);

Patieat responGa!

s{i;~~:,.c.~-~..a~. "-~ol,;iwn~.n~...L-.--0-a_te

____
- _-_-__________

compr~n--::,

!<JW" de:no~on

Did patient receive written m.aterials?.(specify)_~~J.:!.#.-I..'ddl-Lb~.:::.U:1....1L------Plan for follow-up: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Relationship

Patient signature

Patient Te!lching:

Taughtto:

L--mdr- 7K (/_rlrl

~
~

Family

respo~~c~~

return demonstration
P:1tient
Did patient receive written materials? (specify) _ _ _ _ _ _ _ _ _ _ _ _ __
Pl!ln for follow-up: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Patient signature

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PAmNT & FA:VID.Y TEACHING DOC1JM"ENI:\TION

ADDRESSOGRAPH

Your signature below indicates that you fun:e received

the patient education documented

ParientTeachi~------------------------------------------------------

Taught to:

Patient
Family

By__________________________________
oral

written

Date ________________

Patient response: verbal compre.he:1sion

rerum demonstration
Did pari en t receive written materials? {specifY) _____________________________
Pln.n for follow-up: ___________________________________________________

P:ltient sign:mn-e

Relationship

Patient T e!lching: ____________________________________________________

Taught to:

Pari em
F:!..!nily

By___________________________________
Date. _________
oral
\.vnnen

Patient response: verbal comprehe.'lSion

return demonstration
Did patient receive written mat~rials? (specify) ____________________________
Plan for follow-up: __________________________________

Patient signature

Relationship

__

:t83

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Name

K~~

Marital Status

'

Education

-:J_

----

Sf.
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ADOLESCENT~~

SASSI Substance Abuse Subtle Screening lnventu.,

092992 M

{r-u.L\~
Age
L\j Date S lie\ q1
Occup.ation ~- Location
U .- l
~'
FVA

Decision Rules for the Adolescent SASSI

14

13
80

YES

FVOD

12
11

OAT

SAT

12

RAP

___,

II

COR

DEF2

DEF

II

10

PERCENTILE

12

1.

s
s

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2.

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0

YES

70

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3.

I N

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L N
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YES

4.

L,YES
y~

5.

YES

6.

a::

60

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CLASSIFY NON DEPENDENT

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<!>Copyright May. 1990

'lenn Miller

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Name - - - - - - - - - - - - - - - - - - A g e
Marital Status

092992 F

ADOLESCENT FEMALE PROFie

SASSI Substance Abuse Subtle Screening Inventory

Date _ _ __

~i

Location _ _ _ _ _ __

Occupation _ _ _ _ _ __

Education

L
Decision Rules for the Adolescent SASSI

1. lis either FVA or FVOD raw

score 12 or more?
NO

2. 'Is OAT or SAT T Score

70 or more?

l._

NO

3. fAre both OAT and SAT

T scores 60 or more?
NO

4. lis DEF raw score 10 or more

nd DEF2 4 or more?

L_

5.

NO

NO

YES

0
E
p
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N
c 0
A E
l N
T

YES

70

YES

YES

I
r
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13

a:
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60

....Ill

50

SAT

DEF

12

DEF2

10
9

19

17

16

15

14
13
12
11

f---10

1
0

10

9
8
7

11

18

10
4

9
3

98th

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8
7

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Is DEF2
5 or more?

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2
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15th

YES

CLASSIFY NON DEPENDENT

NO

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PERCENTILE

RAP

20

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11

11

40

OAT

-+ 12

....

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H
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11

6. rAre both OEF and SAT T scores 60 or more?

NO

YES

Are both DEF and OAT T scores 60 or more?

I
I
L~.

80

FVA

~~

.. ~

0901938

For each item below, circle the number which reflects how often you have experienced the
situation described.
The numbers represent the following categories:
0 = Never
1 = Once or Twice
2 =Several Times

= Repeatedly

OTHER DRUGS

ALCOHOL
DRANK ALCOHOL DURING THE DAY?

~ 3

2.

TAKEN A DRINK OR DRINKS TO HELP YOU TALK ABOUT

YOUR FEELINGS OR IDEAS?

~1

TAKEN A DRINK OR DRINKS SO YOU WOULDN'T FEEL

TIRED OR TO GIVE-YOU A LIFT WHEN YOU HAVE TO
KEEP GOING?

@1 2

G) 2

@3

3.

0 (!)2 3

4.

0 1

o ID 2

5.

GOTTEN SICK FROM DRINKING? (E.G., VOMITING, DIZZINESS, HEADACHE)

TAKEN DRUGS TO BE MORE AWARE OF YOUR SENSES

(E.G., SIGHT, HEARING, TOUCH, ETC.)?

4.

TAKEN DRUGS SO YOU COULD ENJOY SEX MORE?

o023

5.

TAKEN DRUGS TO HELP YOU FORGET THAT YOU FEEL

HELPLESS AND WORTHLESS?

6.

TAKEN DRUGS TO FORGET SCHOOL, WORK OR FAMILY

PRESSURES?

BECOME VERY SAD OR FELT "DOWN" AFTER HAVING

SOBERED UP?

~1 2 3

7.

GOTTEN INTO TROUBLE WITH THE POLICE BECAUSE

OF DRUGS?

8.

0 1@3

8.

1 2 3

ARGUED WITH YOUR FAMILY OR FRIENDS BECAUSE OF

YOUR DRINKING?

GOTTEN REALLY STONED OR WIPED OUT ON DRUGS

(MORE THAN JUST HIGH)?

9.

HAD A STRANGE EXPERIENCE WHEN DRINKING (SUCH

AS SEEING SOMETHING NOT REALLY THERE) THAT
CAME BACK WHEN YOU HADN'T BEEN DRINKING FOR A
WHILE?

{)1 2 3

9.

TRIED TO TALK A DOCTOR INTO GIVING YOU SOME

PRESCRIPTION DRUG (E.G., TRANQUILIZERS, PAIN
KILLERS, DIET PILLS, ETC.)?

o'Q)23

10.

@)1 2 3

10.

LOST FRIENDS BECAUSE OF DRINKING?

@)1 2 3

11.

FELT REALLY NERVOUS OR SHAKY AFTER HAVING

SOBERED UP?

ry

SPENT YOUR SPARE TIME BUYING, SELLING, TAKING,

OR TALKING ABOUT DRUGS?

11.

USED ALCOHOL AND OTHER DRUGS AT THE SAME

TIME?

~1

12.

TRIED TO KILL YOURSELF WHILE DRUNK?

(o')1 2 3

12.

CONTINUED TO TAKE A DRUG OR DRUGS TO AVOID

THE PAIN OF WITHDRAWAL?

0 (i)2 3

13.

FELT YOUR DRUG USE HAS KEPT YOU FROM GETTING

WHAT YOU WANT OUT OF LIFE?

011)23

14.

BEEN ACCEPTED INTO A TREATMENT PROGRAM BECAUSE OF YOUR DRUG USE?

1 2 3

6.

GOTTEN INTO TROUBLE IN SCHOOL, AT HOME, ON THE

JOB, OR WITH THE POLICE BECAUSE OF DRINKING?

O\U23

7.

0 1 ~3

ft! f\
{!}

2 3

0 1

...)

::?""':::> l f ~

1- ~ t- I

~@

-\--- I_

-1- l t- ?-

p,iol)

-~~

2. TAKEN DRUGS TO HELP YOU FEEL BETTER ABOUT A

PROBLEM?
3.

HAD MORE TO DRINK THAN YOU INTENDED TO?

2 3

~23

@)

b4

1. TAKEN DRUGS TO IMPROVE YOUR THINKING AND

FEELING?

1.

0 1

:.;n.

~123

oG23

~::> l {- t ~ l

?)(?)

-t -:L .-r I 1- :2.

+- 1 +- I

R . . .

-1

l
!

ADOlESCENT

SASSI

FOR~--~

H 1 statement is TRUE or MOSTLY TRUE for you. )ill in the square in the column headed T: that Is.
If 1 statement is FALSE or MOSTLY FALSE for you, fill in the square in the column headed F: that is.

Fill in this way.

0
0

Not like this.

Please try to answer all Questions.

MOST PEOPLE MAKE SOME MISTAKES IN THEIR LIFE.

AT LEAST ONE OF MY PARENTS WAS OFTEN VERY SAD, ANXIOUS. OR UNHAPPY

WHEN I WAS A CHILD.

NO ONE HAS EVER CRITICIZED OR PUNISHED ME.

I HAVE NOT LIVED THE WAY I SHOULD.

0
0
0

I HAVE HAD DAYS, WEEKS, OR MONTHS WHEN I COULDN'T GET MUCH DONE
BECAUSE I JUST WASN'T UP TO IT.
I ALWAYS LISTEN CAREFULLY TO PEOPLE THAT ARE OLDER THAN ME.
I LIKE TO OBEY THE RULES.
I HAVE WANTED TO RUN AWAY FROM HOME.

I OFTEN FEEL SICK TO MY STOMACH.

SOME CROOKS ARE SO CLEVER THAT I HOPE THEY GET AWAY FROM THE POLICE.
MY SCHOOL TEACHERS HAVE HAD SOME PROBLEMS WITH ME'.
I HAVE NEVER DONE ANYTHING DANGEROUS JUST FOR FUN.
I HAVE SOMETIMES DRUNK TOO MUCH BEER OR OTHER ALCOHOLIC DRINK.

MUCH OF MY LIFE IS BORING.

0
~ 0

SOMETIMES I WISH I WERE MORE IN CHARGE OF THE WAY I BEHAVE AND FEEL.

/<

EVERYTHING SEEMS TO BE TURNING OUT JUST LIKE THE BIBLE SAID IT WOULD.

Nome

AT TIMES I FEEL WORN OUT FOR NO SPECIAL REASON'.

I HAVE TRIED TO STAY AWAY FROM PEOPLE I DID NOT WISH TO SPEAK TO.

SOMETIMES I HAVE A HARD TIME SITTING STILL.

I OFTEN FEEL THAT STRANGERS LOOK AT ME AS IF I AM WEIRD.

I CAN BE FRIENDLY WITH PEOPLE WHO DO MANY WRONG THINGS.

I DO NOT LIKE TO SIT AND DAYDREAM'.

II

I AM ALWAYS WELL BEHAVED IN SCHOOL.

1!1

0
0
0
0

I HAVE NEVER BEEN IN TROUBLE WITH THE PRINCIPAL OR WITH THE POLICE

0
0

0
0
0
0
0

,.

'L- L

I BELIEVE THAT PEOPLE SOMETIMES GET CONFUSED.

SOMETIMES I AM NO GOOD FOR ANYTHING AT All".
I BREAK MORE RULES THAN MOST PEOPLE MY AGE.

Last sch - a de completed

f/

l"'t'
St""' s
3 ~ q 'J

Date

IF SOME FRIENDS AND I WERE IN TROioJBLE TOGETHER. I WOULD RATHER TAKE ALL
THE BLAME THAN TELL ON THEM .

II
0

0
0
0

0
0

0
0

0
0

0
0

SWEARING AND CURSING HAVE BECOME A SERIOUS PROBLEM IN OUR SCHOOLS

AND MUST BE STOPPED.

0
0

0
0

0
0
0

I HAVE OFTEN FELT BAD OR SCARED BECAUSE OF THE DRINKING OR DRUG USE OF
SOMEONE IN MY FAMILY.

SOMETIMES I FEEL THAT MY DRUG USE OR DRINKING IS KEEPING ME FPOM

GETTING WHAT I WANT OUT OF LIFE.

I RARELY TALK ABOUT MY REAL FEELINGS OR WORRIES WITH EITHER MY FRIENDS

OR MY FAMILY

I THINK THERE IS SOMETHING WRONG WITH MY MEMORY'

I HAVE BEEN TEMPTED TO HIT SOMEONE
I ALWAYS FEEL SURE OF MYSELF .
I HAVE NEVER BROKEN AN IMPORTANT RULE.
THERE HAVE BEEN TIMES WHEN I HAVE DONE THINGS I DIDNT REMEMBER LATER
I THINK CAREFULLY ABOUT EVERYTHING I DO.
I HAVE USED ALCOHOL OR "POT" TOO MUCH OR TOO OFTEN
NEARLY EVERYONE ENJOYS BEING PICKED ON AND MADE FUN OF.
SOME OF MY FRIENDS HAVE BAD REPUTATIONS .
MOST PEOPLE WILL LIE TO GET WHAT THEY WANT
MOST PEOPLE WILL LAUGH AT A JOKE AT TIMES.
I ALMOST ALWAYS KNOW WHAT TO SAY
I AM OFTEN RESTLESS OR JUMPY .
I SMOKE CIGARETTES REGULARLY.
AT TIMES I HAVE BEEN SO FULL OF PEP THAT I FELT I DIDN'T NEED TO SLEEP FOR
DAYS AT A TIME.
I HAVE SOMETIMES JUST SAT ABOUT WHEN I SHOULD HAVE BEEN WORKING'
I OFTEN FEEL ANGRY BECAUSE PEOPLE DON'T TREAT ME RIGHT
I CAN BE DEPENDED ON TO DO THE THINGS I AM SUPPOSED TO.
AT LEAST ONCE A WEEK I TAKE MEDICINE FOR A STOMACH ACHE.
I HAVE NEVER FELT SAD OVER ANYTHING
I AM USUALLY HAPPY'.
I HAVE NEGLECTED SCHOOL WORK BECAUSE OF DRINKING OR USING DRUGS .
I HAVE TAKEN A DRINK IN THE MORNING TO STEADY MY NERVES OR TO GET RID OF
A HANGOVER

These items are taken from the Psycholog1cal Screening mvenlory

00

o:-_;

~i

PLEASE CONTINUE ON
REVERSE SIDE

se,__l)t}_

-\L S-}= ./h.~~

093092 F

:e=:~~.~~ b y Roc hard

r Lanyon. Ph.D and are used

IT IS ILLEGAL TO
REPRODUCE THIS FORM
Copyright May,

oyGI.iller

(IWestOaks

~JHospital

ll 5 Sll - 8

1e 4 J

70 1

AFTERCARE HOSRIEf.-... IE 1TH

0q
Cf'H

Ci llf B
.

PATIENT NAME: ______~~+~--~------------~0~)-~l~~~-~~,i~---

3./1~/q/

r~l-CS-97

Addressograph 70 8

'~'''

fliiT :--ftll--

'---------------------

DISCHARGE DATE: ______~.--/~t-~--~~

A.

Follow-up Treatment

B.

Living Arrangements:

C.

Support Group Reference (specify vocational, educational, social)

D.

Agency/Resource Referral; (if applicable) _______________________________________

E.

Discharge Medications/Patient Instructions: (May attach a copy of medication

side effect stickers and inc~ude dietary considerations)

th whom, and frequency)

Comments/Side Effects

G:

H:

ni

JJrif!P

Involvement After Discharge:

Relapse Warning: a) How will you know that you need to seek help?
you call if you relapse?

Patient/Family Signature

b)

Who will

flK~;euc
3/b!CJJ

Stafi'~

REV. 6/94

,-..
i

115511-8

70 3

Si.AIJiLN, KEITH
~Q.

GAR~

9H

\lEST 0~~ J19~~~TAL

qqqqq

Ia

CJ-C5-<J7

PHYSICIA.T-i' S TREATMENT ADMITTING ORDERS

TO BE COMPLETED

~ITHIN

I.

Admit to Unit ___~~~~---

II.

Complete body search

'

TWENTY-FOUR (24) HOURS FOLLOY1NG ADMISSION

III.
\

j /\

;\"\'

\~\

IV.
~

Assessments (Psychosocials should be on chart within 48 hours. Please order

IMMEDIATELY. STAFF TO COMPLETE CONSULT REQUEST FORM for each of the following

A)tlJl ass~es

'J

ments.)

r,

..

~-

i-~{Y \.J\\'

3i\'\(
'AI

ocial Service Dept.

2.

Allied Health

rofessional
(_

~ ~

0 ther Assessments (specify) _____________..:__-:-------------------------

Vit::f]> .Signs. -

(Temperature, BP, Pulse, Respiration)

~Routine
VI.

/ Court Ordered

_\)t7"'
__ Psychosocia~ls essment Update
Please specify:

..~_I

v.

'

sychosocial Assessment:

Special~--------,-------------7-----------------------

t.or~;orv .J::::..on fllo"Ck'

~BC Pu: ~R

desired)
_ _Urine Drug
5538 Drug Screen

'v

0321

0909

Lithium Level

0799

0003

_=:_Pregnancy--Test

Additional lab test(s), please specify and justify: _______________________

VII. Diet:

J=;;:~lar

VIII. Pharrnacv:
IX.

_ _ Special (please indicate type): ________________

please write medication orders on the Physician Order Sheets.

Privileges
Legal status:
Grounds:
Telephone:

_____ Involuntary
Supervised
Unsupervised
-----Restricted (to whom) __________

Justification (if restricted): _________________________________________

r.

i---

IX. Privileges (Contin*ed)

~~~estricted

Visitors:
Justification

Restricted (to whom

-------

(if~ricted):

~~

Mail:

Unrestricted

Restricted (to whom

-------

Justification (if restricted):

X.

Jierapv Orders (Verify Benefits)

(j___--

___ Individual:JJ-Frequency
AHP: specify
Hospital Staff

~amily:

1Frequency_-:----AHP:
specify~------------------------------
Hospital Staff

Additional Tests
_ _ _ EKG

Chest x-ray (PA and Lateral)

_____ EEG

____ PPD -(if not done within last 12 months)

(if done within last 12 months, need record)
Please justify_______________________________________________

3 ~)97
Date and Time

Date and Time

Attending Physician
(please indicate if different from

ACit~~ng ,Ph~siciaxy/
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WEST OAKS
The Psychiatric Institute of Houston

PHYSICIAN'S ORDER

Houston, Texas

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2.
SEND YELLOW COPY TO PHARMACY -PINK TO MEDICATION NURSE.
3.
USE ORDERS IN SEQUENCE

r-rml 0004

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WEST OAKS

AFTER PHYSICIAN WRITES A MEDICATION ORDER

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REMOVE YELLOW AND PINK COPIES
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70 3

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18
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"Subsidiary of Heal!hcare America, Inc. Affiliated with The Brown Schools"

REV. 8/94

,,1. .96

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[I

West Oaks
Hospital

PROGRESS
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OOSF

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" Subsidiary of Healthcare America, Inc. Affiliated with The Brown Schools"

REV. 8/94

t"- ...--.

111 West Oaks

1"1 Hospital

DESCRIPTIVE CHARTING INCLUDES IN BEHAVIORAL TERMS

THE PATIENT'S STATUS, THERAPEUTIC INTERVENTIO~~l
RESPONSE TO INTERVENTION AND PLAN, NURSING NOT~S .
MUST REFLECT THE NURSING PROCESS (ASSESSMENT,
PLANS, INTERVENTION AND EVALUATION).
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Form II OOSG

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"Subsidiary of Healthcan: America, Inc. Affiliated with The Brown Sc~oo!s"

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DESCRIPTIVE CHARTING INCLUDES IN BEHAVIORAL TERMS

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RESPONSE TO INTERVENTION AND PLAN, NURSING NOTES
MUST REFLECT THE NURSING PROCESS (ASSESSMENT,
PLANS, INTERVENTION AND EVALUATION).
Form t OOSG

" Subsidiary of Healthcare America. Inc. Affiliated with The Brown S.-hools"

REV. 8194

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DESCRIPTIVE CHARTING INCLUDES IN BEHAVIORAL TERMS THE PATIENT"$ STATUS, THERAPEUTIC INTERVENTION. RESPONSE TO
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EVALUATION)

Form II OOSF

Subsidiary of Healthcare Amenca, Inc. Affiliated wtth The Brown Schools"

REV. 8194

_200
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---

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'

SUMMARY OF GROUPS

Patient Name: . /~. . -~

Problem List (from MTP)
!. _ _ _ _ _ _ _ _ _ _ _ _ _ _ ). _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
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18

Record patient participation/isssues/discussion on the lines

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Use this sheet until full (continue on the back).
TLS 7-8-94

" Subsidiary of Healthcare America, Inc. Affiliated with The Brown Schools"

REV. 7194 ~o

.)C.c,-:1

,---
....
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REV. 7/94

SUMMARY OF GROUPS

Patient Name:
GT. M\.:. ,V'I
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Problem List (from MTP)

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"Subsidiary ofHealthcare America. Inc. Affiliated with The Brown Schools"

n.s 7-8-94
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Form #863 pg 2

204

REV. 7194

14l~G000

RREA/ROUTE/STOP~

8031000

WEST OAKS PSY,:!;.lN'ST HOUSTON

6500 HORNSWOOD..
HOUSTON, ...._T.,..,,-.~.;-~:_._
. r... r(''
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GINGER 8~9.
J;9Nt}::?;:
FAX # 71~:JCj: ...-~it>/:' '

~""'' Sm1thKI1ne Beecham

~U Clinical Laboratories
MICROFILM# 03069744837

10

~tfuiN,KEITH

CENTR(-lL
TIME

REPORT STATUS

FINAL

TEST

RESULT

UNITJ
\

RINALYSIS,
COLOR

REFERENCE
RANGE

COMPLETE

HL

~~PPEARANCE

SPECIFIC GRAVITY
Pli

YELUlW
CLEAR

YELLOW
CLEAR

1. 015
6.5

4.6-8.0

1. 001--1. eu5

NEGA'FIVE
NEGATI,VE

~LUCOSE

. IL I RUBIN
kETONES
OCCULT BLOOD
PROTEIN
NITRITE
LEUKOCYTE ESTERASE
WBC

NEGAtJtvENEGAi'(OE:
NE~ATIVE

S1~~:
4-5:

/HPF

;J;>

e.c

NONE SEEN
1-3

dQUAMOUS EPITHELIAL CELLS

i>1UCUS ri-lf<EADS

>> END OF REPORT

SITE
CODE

1+

<<

NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
< OR :: 5

/HI=F

< ORc:.::..:.

/HPF
/LPF

NONE SEEN
NONE SEEr~

;----ilJ ARE~l:fl_.Q.
-~..J,f;.{STOP: 8031000
.4KS pgy'~ff.:tfilf. HOUSTON

10 '""'~,.JU~,AU..

SB

SmtthKitne Beecham
Clinical Laboratories
MICROFILM#

0306974357~

10

CENTRAL
TIME

FINAL

TEST

- 8033
ZYME
.UCOSE
~EA NITROGEN
CBUNl
REATININE
0N/CREATININE RATIO
JDIUM
'OTASSIUM
;HLOR I DE. ------'--- - - - ..
1~1GNESIUM

:ALCIUM. --- ... . ........ ---

~HOSPHORUS,
INORGANIC
:ROTE IN, TOTRr::- -~
''LBUMIN
i..OBULIN
ALBUMIN/GLOBULIN RATIO
BILIRUBIN, TOTAL
~~LI(,I=lL I NE PHOSPHATASE
LDH, TOTAL
GGT
AST <SGOT)
ALT <SGPT>
URIC ACID
l rmi'J, TOTAL
IRON BINDING CAPACITY
~~ SATURATION
TRIGLYCERIDES
CHOLESTEROL, TOTAL

UNITS\

RESULT

REFERENCE
RANGE

HL
84

1'1G/DL
MG/DL
MG/DL
\CALC)
MEQ/L

12
1.1

11
141
4. 1

70-115

7-25
0.7-1.4
6-25

135-146

1'1EQ/L

1ilJ2

MEQ/L

1.8

MEQ/L

95-11218
1. 2-2. 0

MG/DL

8. 5--10. 3

1'1G/DL
G/DL
c:;,: DL..

6.0-8.5

:~ij~:> . ;s-,_:
7. 1

4.4
2.'7

3.

G/DL :U~LCl
:Cf.1LCl
1'1lJ / DL
U/L
U/L
U/L
U/L
U/L

1.6

1.0
109
150
18

26
14
4.5
131
291

2~5.

0. 8-2. IZI

0. 0-1. 3
30-225
0-250
0-E:-5
0'--42
0-48
4~0..:.:8;~

l'lG/DL
r1CG/ DL

25-170

rlCG./ DL.

200-450

45
47
163

\U4LCi
MG/DL

12-57

MG/DL

C170

HDL-CHOLESTEROL

75

r1G/DL.)

> 34

LDL-CHOLESTEROL

79

C:lOL/HOLC

f~ATIO

PLATELET CT & DIFF

WHITE BLOOD CELL COUNT
R~D BLOOD CELL COUNT
HEI>lOGLOB IN
HEJ>1ATOCR IT

::.

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<200

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1.
FL.

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3IZI. 1

>>

HL
HL
HL

HL
5.8
4.89
14.7
43.9
89.6

l'lCV
1'1LH

SITE
CODE

REPORT CONTINUED ON NEXT PAGE

((

5--13.0
4. 10-5. 30
12. 0---1&.0
Lf.

3E:.. 0-A9. 0
7t:l. 0---102.0
~::5 . 0-35. 0

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2100 AR~.'t:t~aQ~l~9HOP :-. 803:1000..

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~U Clinical Laboratories

MICROFILM# 0306974357g

CENTRAL
TIME
FINAL
PLATELET CT

.:He

33.6
214.
2987
51.5
2105
36.3

.ATELET COUNT
JSOLUTE NEUTROPHILS
'::UTROPHILS
pqOLUTE LYMPHOCYTES
;HOCYTES
BSOLUTE MONOCYTES
JNOCYTEs------ ....
BSOLUTE EOSJNOPHILS
OS I NOPH rt::s..- -- -..
4BSOLUTE BASOPHILS
.3ASOPHILS
ID PLASMA REAGIN
>>

CELLS/MCL

1200-5200

1-

CELLS/MCL
CELLS/MCL

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200-1100

1-

15'l
0.4

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31. IZI-31. 0
130-400
1800-8000

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1-

THOUS/MCL
CELLS/t>1CL

CELLS/t>lCL

50-500
0-200

~{.

NON . - REACTIVE

HL

.-- ,.- I l - Q0
l l ':i':Jl..

BOYS: 2 TO 18 YEARS
PHYSICAL GROWTH
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'"'c::SPONSE

MEDS NOT GIVEN

INJECTION SITES:

Pallen! Aslee-p

Righi Oelloid Ate,'\

VI

Lei! A.noomen

Ofl 01 Uo.l

1!.

lch Deltoid Area

VII

Rqu ThiQh

Retused

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Ricj'lt Gluteal A.re11

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Laftf~

Loll Olutet Area

DC
1(

R~Qf\1\olerllrtl~leal ~-----t--+--------J-LeltVenuoglulttal

~-----+--+-----_j__

o.)

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A.R. VERIFIED

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H

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br. G.74Rb

-------,---------,-------

0- 5-q-r

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MEOS NOT GIVEN

P

P.'lhcnt A5~("0

Ott OtUnot

INJECTION SITES:
l

R.gt'll Deltooa AfC.l

rr:

r----

r-- r

r-
8'6-Y~

A.R. VERIFIED

(:

Rooa: 1185

KfiTH

TAB 751'16

V~AXINE

Star
19N

Sto~
81351)

03/06
CDS

0~/05

1900

0859

03/0&

~/05

RISPERM.

Cis

iR:ID..I~ IM'IBIOTICS

~CILLINS

SOED

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1-1' \'>

0 '! 3 '1

0788

l/1ct.i

2000

f!e.."W

C(5

COG

EFFEXOR

1900

0859

0700

03/0&

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2000

PO TWICE ADAY

COG

DiS

...

MD Phone: 71J-q7J-1007

f~;

RISPERIDAL

=)

(11)

TAB 21'16

RISPERIDONE
..
PO AT BEDTIME

..:...

Allergies
Patient ID: 50388
Hgt: 0cl Wgt: 72.57kg MRI: 8843
Sex: M Age: 18
Diagnosis: SUBSTANCE ABUSE
BSA:
0
Physician: GARB, ROtRD

Nau: ST. AUBIN,

Medication
TAB 1146
RISPERIIXJE
PO EVERY NORNIN6

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01101 Unt

RehiS@O

NPOlStuches

IV

NPQ.- Surr,cy

RQht De1t0od L'a

nJOMmutf"'S

il
C

Retiet ul

00 Mullll'i

No Rehel

1105

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Left Denoid

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RIQtlt Gluleal Arril

Lei! Cluteat Area

Roqtll 1\b(crT'I('n

ST. AUBIN, KEITH

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INJECTION SITES:

MEDS NOT GIVEN

VI

Lcll Abdomen

vu

RIQht Thigh

VIII

Leil n,igl,

IX

'

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I~

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RIQht Vantrogluteal

LRII

VQfllfO~teal

50388

Pr1nted: 11:11 on 03/07/97

Page 1 of . .

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