MPC 827 (8/30/19)
ofpage
Docket No.
REVIEW ORDER
Antipsychotic Medication
Commonwealth of Massachusetts
The Trial Court
Probate and Family Court
First Name
Last Name
Middle Name
In the Interests of:
Incapacitated Person
Division
After consideration of the submitted pleadings, it is Ordered that:
(date)
Blood level testing, as appropriate, shall be administered in accordance with current clinical protocols. Side effect
medication(s) may be administered if clinically indicated.
, the Clinician having examined the incapacitated
The plan for administration of antipsychotic medication(s) to the Incapacitated Person as contained in the Clinician's 1.
Affidavit and Report dated
person on
(date)
, is approved.
(date)
at
A.M. P.M.
This approval shall expire at 4:00 P.M. on that date unless sooner extended.
The approved Treatment Plan shall be reviewed on2.
and file a written report to the Court for the next scheduled review hearing which sets forth the following:
A. Where, and in what circumstances the Incapacitated Person is currently living;
The substance of the Monitor's meeting with the Incapacitated Person;B.
The Monitor's review of the treating clinician's Court-ordered treatment reports in terms of completeness and
responsiveness to the Court's Order as well as consistency with the Incapacitated Person's medical records;
C.
Types and dosages of all medications administered to the Incapacitated Person and whether or not administration of
the authorized medications is in compliance with the Court's Order;
D.
Whether the Incapacitated Person remains incapable of making medical treatment decisions and whether the
conditions and circumstances which justified the Court's present Order authorizing treatment with antipsychotic
medication and other medications have substantially changed;
E.
The substance of the Monitor's interview of the treating clinician, whether in person or by telephone, regarding the
Incapacitated Person's present status and treatment needs, and, if the treating clinician is/has been unavailable to
the Monitor, details of attempts to contact the treating clinician should be outlined with specificity and the clinician's
progress notes may be referred to instead;
F.
The substance of the interview of associated staff, whether in person or by telephone, regarding the Incapacitated
Person's present status and treatment needs.
G.
(name)
The Monitor,
3.
, shall continue to monitor the Incapacitated Person
which is filed with the Court and expressly made part of this Order.
(date)
The parties shall comply with a stipulation or agreement of the parties dated4.
Other:5.
Date
JUSTICE
JUDICIAL DESIGNEE
AT ANY TIME, ANY INTERESTED PARTY MAY MOVE TO ALTER, EXPAND, LIMIT OR TERMINATE THIS ORDER.
