Purple Book

(see Eating Disorders specific info in italics)


When patients arrive, they are automatically placed on ward restriction (AL1) and no sharps for a 24-hour evaluation period and need to be reassessed to determine if activity level may be changed. If the team agrees that patients can contract for safety from self-harm and have been fully consuming their nutritional requirements, then they can move AL3 and “Sharps with Supervision.” This allows them to come to off unit groups and school, getting them engaged and functioning.

For ED Program: As a precautionary measure, they may also be placed on “day room” and “bathroom observation” status for safety and evaluation of symptoms and their level of control of their symptoms. (See below for further details)

Statuses need to be regularly reviewed at treatment planning and/or rounds. See below for further status definitions.

For ED Program: Patients admitted with eating disorders are often medically compromised and are at risk for refeeding syndrome. They usually require daily vitals and frequent lab draws. Phosphorus and magnesium are commonly low during refeeding and require special attention. Please consult your attending / treatment team about specific needs and frequency.

Activity Level Status Definitions

  • AL1: Restricted to the
  • AL2: May leave off unit with
  • AL3: May leave unit with staff as part of a patient group, may not leave the hospital building. 1:1 with staff for tests.
  • AL4: Can be considered after patient has progressed within their treatment program and have reached a particular relapse prevention practice status such as physical RT, grocery shopping with OT and/or meals out in Westwood Village with staff or parents.

Patient Status/Restrictions and Observations

  • CO (Close Observation) – Patient must be physically seen and assessed every 15

Exception is if patient is in off-unit activity such as OT. Off unit staff is responsible for patient. CO includes environmental checks such as looking for sharps in patient rooms

  • CE (Constant Eyesight) – Patient must be within constant eyesight of CE differs from 1:1 in that staff can observe more than one CE patient at a time.
  • 1:1 Patients – 1 patient, 1 staff ratio. If you are in dayroom, there must be another staff present to observe the other patients because your job is to watch only that one particular
  • SO (Suicide Observation) – SO is used for patients who are imminently suicidal (have plan with intent to carry out). Patient must be within arms length of staff at all times. Patient’s room is stripped of any potentially dangerous Only an attending M.D.


can D/C patient’s SO status.

  • Dayroom Status – Patient is limited to dayroom during free time. Reasons for dayroom status include exercising, purging, SI/SIB, refusing Patient cannot go back to their room unless accompanied by staff. Note: Two trips to room per shift. Patients must remain in the Day Room and may leave only when accompanied by staff. Patients are encouraged to bring all items they will need for the day, such as schoolwork and/or journal, with them to the Day Room in the morning to minimize trips to their room during the day. Patients may only use the bathroom in the Day Room, not their room, to minimize trips to their room during the day.
  • Bathroom Observations – Patients on “OBS” must be accompanied to the Make sure the bathroom door is open so that you can see patient’s face/mouth at all times. Some patients may request you turn on the faucet to drown out the sound.

Dayroom BR may be used and staff will pull curtain for privacy. Staff to check toilet for vomit or food before patient flushes.

  • Observation status (“OBS”) means patients must remain in eyesight of a staff member after eating, including while using the bathroom or when OBS start from end of meal or end of supplement and end after they have prepared for bed. OBS can be ordered for a specific number of hours post meal, or may be OBS as needed by patient.

Meal Status


When patients are admitted they get assigned a meal status which begins with sitting at the monitored table. Patients progress to “self-monitored meals” status after demonstrated ability to control behaviors. Rarely does a patient reach self-regulated meals on an IP unit as this would be a more typical status to consider once in a lower level of care, such as PHP.


  • Monitored/Calorie Count (CC): Patients sit at table with Meal tickets are removed from tray and placed face down on the table to take focus off food and to discourage talk about calories.
  • Self-Monitored/Unsupervised Calorie Count: Patients sit at table without Meal tickets are removed from tray during prep.
  • Self-Regulated/Off-Calorie Count: Patients sit at table without We do not record their calories; meal tickets may be left on tray.
  • Extra Time with meals: Typically granted only when patients have reached a nutritional intake of 750 calories at meals.
  • 1:1 Meals: If patients are struggling to demonstrate appropriate eating behaviors while eating in the dayroom with peers and/or are non-cooperative with completing their required nutrition, they may be placed on 1:1 meal status. The 1:1 support will allow them space away from their peers, which will be less disruptive to the milieu, and to receive closer support and feedback for what they need to work on in order to be at a place to return to the table with their peers .Patients on 1:1 at meals will eat in the Multipurpose They are given the full 30 minutes, even if they do not eat anything (unless adjusted by the treatment team to 15 minutes). Nursing staff encourages the patient to “do the best they can” and encourage social talk. They are discouraged from talking about food/calories. After 30 minute time limit is up and nursing staff will supplement patient for food not eaten, in the Multipurpose Room.


Increasing practice and responsibility:

As the patients demonstrate basic competency with completing their meals and snacks, they may begin to want to have more practice and responsibility within the program which will also ready them for their next level of care.

  • Self-Select Snacks: Patients with the self-select option will come to the Dining Room 5 minutes before snack period begins to select their snack. Patients on self-select may request to bring in food from home for their snacks, and this request must go through Dietitian. Outside tea will not be Patients may also be able to participate in grocery shopping to obtain further options with OT, if they have reached their physical RT weight and have AL 4 status.
  • Exposure Meals: If it’s within their program, patients may have Relapse Prevention Pass to practice meals/snacks in the cafeteria with family. MD order must be written before patient can go off unit with family for meal/snack. Order must state with whom the patient can eat with; which meals/snacks patient can have off the unit; whether or not patient is expected to eat food from tray, home, or cafeteria, and if they may take some items from tray to supplement food from cafeteria/home.

Typical practice progression (variability does occur):

  • Eating tray with family on the unit while the family brings in food for themselves to eat at this shared mealtime. Parents need to be coached to bring “appropriate meals” to complete for good role modeling/closely mirroring the patient’s tray.
  • May have visiting off unit while seated (no snacks or meals at this time). Parents need specific guidelines for use of visiting time (talk socially or play a game while seated) for time frame (~15-30 minutes).
  • Occupational Therapy Cooking Group practice where patients learn to plan their menu and portion while using the Meals (consisting of a main entrée and dessert) are selected and prepared by the patients in the group.
  • Snack/Meal practice in the cafeteria with staff, typically Dietitian
  • Eating meal with family on unit. Family brings a meal to share with the patient-no
  • Snack practice in cafeteria with Food items purchased in cafeteria as opposed to bringing food from unit.
  • Meal practice in the cafeteria with Food items purchased in cafeteria as opposed to bringing food from unit.
  • Snack or meal practice out in the community with staff and/or family when patient reaches physical RT weight range, 7 beneath the bottom of their target weight range.


Tips For Case Coordinator (you!):

  • Gather collateral from child and parent
    • (For ED cases: also include lowest and highest weight, h/o purging, exercising)
  • Call outpatient providers within 24 hours of admission. Consents are not technically needed for most recent providers but best practice is to obtain them. Gather past records as If patients are returning to these providers, they should be updated on a regular basis.
  • Family Meetings (1 hour each) should be scheduled within 5 business days of

Times TBD with CSW.

  • First family meeting should focus on detailed developmental history, in addition to answering questions and providing updates.
  • Early on in tx, psychoeducation should be given with regard to dx and
  • Leave time in every meeting to address questions
  • Patient to be seen every day for 30 minutes to an
    • (For ED patients: avoid mealtimes, 8:15, 12:15, 3:15 or 5:15). Notify nursing staff if you plan to take the patient off the unit.
  • We are encouraged to update parents daily – 10-minute phone calls at Medication increases/decreases should be told to parents. If child is tubed or restrained, please relay it to parents.
  • Tx planning – address dx, medications, focus of tx, and length of stay
    • (For ED patients: also report weight gain Monday to Monday, length of stay, calorie increases/ decreases, weight range, (weight gain Monday to Thursday will be discussed during Friday rounds)
  • Please write treatment orders and discuss treatment changes with patient in a timely manner following treatment planning. If changes are made from what was decided in treatment planning, please notify the team via communication with nursing or email team members of changes in the care plan so we can all remain on the same page with the patient in our approach.
    • For ED Program: Each child on ED program will be assigned a target weight range-corresponding to a BMI at the 25th% . Target weight range will be a 5# range. Dietitian will monitor weights 2x per week and will adjust calories as needed in conjunction with treatment team.
    • Generally, we expect patients to gain between 2-4lbs per
    • If patient are medically stable and on AL3, you are allowed to take them off unit to meet with Please do not take them on long walks and make sure they sit during your sessions. IMPORTANT: Sign out patient and let nursing staff know that you are leaving the unit with your patient.

If your rotation is between September and May, school is in session. Please fill out MD portion on school consent so that your patient can obtain credits for school.