SOP 508.30-att-4: Abbreviated Psychiatric Admission Note (M70-01-04)

Division:
Health Services
Effective Date:
December 9, 2019
Topic Area:
Mental Health Evaluations/Screenings/Treatment
PowerDMS:
View on PowerDMS
Length:
139 words

Summary

This form is used to document psychiatric admissions for offenders admitted to acute care units in GDC facilities. Mental health professionals complete the form within 24 hours or the next business day, recording the patient's chief complaint, medical history, mental status evaluation, clinical assessment, and diagnostic impressions. The completed form is placed in the offender's mental health file and retained for 10 years after the offender no longer requires mental health services.

Key Topics

  • psychiatric admission
  • acute care unit
  • mental health documentation
  • diagnostic assessment
  • psychiatric evaluation
  • chief complaint
  • mental status exam
  • diagnostic impressions
  • psychiatrist signature
  • mental health records

Full Text

SOP 508.30
Attachment 4

12/9/19

|ABBREVIATED PSYCHIATRIC
ADMISSION NOTE
(FOR ACUTE CARE UNIT)|PATIENT IDENTIFICATION
Facility: ___________________________________________
Offender: _________________________________________
GDC ID#: _____________________ DOB: ______________
Race: ___________________ Sex: _____________________|
|---|---|
|Chief Compliant:




History of Present Illness:




Mental Status:




Assessment:






Diagnostic Impressions:

Primary Diagnoses: ________________________________________________________________________
Other: ___________________________________________________________________________________
Other:____________________________________________________________________________________
Other:____________________________________________________________________________________
Other: ____________________________________________________________________________________

(To Be Completed within 24 hours or next Business Day).


_________________________________________________________________________
Psychiatrist's Signature Printed/Typed Name Date

|Chief Compliant:




History of Present Illness:




Mental Status:




Assessment:






Diagnostic Impressions:

Primary Diagnoses: ________________________________________________________________________
Other: ___________________________________________________________________________________
Other:____________________________________________________________________________________
Other:____________________________________________________________________________________
Other: ____________________________________________________________________________________

(To Be Completed within 24 hours or next Business Day).


_________________________________________________________________________
Psychiatrist's Signature Printed/Typed Name Date

|

Form no. M70-01-04 Page 1 of 1

Retention Schedule: Upon completion this form shall be placed in the offender’s mental health file (section 1). At the end of the
offender’s need for mental health services and/or sentence, the mental health file shall be placed within the offender’s health record
and retained for 10 years.

Attachments (5)

  1. Acute Care Unit Treatment Plan (Form M70-01-01) (147 words)
  2. Acute Care Unit Discharge Summary (86 words)
  3. Acute Care Unit Admission Log (58 words)
  4. Abbreviated Psychiatric Admission Note (M70-01-04) (139 words)
  5. Acute Care Unit Discharge Summary Note (Form M70-01-05) (124 words)
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