SOP_NUMBER: 508.30-att-4
TITLE: Abbreviated Psychiatric Admission Note (M70-01-04)
DIVISION: Health Services
TOPIC_AREA: Mental Health Evaluations/Screenings/Treatment
EFFECTIVE_DATE: 2019-12-09
WORD_COUNT: 139
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/420247
URL: https://gps.press/sop-data/508.30-att-4/
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
ATTACHMENTS:
1. Acute Care Unit Treatment Plan (Form M70-01-01)
URL: https://gps.press/sop-data/508.30-att-1/
2. Acute Care Unit Discharge Summary
URL: https://gps.press/sop-data/508.30-att-2/
3. Acute Care Unit Admission Log
URL: https://gps.press/sop-data/508.30-att-3/
4. Abbreviated Psychiatric Admission Note (M70-01-04)
URL: https://gps.press/sop-data/508.30-att-4/
5. Acute Care Unit Discharge Summary Note (Form M70-01-05)
URL: https://gps.press/sop-data/508.30-att-5/
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FULL TEXT:
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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.