SOP 508.31-att-2: Crisis Stabilization Unit Psychiatric Admission Form (M70-02-02)
Summary
Key Topics
- Crisis Stabilization Unit
- psychiatric admission
- mental health evaluation
- CSU intake
- psychiatric assessment
- mental status examination
- diagnostic impressions
- past psychiatric history
- self-injury
- crisis intervention
- offender mental health
- GDC medical forms
Full Text
SOP 508.31
Attachment 2
12/9/19
|CRISIS STABILIZATION UNIT
PSYCHIATRIC ADMISSION FORM|PATIENT IDENTIFICATION
Facility: __________________________________________
Offender: _________________________________________
GDC ID#: _____________________ DOB: _____________
Race: __________________ Sex: _____________________|
|---|---|
|Chief Compliant or Reason for Admission:
History of Present Illness:
PAST PSYCHIATRIC HISTORY (Be sure to include a summary of your chart review, a history of Psychiatric
Hospital admissions, Crisis Stabilization Unit admissions and self-injuries):
Mental Status:
|Chief Compliant or Reason for Admission:
History of Present Illness:
PAST PSYCHIATRIC HISTORY (Be sure to include a summary of your chart review, a history of Psychiatric
Hospital admissions, Crisis Stabilization Unit admissions and self-injuries):
Mental Status:
|
Form no. M70-02-02 Page 1 of 2
Retention Schedule: Upon completion, this form shall be placed in the offender’s medical file (Infirmary Section with CSU/ACU packets) and retained for ten (10)
years.
SOP 508.31
Attachment 2
12/9/19
|CRISIS STABILIZATION UNIT
PSYCHIATRIC ADMISSION FORM|PATIENT IDENTIFICATION
Facility: _________________________________________
Offender: _______________________________________
GDC ID#: _____________________ DOB: ____________
Race: __________________ Sex: ____________________|
|---|---|
|Assessment:
Diagnostic Impressions:
Principal Diagnosis:___________________________________________________________________________ __
Other:|Assessment:
Diagnostic Impressions:
Principal Diagnosis:___________________________________________________________________________ __
Other:|
|
Other: ___________________________________________________________________________|
Other: ___________________________________________________________________________|
|
Other:|
Other:|
|||
|(To Be Completed within 24 hours or next Business Day).
__________________________________________________________________________
Psychiatrist's Signature Printed/Typed Name Date
|(To Be Completed within 24 hours or next Business Day).
__________________________________________________________________________
Psychiatrist's Signature Printed/Typed Name Date
|
Form no. M70-02-02 Page 2 of 2
Retention Schedule: Upon completion, this form shall be placed in the offender’s medical file (Infirmary Section with CSU/ACU packets) and retained for ten (10)
years.