SOP_NUMBER: 508.31-att-2
TITLE: Crisis Stabilization Unit Psychiatric Admission Form (M70-02-02)
DIVISION: Health Services
TOPIC_AREA: 508 Policy - Mental Health, Suicide Prevention, ACU, CSU, BTU
EFFECTIVE_DATE: 2019-12-09
WORD_COUNT: 218
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/513929
URL: https://gps.press/sop-data/508.31-att-2/
SUMMARY:
This form is used to document psychiatric admissions to the Crisis Stabilization Unit (CSU) in Georgia Department of Corrections facilities. It requires medical staff to record the patient's identification information, chief complaint, history of present illness, past psychiatric history including prior hospitalizations and self-injuries, mental status examination, assessment, and diagnostic impressions. The psychiatrist must complete and sign the form within 24 hours or the next business day, and the completed form is retained in the offender's medical file for ten years.
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
ATTACHMENTS:
1. CSU_ACU Daily Nursing Clinical Assessment
URL: https://gps.press/sop-data/508.31-att-1/
2. Crisis Stabilization Unit Psychiatric Admission Form (M70-02-02)
URL: https://gps.press/sop-data/508.31-att-2/
3. Abbreviated Psychiatric Admission for CSU (M70-02-03)
URL: https://gps.press/sop-data/508.31-att-3/
4. Crisis Stabilization Unit Treatment Plan
URL: https://gps.press/sop-data/508.31-att-4/
6. Crisis Stabilization Unit Discharge Summary
URL: https://gps.press/sop-data/508.31-att-6/
7. Crisis Stabilization Unit Admission Log
URL: https://gps.press/sop-data/508.31-att-7/
8. CSU Referral Report (M70-02-08)
URL: https://gps.press/sop-data/508.31-att-8/
9. CSU Discharge Summary Note (Form M70-02-09)
URL: https://gps.press/sop-data/508.31-att-9/
10. Crisis Stabilization Unit (CSU) Admission Cover Page
URL: https://gps.press/sop-data/508.31-att-10/
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FULL TEXT:
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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.