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SOPs/Patient-Care/SOP-MHI-001-Admission-Assessment.md
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# Standard Operating Procedure: Psychiatric Inpatient Admission and Assessment
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| Document ID | SOP-MHI-001 |
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|-------------|-------------|
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| Title | Psychiatric Inpatient Admission and Comprehensive Assessment |
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| Revision | 1.0 |
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| Effective Date | [DATE] |
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| Author | [AUTHOR] |
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| Approved By | [APPROVER] |
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| Department | Inpatient Psychiatry |
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---
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## 1. Purpose
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To establish standardized procedures for the admission and comprehensive psychiatric assessment of patients to the inpatient psychiatric unit, ensuring safety, regulatory compliance, and appropriate treatment planning.
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## 2. Scope
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This procedure applies to all psychiatric inpatient admissions including:
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- Voluntary admissions
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- Involuntary/emergency detentions
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- Transfers from other facilities
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- Forensic admissions
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- Medical clearance requirements
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## 3. Responsibilities
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### 3.1 Admitting Psychiatrist
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- Conduct psychiatric evaluation
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- Determine admission criteria met
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- Establish initial treatment plan
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- Complete admission documentation
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### 3.2 Nursing Staff
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- Conduct nursing admission assessment
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- Complete safety assessment and precautions
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- Inventory personal belongings
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- Orient patient to unit
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### 3.3 Social Worker
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- Conduct psychosocial assessment
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- Contact family/supports
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- Begin discharge planning
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- Assess resource needs
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### 3.4 Mental Health Technicians
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- Assist with admission process
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- Implement observation levels
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- Secure patient belongings
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## 4. Definitions
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| Term | Definition |
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|------|------------|
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| Voluntary Admission | Patient consents to hospitalization |
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| Involuntary Hold | Legal detention for evaluation/treatment without consent |
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| 1:1 Observation | Continuous direct observation by staff member |
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| Elopement Precautions | Measures to prevent unauthorized departure |
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| Medical Clearance | Confirmation patient is medically stable for psychiatric unit |
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## 5. Procedure
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### 5.1 Pre-Admission Requirements
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#### 5.1.1 Medical Clearance
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Before admission to psychiatric unit, patient must have:
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- [ ] Medical history and physical examination
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- [ ] Vital signs within acceptable parameters
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- [ ] Laboratory studies per protocol
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- [ ] Medical conditions stabilized or treatment plan in place
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- [ ] Clearance from ED physician or medicine consultant
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**Minimum Laboratory Studies:**
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| Test | Required |
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|------|----------|
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| Complete Blood Count | ☐ |
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| Comprehensive Metabolic Panel | ☐ |
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| Urinalysis | ☐ |
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| Urine Drug Screen | ☐ |
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| Blood Alcohol Level | ☐ |
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| Pregnancy Test (if applicable) | ☐ |
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| Additional (as indicated) | |
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#### 5.1.2 Legal Status Determination
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| Status | Documentation Required |
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|--------|------------------------|
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| Voluntary | Signed voluntary admission form |
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| Involuntary | Completed legal detention documents, physician certification |
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| Court-Ordered | Court order, sheriff documentation |
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| Minor | Parent/guardian consent OR court order |
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### 5.2 Admission Process
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#### 5.2.1 Patient Arrival
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1. Greet patient and escort to admission area
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2. Verify identity with two identifiers
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3. Confirm legal status and documentation
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4. Apply identification band
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#### 5.2.2 Safety Search and Contraband Removal
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**Required for all admissions:**
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- [ ] Wand metal detector screening
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- [ ] Personal search (same-gender staff)
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- [ ] Belongings search
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- [ ] Remove and secure contraband
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**Contraband List:**
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| Always Remove | Document Securely |
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|--------------|-------------------|
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| Sharps, blades | Medications |
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| Ligature materials (belts, cords, laces) | Valuables |
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| Drugs/alcohol | Electronics (per policy) |
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| Weapons | Lighters/matches |
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| Glass items | |
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Document all items on FRM-MHI-001 Belongings Inventory.
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#### 5.2.3 Observation Level Assignment
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| Level | Criteria | Monitoring |
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|-------|----------|------------|
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| 1:1 Continuous | Active suicidal/homicidal, severe agitation | Within arm's reach |
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| Close Observation | Recent attempt, high risk | Every 5-15 minutes |
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| Routine | Low/moderate risk | Every 15-30 minutes |
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| Open | No safety concerns | Per unit routine |
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### 5.3 Psychiatric Evaluation
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#### 5.3.1 Comprehensive Psychiatric Assessment
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**Required within 24 hours of admission:**
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1. **Chief Complaint and History of Present Illness**
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- Current symptoms and duration
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- Precipitating events
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- Previous episodes
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- Current stressors
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2. **Psychiatric History**
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- Previous diagnoses
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- Hospitalizations
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- Outpatient treatment
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- Medication trials
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- ECT or other treatments
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3. **Suicide/Violence Risk Assessment**
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**Suicide Risk:**
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| Factor | Present |
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|--------|---------|
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| Current ideation | ☐ Yes ☐ No |
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| Plan | ☐ Yes ☐ No |
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| Intent | ☐ Yes ☐ No |
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| Access to means | ☐ Yes ☐ No |
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| Previous attempts | ☐ Yes ☐ No |
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| Protective factors | |
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**Violence Risk:**
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| Factor | Present |
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|--------|---------|
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| Homicidal ideation | ☐ Yes ☐ No |
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| Identified target | ☐ Yes ☐ No |
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| History of violence | ☐ Yes ☐ No |
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| Command hallucinations | ☐ Yes ☐ No |
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| Access to weapons | ☐ Yes ☐ No |
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4. **Substance Use History**
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- Substances used
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- Quantity, frequency, route
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- Last use
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- Withdrawal history
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- Treatment history
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5. **Medical History**
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- Chronic conditions
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- Current medications
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- Allergies
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- Recent medical issues
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6. **Family History**
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- Psychiatric disorders
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- Substance use disorders
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- Suicide history
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7. **Social/Developmental History**
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- Education
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- Employment
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- Living situation
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- Relationships
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- Legal history
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- Trauma history
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8. **Mental Status Examination**
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| Domain | Findings |
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|--------|----------|
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| Appearance | |
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| Behavior | |
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| Speech | |
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| Mood | |
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| Affect | |
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| Thought Process | |
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| Thought Content | |
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| Perceptions | |
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| Cognition | |
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| Insight | |
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| Judgment | |
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9. **Diagnosis (DSM-5)**
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- Primary diagnosis
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- Secondary diagnoses
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- Medical conditions
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- Psychosocial stressors
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### 5.4 Nursing Admission Assessment
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Complete within **8 hours** of admission:
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- [ ] Vital signs
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- [ ] Pain assessment
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- [ ] Fall risk assessment
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- [ ] Skin assessment
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- [ ] Nutritional screen
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- [ ] Medication reconciliation
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- [ ] Allergies verified
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- [ ] Current symptoms
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- [ ] Functional status
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- [ ] Sleep patterns
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- [ ] Safety precautions implemented
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### 5.5 Treatment Planning
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#### 5.5.1 Initial Treatment Plan (within 24 hours)
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- Provisional diagnoses
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- Initial medication orders
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- Observation level
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- Activity level
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- Diet
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- Laboratory/diagnostic orders
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- Consultation requests
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- Initial goals
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#### 5.5.2 Comprehensive Treatment Plan (within 72 hours)
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- Multidisciplinary input
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- Patient participation
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- Measurable goals
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- Interventions by discipline
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- Discharge criteria
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- Estimated length of stay
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### 5.6 Patient Rights and Orientation
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#### 5.6.1 Rights Information
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Provide and document receipt of:
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- [ ] Patient rights document
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- [ ] Grievance procedure
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- [ ] Privacy practices
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- [ ] Voluntary/involuntary rights specific to status
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- [ ] Right to refuse treatment (voluntary)
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- [ ] Advance directive information
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#### 5.6.2 Unit Orientation
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- [ ] Room assignment
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- [ ] Unit layout (exits, bathroom, common areas)
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- [ ] Schedule (meals, groups, visiting)
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- [ ] Rules and expectations
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- [ ] How to contact staff
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- [ ] Telephone use
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- [ ] Personal belongings policy
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### 5.7 Special Populations
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#### 5.7.1 Minors
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- Parental/guardian involvement
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- Age-appropriate assessments
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- Educational needs assessment
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- Child protective services notification if indicated
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#### 5.7.2 Geriatric Patients
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- Enhanced medical monitoring
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- Cognitive assessment
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- Fall precautions
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- Medication review for appropriateness
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#### 5.7.3 Forensic Patients
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- Legal hold documentation
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- Notification requirements
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- Security considerations
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- Court date tracking
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## 6. Documentation
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- FRM-MHI-001 Belongings Inventory
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- FRM-MHI-002 Admission Safety Assessment
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- FRM-MHI-003 Suicide Risk Assessment
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- Psychiatric Evaluation
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- Nursing Admission Assessment
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- Social Work Assessment
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- Treatment Plan
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- Patient Rights Acknowledgment
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## 7. Regulatory Compliance
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| Regulation | Requirement |
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|------------|-------------|
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| The Joint Commission | Assessment within 24 hours |
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| CMS | Treatment plan within 72 hours |
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| State Mental Health Code | Involuntary hold procedures |
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| EMTALA | Medical screening examination |
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## 8. References
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- State mental health statutes
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- The Joint Commission standards
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- CMS Conditions of Participation
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- Institutional policies
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---
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## Revision History
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| Rev | Date | Description | Author |
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|-----|------|-------------|--------|
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| 1.0 | [DATE] | Initial release | [AUTHOR] |
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