mental-health-inpatient/SOPs/Patient-Care/SOP-MHI-001-Admission-Assessment.md

Standard Operating Procedure: Psychiatric Inpatient Admission and Assessment

Document ID	SOP-MHI-001
Title	Psychiatric Inpatient Admission and Comprehensive Assessment
Revision	1.0
Effective Date	[DATE]
Author	[AUTHOR]
Approved By	[APPROVER]
Department	Inpatient Psychiatry

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1. Purpose

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.

2. Scope

This procedure applies to all psychiatric inpatient admissions including:

• Voluntary admissions
• Involuntary/emergency detentions
• Transfers from other facilities
• Forensic admissions
• Medical clearance requirements

3. Responsibilities

3.1 Admitting Psychiatrist

• Conduct psychiatric evaluation
• Determine admission criteria met
• Establish initial treatment plan
• Complete admission documentation

3.2 Nursing Staff

• Conduct nursing admission assessment
• Complete safety assessment and precautions
• Inventory personal belongings
• Orient patient to unit

3.3 Social Worker

• Conduct psychosocial assessment
• Contact family/supports
• Begin discharge planning
• Assess resource needs

3.4 Mental Health Technicians

• Assist with admission process
• Implement observation levels
• Secure patient belongings

4. Definitions

Term	Definition
Voluntary Admission	Patient consents to hospitalization
Involuntary Hold	Legal detention for evaluation/treatment without consent
1:1 Observation	Continuous direct observation by staff member
Elopement Precautions	Measures to prevent unauthorized departure
Medical Clearance	Confirmation patient is medically stable for psychiatric unit

5. Procedure

5.1 Pre-Admission Requirements

5.1.1 Medical Clearance

Before admission to psychiatric unit, patient must have:

• Medical history and physical examination
• Vital signs within acceptable parameters
• Laboratory studies per protocol
• Medical conditions stabilized or treatment plan in place
• Clearance from ED physician or medicine consultant

Minimum Laboratory Studies:

Test	Required
Complete Blood Count	☐
Comprehensive Metabolic Panel	☐
Urinalysis	☐
Urine Drug Screen	☐
Blood Alcohol Level	☐
Pregnancy Test (if applicable)	☐
Additional (as indicated)

5.1.2 Legal Status Determination

Status	Documentation Required
Voluntary	Signed voluntary admission form
Involuntary	Completed legal detention documents, physician certification
Court-Ordered	Court order, sheriff documentation
Minor	Parent/guardian consent OR court order

5.2 Admission Process

5.2.1 Patient Arrival

1. Greet patient and escort to admission area
2. Verify identity with two identifiers
3. Confirm legal status and documentation
4. Apply identification band

5.2.2 Safety Search and Contraband Removal

Required for all admissions:

• Wand metal detector screening
• Personal search (same-gender staff)
• Belongings search
• Remove and secure contraband

Contraband List:

Always Remove	Document Securely
Sharps, blades	Medications
Ligature materials (belts, cords, laces)	Valuables
Drugs/alcohol	Electronics (per policy)
Weapons	Lighters/matches
Glass items

Document all items on FRM-MHI-001 Belongings Inventory.

5.2.3 Observation Level Assignment

Level	Criteria	Monitoring
1:1 Continuous	Active suicidal/homicidal, severe agitation	Within arm's reach
Close Observation	Recent attempt, high risk	Every 5-15 minutes
Routine	Low/moderate risk	Every 15-30 minutes
Open	No safety concerns	Per unit routine

5.3 Psychiatric Evaluation

5.3.1 Comprehensive Psychiatric Assessment

Required within 24 hours of admission:

1. Chief Complaint and History of Present Illness

   • Current symptoms and duration
   • Precipitating events
   • Previous episodes
   • Current stressors

2. Psychiatric History

   • Previous diagnoses
   • Hospitalizations
   • Outpatient treatment
   • Medication trials
   • ECT or other treatments

3. Suicide/Violence Risk Assessment

   Suicide Risk:

   Factor	Present
   Current ideation	☐ Yes ☐ No
   Plan	☐ Yes ☐ No
   Intent	☐ Yes ☐ No
   Access to means	☐ Yes ☐ No
   Previous attempts	☐ Yes ☐ No
   Protective factors

   Violence Risk:

   Factor	Present
   Homicidal ideation	☐ Yes ☐ No
   Identified target	☐ Yes ☐ No
   History of violence	☐ Yes ☐ No
   Command hallucinations	☐ Yes ☐ No
   Access to weapons	☐ Yes ☐ No

4. Substance Use History

   • Substances used
   • Quantity, frequency, route
   • Last use
   • Withdrawal history
   • Treatment history

5. Medical History

   • Chronic conditions
   • Current medications
   • Allergies
   • Recent medical issues

6. Family History

   • Psychiatric disorders
   • Substance use disorders
   • Suicide history

7. Social/Developmental History

   • Education
   • Employment
   • Living situation
   • Relationships
   • Legal history
   • Trauma history

8. Mental Status Examination

   Domain	Findings
   Appearance
   Behavior
   Speech
   Mood
   Affect
   Thought Process
   Thought Content
   Perceptions
   Cognition
   Insight
   Judgment

9. Diagnosis (DSM-5)

   • Primary diagnosis
   • Secondary diagnoses
   • Medical conditions
   • Psychosocial stressors

5.4 Nursing Admission Assessment

Complete within 8 hours of admission:

• Vital signs
• Pain assessment
• Fall risk assessment
• Skin assessment
• Nutritional screen
• Medication reconciliation
• Allergies verified
• Current symptoms
• Functional status
• Sleep patterns
• Safety precautions implemented

5.5 Treatment Planning

5.5.1 Initial Treatment Plan (within 24 hours)

• Provisional diagnoses
• Initial medication orders
• Observation level
• Activity level
• Diet
• Laboratory/diagnostic orders
• Consultation requests
• Initial goals

5.5.2 Comprehensive Treatment Plan (within 72 hours)

• Multidisciplinary input
• Patient participation
• Measurable goals
• Interventions by discipline
• Discharge criteria
• Estimated length of stay

5.6 Patient Rights and Orientation

5.6.1 Rights Information

Provide and document receipt of:

• Patient rights document
• Grievance procedure
• Privacy practices
• Voluntary/involuntary rights specific to status
• Right to refuse treatment (voluntary)
• Advance directive information

5.6.2 Unit Orientation

• Room assignment
• Unit layout (exits, bathroom, common areas)
• Schedule (meals, groups, visiting)
• Rules and expectations
• How to contact staff
• Telephone use
• Personal belongings policy

5.7 Special Populations

5.7.1 Minors

• Parental/guardian involvement
• Age-appropriate assessments
• Educational needs assessment
• Child protective services notification if indicated

5.7.2 Geriatric Patients

• Enhanced medical monitoring
• Cognitive assessment
• Fall precautions
• Medication review for appropriateness

5.7.3 Forensic Patients

• Legal hold documentation
• Notification requirements
• Security considerations
• Court date tracking

6. Documentation

• FRM-MHI-001 Belongings Inventory
• FRM-MHI-002 Admission Safety Assessment
• FRM-MHI-003 Suicide Risk Assessment
• Psychiatric Evaluation
• Nursing Admission Assessment
• Social Work Assessment
• Treatment Plan
• Patient Rights Acknowledgment

7. Regulatory Compliance

Regulation	Requirement
The Joint Commission	Assessment within 24 hours
CMS	Treatment plan within 72 hours
State Mental Health Code	Involuntary hold procedures
EMTALA	Medical screening examination

8. References

• State mental health statutes
• The Joint Commission standards
• CMS Conditions of Participation
• Institutional policies

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Revision History

Rev	Date	Description	Author
1.0	[DATE]	Initial release	[AUTHOR]