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] |