Assessment and Evaluation Procedures

Inpatient:

The treatment team, comprised of, but not limited to, psychiatrists, registered nurses, psychiatric aides, psychologists, psychiatric social workers, special education teachers, activity therapists, the patient and significant others, develops a comprehensive Individualized Treatment Plan.  This Plan incorporates medical, psychiatric, psychological, social service, educational, activity, and nursing assessments and it describes and delineates the goals to be reached during the course of treatment. A description of the assessments is as follows:

1. Medical and Psychiatric – An initial biopsychosocial assessment, which includes history, physical and mental status examinations as well as a working diagnosis and preliminary treatment plan, must be completed within 24 hours of admission of the patient to the unit.  Appropriate orders are written immediately after completion of the assessment by the physician. 


2. Nursing – A nursing assessment is completed by a registered nurse within eight (8) hours of an admission and is used to determine priorities for nursing care.  The assessment reflects the patient's physical and emotional needs.


3. Social Service – A comprehensive assessment shall be completed within 72 hours of admission.  This is a psychosocial profile of the patient and family systems which is used in diagnostic assessment and in multidisciplinary treatment and discharge planning.


4. Rehabilitation Services – An initial Recreational Therapy assessment shall be completed within 72 hours; a comprehensive assessment shall be developed within seven (7) working days.  This is a profile of the patient's physical and mental abilities and limitations to participate in activities. An initial Occupational Therapy assessment may be completed within 72 hours; a comprehensive assessment shall be completed within seven (7) days of admission. This is a profile of the patient's ability to perform daily living skills or sensory motor/visual perceptual development, task behaviors and social interactions.


5. Education – An educational screening process is completed with patients within 48 hours of admission (during the work week) to include contacting home schools for records.  Ongoing diagnostic teaching procedures continue during the patient’s hospitalization and appropriate academic screening tools are utilized based on individual needs.


6. Dietary – An assessment shall be completed within three (3) days; if considered high priority, an assessment will be completed within 24 hours of referral.

Partial Hospitalization:

1. Medical and Psychiatric – A complete medical and psychiatric history must be obtained within three (3) treatment days.  If the patient is transferred from another inpatient unit (other than M3HC), an admission note is required by the Day Treatment staff.  A mental status must be performed and recorded within the first treatment day and include an impression/diagnosis. If the person is transferred from an inpatient unit, the current mental status will be included in the admission note. If a physical examination was performed within six (6) months of the current admission, the results shall be obtained.


2. Nursing – A nursing assessment is completed by a registered nurse within eight (8) hours of an admission and is used to determine priorities for nursing care. The assessment reflects the patient's physical and emotional needs.


3. Education – An educational screening process is completed with patients within 48 hours of admission (during the work week) to include contacting home schools for records.  Ongoing diagnostic teaching procedures continue during the patient’s hospitalization and appropriate academic screening tools are utilized based on individual needs.


4. Rehabilitation Services –  A Recreational Therapy assessment shall be developed within seven (7) treatment days.  A profile of the patient's physical and mental disabilities and limitations to participate in activities.  An Occupational Therapy assessment shall be completed within seven (7) working days of referral. This is a profile of the patient's social interactions, sensory motor development, and visual perceptual skills.


5. Dietary – An assessment shall be completed within three (3) days; if considered high priority, an assessment will be completed within 24 hours of referral.