Inpatient Psychiatric Precertification Form

OH Mental Health and Addiction Services

Inpatient Psychiatric Precertification Form

Page 1 of 5

Referral Information
Date Sent to Permedion: / 5/13/2014
Hospital/Facility Name: / HMS
Contact Person: / Jessica Dallas
Email address: /
Phone: / (614) 839-3354 / Fax: / (855) 974-5394
Address, City, St, Zip: / 350 Worthington Rd, Suite H, Westerville, OH 43081
Provider NPI Number: / 123-456-7891
Date of Admission: / 5/13/2014
Admission source: / OSU ER
Involuntary admission: / Yes / X / No
Admission Type: / Pre-Admission / X / Emergency
Recipient Information
Recipient Last Name: / Doe / First Name: / John / Suffix:
Social Security #: / 123-45-6789 / Medicaid ID#: / 123456789101
Gender: / X / Male / Female / Race: / Caucasian / DOB / 3/15/05 / Age: / 9
Marital Status: / X / Single / Married / Divorced
Widowed / Other: (explain)
Living Arrangements: / Alone / Court Ordered / Group Home/Half-Way House
Homeless/ Shelter / Non-Relatives / Foster Home
X / Relatives / Nursing Home / Assisted/Supervised
Parents/Guardian / Spouse/Significant Other / Other: (explain)
Address: / 1234 West Street
City, St, Zip: / Columbus, OH 43215
Telephone: / (614) 321-3334
Responsible Party Information
Responsible Party (Last Name, First Name) / Franklin County Children Services
Telephone: / (614) 278-8887 / County: / Franklin
Relationship: / Self / Parent(s)/Guardian / Court
X / Gov. Agency / Other: (explain)
Address same as recipient
Address: / 855 West Mound Street
City, St, Zip: / Columbus, OH 43223
Initial Treatment
Axis I (Primary) / Mood Disorder NOS / ICD-9/10
Additional Axis I: / ADHD / ICD-9/10
Additional Axis I: / ICD-9/10
Additional Axis I: / ICD-9/10
Axis II: / Diagnosis Deferred / ICD-9/10
Axis III (Primary): / ICD-9/10
Additional Axis III: / ICD-9/10
Additional Axis III: / ICD-9/10
Additional Axis III: / ICD-9/10
Axis IV: Psychosocial and Environmental Problems: (“X” and explain all that apply)
X / Problems with primary support group / Pt resides with his aunt
Problems related to social environment
Educational problems
Occupational problems
Housing problems
Economic problems
Problems with access to Health Care Services
Problems related to interaction with legal system
X / Other psychosocial and environmental problems / In custody of Franklin County Children Services
Axis V: / Current GAF: 18 / Past Year GAF: 40
Please “X” and explain all that apply:
Auditory hallucinations / Pt denies
Visual hallucinations / Pt denies
Delusions / Pt denies
Paranoia / Pt denies
Bizarre thinking / Pt denies
X / Thought content / Threats to kill self/foster family
X / Anxiety level / Heightened level- anxious and tense
X / Appearance / Neat
X / Mood / Irritable-angry
X / Affect / Labile-not in good control
X / Behavior / Agitated-impulsive-disinterested
X / Speech / Vague-evasive
X / Cognition / Easily distracted- poor concentration
X / Insight/Judgment / Limited/impaired
X / Sleep / Difficulty sleeping through the night
X / Hygiene / Neat
X / Nutrition / WNL
Presenting Symptoms
Imminent risk to self through: (“X” all that apply and provide detail in box below)
Recent suicide attempt or serious self harm?
X / A current plan for self harm?
Command auditory hallucinations for Suicide or self harm?
Imminent risk to harm another through (“X” all that apply and provide detail in box below)
X / Recent Action
X / Current Plan
Command auditory hallucinations
Inability to care for self? (Provide details below)
Pt was a direct admission from OSU ER where pt presented earlier this day in emergent manner following a violent tirade. As limits were placed upon him, pt verbalized that he wanted to die with desire to drive the car off a bridge. As Foster Mom was trying to take pt to ER, he grabbed the steering wheel, turned the car on and stated that he wanted to wreck the car with them in it. No previous attempts/gestures of suicide. As limits were placed on his behavior, pt became highly upset and assaulted his foster mom by hitting, kicking, biting her. Pt made verbal threats to kill her and the other children in the home. Pt punched an adult friend of foster mom in the face.
Other psychosocial dysfunction or mental instability requiring psychiatric inpatient care?(Provide details below)
Psychosocial dysfunction AEB: Not able to be maintained at school. Pt requires constant observation by family due to impulsivity.
Mental instability AEB: Highly assaultive/aggressive behavior= hitting, biting, kicking foster mom. Verbalizing threats to kill foster mom and other children in the home. Verbalizing thoughts/desire to die- wanting to drive off bridge.
Severe disability requiring hospitalization due to the severe symptoms such as hallucinations, mania or acute psychosis? (Provide details below)
Pt denies psychosis. Severe symptoms include: lability of mood (angry-irritable-impulsive). Behaviors- assaultive- not in good control. Disruptive to foster home, not able to maintain. Hospitalization required AEB: thoughts/desire to die- threats to kill foster mom and other children.
Discharge Plan: (Provide details below)
To discharge on current inpatient medication.
To discharge to custody of FCCS.
To refer to outpatient counseling at Buckeye Ranch.
To discuss disposition with caseworker at FCCS.
Current Medications
Please list all current medications:
Drug Name / Daily Dosage / Frequency / Start / Diagnosis
None reported.
Compliant with Current Medications? / Yes / No / X / Not Applicable
Prior Psychotropic Medications
Please list all prior mediations
Drug Name / Daily Dosage / Start / End / Diagnosis
Concerta / Unknown / Unknown / Unknown / ADHD
Clonidine / Unknown / Unknown / Unknown / ADHD
Compliant with Current Medications? / Yes / No / X / Not Applicable
Substance Abuse History
Please complete all applicable rows
Drug Name / Frequency / Last Use / Route / 1st Time / Amount per Use / Comments
Alcohol / Patient denies
Cannabis
Hallucinogens
Benzodiazepines
Inhalants
Amphetamines
Barbiturates
Narcotics
OTC Meds
Other
Impact of Substance abuse on treatment: (explain below)
Patient denies.
Toxicology Screen Results:
Not indicated.
Prior Treatment
Other Mental Health Interventions/Services (Please complete for each facility)
Agency/Facility Name / Type of Service / Dates of Service / Frequency of Service (Hours/day)
Buckeye Ranch / Outpatient / Current
Legal History
Please “X” all apply and explain:
Current Legal charges
Pending court date(s)
Past legal issues
X / Current domestic violence in home / Hitting/biting/kicking foster mom.
History of domestic violence
X / Physically destructive acts/property destruction / Threats to break out school windows.
Currently on probation/parole
Abuse (Physical, Emotional, Sexual, Neglect, Elder, Other
Please “X” all apply and explain:
Recent Abuse / Patient denies.
X / Past Abuse / Hx of physical abuse- was locked in attic.
Additional Information:
Health Home (if applicable)
County: / Not applicable.
Agency:
Inpatient Treatment History
Prior Inpatient Treatment? / X / No / Yes(list dates, frequency, facility and outcome below)
Readmission within the past 30 days? / X / No / Yes
Number of lifetime admissions / 1-This one
Number of admissions in the past year / 0
Please complete for each admission:
Month / Year / Facility / Length of Stay
Not applicable.
Children & Adolescents Only (Under 21)
Please “X” all that apply and explain
X / The CON has been completed and signed by a physician and is on the medical record
X / Children’s Services involvement / As guardian
Legal/Law enforcement involvement
Other Information
Geriatric Patients 65 years and older
Please “X” all that apply and explain (including onset):
Delirium (acute onset less than 48 hours) / Not applicable.
Dementia
Disturbance in behavior (new)
Presence of psychosis (new)
If patient resides in a supervised setting, explain the need for inpatient level of care at this time:
Is this patient a transfer from another hospital to the current hospital? / Yes / X / No
Reason for transfer:
Is this patient a transfer from another unit to the current unit? / Yes / X / No
Other Pertinent Information
Please provide any other pertinent information that pertains to the inpatient admission:
I affirm all information is a true and accurate description of the above individual.
Completed by: / Jessica Dallas, MSW, LSW
Date: / May 13, 2014