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Option
Refer to Secondary Review
What action will be taken / How treatment plan will be affected by results
The specific question(s) the testing is intended to answer
The test(s) to be administered AND number of hrs requested
Assessment to date
History
Description of symptoms AND functional impairment
Patient diagnosis
Patient demographics
Action
Medication / Substance use will not confound results
Testing Hx
Condition
Action
Medication / Substance use will not confound results
Testing Hx
Brain damage suspected / diagnosed
Authorize 6 to 12 treatments over 1 yr
Evaluation by anesthesia provider
Evaluation by ECT-priviliged psychiatrist w/in last mo
Review of all systems
Review / Update Hx
Informed consent obtained from patient / guardian
Indications for continuation / maintenance
Positive response to acute / short-term ECT
Authorize 6 to 12 treatments w/in 4 wks
Medical assessment
Evaluation by ECT-priviliged psychiatrist
Evaluation by anesthesia provider
PE
Hx
Informed consent obtained from patient / guardian
ECT indications
Acute symptoms
If criteria not met, apply Alternate Level of Care (ALOC) or refer for Secondary Review
If criteria met, authorize Continued Stay
Symptom / Behavior specific treatment plan developed by interdisciplinary team
Emergent evaluation
Psychiatric medication evaluation
PRN medication at least 2x/24h to control symptoms / adverse effects
Emergency medication at least 1x/24h
Seclusion at least 1h
Mechanical / Physical restraint at least 1x/24h
Vital signs at least q2h
Observation
Psychiatric medication nonadherence AND increased comorbid medical risk
Severe psychiatric medication reaction
Sexually inappropriate / aggressive
Sexual assault / Rape attempt on unit w/in last 72h
Assaultive / Threatening
Self-mutilation w/in last 72h AND increase in intensity / pattern
Profound functional impairment AND inability to cooperate with needed care
Suicidal / Homicidal ideation
Suicide / Homicide attempt w/in last 72h
Anxiety AND associated symptoms increasing / uncontrolled
Action: Apply Functioning
Psychiatric medication nonadherence AND comorbid medical condition
Anxiety and associated symptoms / behavior
Anxiety symptoms
Suicidal / Homicidal ideation
Action: Admit to Inpatient / Observation
Acute mental status change / Delirium AND medically cleared for admission
Severe psychiatric medication reaction
Psychiatric medication nonadherence AND increased comorbid medical risk
Self-mutilation AND increase in intensity / pattern
Suicidal / Homicidal ideation
Suicide / Homicide attempt
Command hallucinations WITH direction to harm self / others
If criteria not met, apply Alternate Level of Care (ALOC) or refer for Secondary Review
If criteria met, authorize Continued Stay
Symptom / Behavior specific treatment plan developed by interdisciplinary team
Emergent evaluation
Psychiatric medication evaluation
PRN medication at least 2x/24h to control symptoms / adverse effects
Emergency medication at least 1x/24h
Seclusion at least 1h
Mechanical / Physical restraint at least 1x/24h
Vital signs at least q2h
Observation
Psychiatric medication nonadherence AND increased comorbid medical risk
Severe psychiatric medication reaction
Sexually inappropriate / aggressive
Sexual assault / Rape attempt on unit w/in last 72h
Threatening WITH intent to harm
Assaultive
Self-mutilation w/in last 72h AND increase in intensity / pattern
Suicidal / Homicidal ideation
Suicide / Homicide attempt w/in last 72h
Fire setting w/in last 48h
Reckless / Impulsive / Angry outbursts
Intensive Outpatient - Transportation Available
Intensive Outpatient - Support System
Intensive Outpatient - Patient
Partial Hospital - Transportation Available.
Partial Hospital - Support System
Partial Hospital - Patient
Inpatient / Observation - Support System
Inpatient / Observation - Patient
Role Performance
Relationships
ADLs / IADLs
Action: Apply Functioning
Action: Admit to Inpatient / Observation
Psychiatric medication nonadherence AND comorbid medical condition
Reckless / Impulsive
Suicidal / Homicidal ideation
Acute mental status change / Delirium AND medically cleared for admission
Severe psychiatric medication reaction
Psychiatric medication nonadherence AND increased comorbid medical risk
Self-mutilation AND increase in intensity / pattern
Loss of behavioral control AND unable to follow instructions / negotiate
Fire setting WITH intent to harm
Suicidal / Homicidal ideation
Suicide / Homicide attempt
Command hallucinations WITH direction to harm self / others
If criteria not met, apply Alternate Level of Care (ALOC) or refer for Secondary Review
If criteria met, authorize Continued Stay
Symptom / Behavior specific treatment plan developed by interdisciplinary team
Emergent evaluation
ECT
Psychiatric medication evaluation
PRN medication at least 2x/24h to control symptoms / adverse effects
Emergency medication at least 1x/24h
Seclusion at least 1h
Mechanical / Physical restraint at least 1x/24h
Vital signs at least q2h
Observation
Psychiatric medication nonadherence AND increased comorbid medical risk
Severe psychiatric medication reaction
Sexually inappropriate / aggressive
Sexual assault / Rape attempt on unit w/in last 72h
Impulsive / Agitated AND unable to follow instructions / negotiate needs
Assaultive / Threatening
Profound functional impairment
Catatonia
Self-mutilation w/in last 72h AND increase in intensity / pattern
Suicidal / Homicidal ideation
Suicide / Homicide attempt w/in last 72h
If criteria not met, apply Alternate Level of Care (ALOC) or refer for Secondary Review
If criteria met, authorize Continued Stay
Symptom / Behavior specific treatment plan developed by interdisciplinary team
Emergent evaluation
ECT
Psychiatric medication evaluation
PRN medication at least 2x/24h to control symptoms / adverse effects
Emergency medication at least 1x/24h
Seclusion at least 1h
Mechanical / Physical restraint at least 1x/24h
Vital signs at least q2h
Observation
Psychiatric medication nonadherence AND increased comorbid medical risk
Severe psychiatric medication reaction
Sexually inappropriate / aggressive
Sexual assault / Rape attempt on unit w/in last 72h
Impulsive / Agitated AND unable to follow instructions / negotiate needs
Assaultive / Threatening
Profound functional impairment
Catatonia
Self-mutilation w/in last 72h AND increase in intensity / pattern
Suicidal / Homicidal ideation
Suicide / Homicide attempt w/in last 72h
Psychotic symptoms increasing / uncontrolled
Intensive Outpatient - Transportation Available
Intensive Outpatient - Support System
Intensive Outpatient - Patient
Partial Hospital - Transportation Available.
Partial Hospital - Support System
Partial Hospital - Patient
Inpatient / Observation - Support System
Inpatient / Observation - Patient
Role Performance
Relationships
ADLs / IADLs
Action: Apply Functioning
Action: Admit to Inpatient / Observation
Self-mutilation
Psychiatric medication nonadherence AND comorbid medical condition
Psychotic symptoms
Known Hx of psychosis
Suicidal / Homicidal ideation
Catatonia
Acute mental status change / Delirium AND medically cleared for admission
Severe psychiatric medication reaction
Psychiatric medication nonadherence AND increased comorbid medical risk
Self-mutilation AND increase in intensity / pattern
Psychotic symptoms uncontrolled WITH potential to harm self / others
Initial onset of psychotic symptoms AND supports unable to ensure safety
Suicidal / Homicidal ideation
Suicide / Homicide attempt
Command hallucinations WITH direction to harm self / others
Action: Admit to Inpatient / Observation
Action: Apply Functioning
Psychiatric medication nonadherence AND comorbid medical condition
Depressed mood
Suicidal / Homicidal ideation
Catatonia
Acute mental status change / Delirium AND medically cleared for admission
Severe psychiatric medication reaction
Psychiatric medication nonadherence AND increased comorbid medical risk
Self-mutilation AND increase in intensity / pattern
Suicidal / Homicidal ideation
Suicide / Homicide attempt
Command hallucinations WITH direction to harm self / others
Role Performance
Relationships
ADLs / IADLs
Intensive Outpatient - Transportation Available
Intensive Outpatient - Support System
Intensive Outpatient - Patient
Partial Hospital - Transportation Available.
Partial Hospital - Support System
Partial Hospital - Patient
Inpatient / Observation - Support System
Inpatient / Observation - Patient
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