Inpatient Admission Form – Fill Out and Use This PDF

The Inpatient Admission form serves as a critical document for individuals being admitted to a psychiatric hospital, encapsulating key information such as personal identification, medical history, diagnosis, and treatment plans. This comprehensive form, used specifically at facilities like the one at 12357-B Riata Trace Parkway, Austin, Texas, ensures that healthcare providers have a thorough understanding of the patient's current health status and previous treatments. For those preparing for an inpatient stay, completing this form accurately is a pivotal step toward receiving tailored care. For a seamless admission process, you are encouraged to fill out the form by clicking the button below.

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Inpatient Admission Form PDF Details

When a person requires psychiatric hospital inpatient admission, a comprehensive process is initiated, beginning with the completion of a meticulously detailed form. This form, utilized by psychiatric facilities, encompasses a wide spectrum of information vital to the patient's admission and subsequent care. Situated at 12357-B Riata Trace Parkway, Suite 150 in Austin, Texas, the facility requires numerous pieces of identifying information such as Medicaid number, personal details, and specific contacts. It delves deeper by seeking insights into the patient's primary symptoms that necessitate acute hospital care, any events triggering the admission, as well as other relevant clinical information like the patient's current medications, substance use history, and any prior psychiatric treatments. This form not only captures details regarding the admitting diagnosis and any additional diagnoses but also includes a functional assessment score for a more rounded view of the patient's needs. Importantly, it outlines the expected duration of stay, projected discharge date, and post-discharge care plans, all crucial for ensuring a seamless transition. The attending physician's signature anchors the form, underscoring the gravity and necessity of the information provided for a well-informed and tailored approach to inpatient psychiatric care.

Question	Answer
Form Name	Inpatient Admission Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	online admission form, admisan form, admission form, davita admission form

Form Preview Example

Psychiatric Hospital Inpatient Admission Form

12357-B Riata Trace Parkway, Suite 150

TMHP CCIP

Phone: 1-800-213-8877

Austin, Texas 78727-6422

Fax: 1-512-514-4211

I. Identifying information:

Medicaid #:

Date:

Last name:

First name:

Middle initial:

Date of birth:

Age:

Sex:

Date of admission:

Time:

Facility name:

Provider #:

Name of contact person:

Commitment Type:

Effective Date:

County:

Judge:

(if applicable)

Referral source: [

] Admitting MD

[

] MH Professional

[

] DPRS

[

] Other (list):

Current living arrangements: [ ] With parent(s)

[

] Group/foster home

[

] Other (list):

IIA. Primary symptom described in “specific observable behavior” that requires acute hospital care:

(Include: Precipitating events leading to admission)

IIB. Other relevant clinical information, including inability to benefit from less restrictive setting:

(Attach additional pages or documents, as necessary)

IIC. Psychiatric medications (Include total daily dose)

IID. Present and past drug/alcohol usage:

Name of chemical

Current use?

IIE. Past psychiatric treatment

1. Number of previous inpatient admissions: [

]

Dates of most recent inpatient stay:

2. Previous ambulatory/outpatient treatment (provider or facility, frequency) – If none, why:

III. Admitting diagnosis (Axis I):

IV. Additional diagnosis (Axis I and Axis II):

V. Functional assessment scores (DSM IV):

GAF

[

]

VI. No. of hospital days requested:

[

] Dates:

Projected discharge date (required):

VII. Aftercare Plan:

Provider or Facility:

Frequency:

Signature (Attending MD):

Date:

Print name:

Provider number:

Provider license number:

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1. Whenever completing the admission assessment forms and, ensure to incorporate all of the important blanks in their associated area. This will help facilitate the process, allowing for your information to be handled promptly and properly.

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2. Once your current task is complete, take the next step – fill out all of these fields - IIC Psychiatric medications, IID Present and past drugalcohol, Name of chemical, Current use, IIE Past psychiatric treatment, Number of previous inpatient, Dates of most recent inpatient, Previous ambulatoryoutpatient, III Admitting diagnosis Axis I, IV Additional diagnosis Axis I and, V Functional assessment scores DSM, VI No of hospital days requested, Projected discharge date required, VII Aftercare Plan, and Provider or Facility with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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Concerning IIE Past psychiatric treatment and Projected discharge date required, be sure that you review things here. Both of these could be the most important ones in the document.

3. In this specific step, look at Frequency, Signature Attending MD, Date, Print name, Provider number, and Provider license number. All these will have to be filled in with greatest awareness of detail.

Guidelines on how to prepare rte admission form No Download Needed pdf portion 3

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Inpatient Admission Form – Fill Out and Use This PDF

Inpatient Admission Form PDF Details

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How to Edit Inpatient Admission Form Online for Free

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