Mh 302 Form – Fill Out and Use This PDF

HOW TO COMPELTE 5150 APPLICATION FOR 72 HOUR DETENTION

Numbers 1-6: Detainment Advisement (See Appendix A for form)

The purpose of the detainment advisement is to inform the mentally ill individual that they have rights, are not under arrest and may take approved possessions with them to the hospital.

Print your name on this line (1).

The Advisement (located in the upper right hand corner of the form) should be read to clients. “Advisement complete” or “Advisement incomplete” should be checked (2).

If a patient is too ill to comprehend the verbal advisement, then do not read the Advisement, check

“Advisement incomplete” and document the reason in number (3).

If the Advisement is successfully read to the client, print your name in the section labeled “Advisement Completed By,” (4) print your position: Police Officer, Sheriff’s Deputy, etc…(5), and note the date (6).

The patient will receive a written advisement if, after being appropriately assessed at the hospital, he/she is

admitted.

Number 7-10: Application is Made To:

The name, address and phone number of the hospital or emergency room where the client will be transported is documented on this line (7).

Be as specific as possible in order to inform the ambulance driver or other applicable parties of the exact location of the receiving facility.

When indicating the name of the patient in the “Admission of” section (8), use the patient’s complete name.

Complete names are helpful in order to increase the likelihood the receiving facility can correctly identify the patient.

Completing the “Residing at” section (9) is critical. The address should be complete with zip code and phone number, if possible. Again, the receiving faculty may have only he 5150 form as identifying information, so the more complete the personal data, the better.

Circle the “Section 5150” or “Section 5585” to indicate which type of hold you are writing on the line below

(9).

The section below “Residing at” (10) is critical for the completion of the 5150/5585. You should put all the contact information available to you in this section. Neighbor’s names and phone numbers, parents, friends, case managers, conservator, landlord, treating clinician and so on. Hospital discharge planning often depends on the accuracy of this information.

Number 11: . . . Person’s Condition was called to my Attention

This section (11) identifies how the client came to your attention.

This information should be as complete as possible; it should include who initially contacted you, a short description of why the caller wanted assistance and what the client was doing to require an emergency assessment (initial complaint).

All descriptions are to be behavioral and not diagnostic.

Some examples of behavioral descriptions are:

“Called by resident to access a client that was running naked in the street,”

“Call from patient’s mother saying consumer was suicidal,”

 “Called by school principal to assess student who expressed suicidal thoughts to school counselor,”

“Called by roommate because person threatened a neighbor,”

“Called by therapist at County mental health clinic that client known to them just called saying he was going to kill himself.”

In this section, do not put diagnostic description like “Patient is well known bi-polar disorder,” or “Patient suffering from major depression and ….”, or “Patient paranoid schizophrenic who is threatening people in the street.”

In this section do not put psychiatric jargon. For example: “Patient hallucinating and delusional,” “Patient having ideas of reference,” “Patient in manic state,” “Consumer psychotic.”

Number 12: “The following information has been established …”

This section (12) is the “heart” of the 5150/5585. The descriptions of the behaviors (not psychiatric diagnosis) that lead you to believe this patient can be held based on the three criteria (Danger to Self, Danger to Others or Gravely Disabled) is written in this section.

Behavioral descriptions mean writing what the patient DOES and SAYS, not what clinical term encompasses that behavior

Examples are:

 “Patient pacing about the room yelling” instead of “Patient anxious & agitated.”

“Patient hearing voices that say …” rather than “Patient having auditory hallucinations.”

“Consumer tells me that the TV is speaking to him about things,” rather than, “Consumer experiencing thought insertion.”

“Patient seeing CIA agents about to attack him,” instead of “Patient experiencing visual hallucinations.”

“Patient feels he is married to Jennifer Lopez,” rather than “Patient delusional.”

“Patient says that he is sure someone is watching him from the vents in his apartment,” rather than “Patient paranoid schizophrenic with fixed delusional disorder.”

“Patient says she is going to kill herself by overdose because her boyfriend left her,” rather than “Patient has suicidal ideation and intent after failed romance.”

Quotes from the patient are highly desirable.

Behavioral descriptions from reliable sources are often very helpful. Be sure to identify the source. It is not

necessary to document name of someone who wishes to remain anonymous who is concerned about retaliation (neighbor’s full name, etc.).

Write enough to justify your decision to “hold” the patient.

May not write confidential and/or sensitive medical information in the narrative, such as “Patient has

AIDS.” The following is better: “patient has terminal/life threatening illness.”

May not list medications in the body of the 5150 (11, 12). If you must report medications, list them in section (10).

Do not diagnose the patient.

Do not predict future actions, just describe what you see and hear.

Keep in mind that a “hold” is meant to be written by a non-clinical person and is NOT a diagnostic assessment.

Numbers 13, 14 15, 16, 17, 18, 19: Criteria, Signatures, Timing and Medical ER Timing:

The following information refers to the final parts of the 5150/5585:

Check the box that correctly defines the criteria for the hold (13).

Sign the hold (14) and include your degree (LCSW, MD, Ph.D., LPT, MFT).

Date (15) and time (16) the hold (very important). This protects the patient’s rights and notifies the hospital when the patient should be evaluated for release.

Write the correct phone number (17) of your agency

Write the correct name (18) of your agency

Write the correct address (19) of your agency