Date
of Last Review 10/13/08
SME: Director of Social Services
If you have questions regarding the content of this site please contact the
Policy and Procedure Committee. If you
experience any technical problems please contact the MIS Department.When completed:
The Social Services clinician completes the
F23
Application for Modification
when the attending physician has decided:
 | To modify the inpatient commitment to an outpatient commitment as described in Certificate of Medical Examination - Inpatient to Outpatient and/or |
| To change the inpatient program |
Completion:
The Social Services clinician, following the format of the form, documents the following:
| Specific information about the order for inpatient commitment |
| The specific reasons for the request for modification |
| The name and address of the outpatient clinic |
| The name of the physician responsible for the outpatient treatment |
| The specific modification requested |
The Social Services clinician obtains patient's/guardian's signature on the Petition for Outpatient Commitment-Notification/Acknowledgment. This form documents the patient's/guardian's awareness of the following:
| Physician is seeking to modify the inpatient commitment |
| His/her right to a hearing about the proposed modification |
| His/her decision about whether or not to request a hearing |
If a patient/guardian requests a hearing, the Social Services clinician (having made copies for the medical record) attaches a copy of the Petition for Outpatient Commitment to the F23 Application and delivers both documents to the court. The court provides a hearing, legal representation, citation, and service.
When completed:
The attending physician completes the Certificate of Medical Examination when s/he:
| Decides to discharge a patient committed to UTHCPC |
| Determines that the patient will, if not treated, be a significant risk to meet again the criteria for inpatient commitment |
| Determines that outpatient treatment under court order is the least restrictive alternative |
Copies of form:
Staff sends the original completed form to the court via the HCPI/MHMRA Court Liaison and places the last copy in the patient's medical record.
When completed:
The attending physician completes the Request for Dismissal of Modification if a patient does not require the above modification.
Copies of form:
Staff sends the original completed form to the court via the HCPI/MHMRA Court Liaison and places the last copy in the patient's medical record.
When completed: The attending physician completes the Request for Patient Transfer to a State Facility, form and the head nurse signs for a patient whose condition or situation warrants treatment in another inpatient facility.
Copies of form:
Staff sends the original completed form to the court via the HCPI/MHMRA Court Liaison and places the yellow copy in the patient's medical record.
Approval:
The HCPI/MHMRA Court Liaison notifies the treatment team on approval or denial of the request.
When completed:
The attending physician completes a Termination of Court-Ordered Inpatient Mental Health Services and forwards it to the head nurse to sign in the following conditions:
| The court order expires, or is about to expire |
| The Administrator and the attending physician determine that: |
 | The patient no longer meets inpatient criteria |
| Outpatient court-ordered services would not be appropriate |
Copies of form:
The head nurse forwards the original to HCPI/MHMRA Court Liaison to be filed with the court, returns the yellow copy to the patient's medical record and gives the patient the pink copy.
Discharge of patient:
If the patient is being discharged to outpatient status, s/he can be released as soon as s/he receives a completed copy of the form.
A patient can initiate a Letter of Retraction prior to an Order of Protective Custody. Staff handles the letter using the same steps taken to initiate the Request for Release.
A patient can initiate a Request for Release from Voluntary Admission.
Reference: See the next topic.
Related to regulatory standards
If you have questions regarding the content of this site please contact the Policy and Procedure Committee. If you experience any technical problems please contact the MIS Department.
