Involuntary Hospitalization Evaluation Note

Note Type: Involuntary Hospitalization Evaluation Note

Date/Time of Evaluation: [Start time] to [End time]

Documentation Time: [Date and time of documentation]

Location: [ED / PES / inpatient unit / consult service] — [Specific area/unit/site]

Evaluator: [Name], [Credentials]

Interpreter: [Name or ID], [Language], [In-person / phone / video] (Omit line if interpreter not used)

Referral Source: [Referring individual/agency and role]

Legal Status at Evaluation: [Voluntary / Emergency hold / Under petition / In custody] — [Jurisdiction], [Hold/petition type], [Initiation time/date], [Expiration if applicable]

Reason for Evaluation

[Precipitating event and chief concern] [Specific legal question: evaluation for involuntary hospitalization due to danger to self, danger to others, and/or grave disability] [Immediate safety concerns including elopement risk, weapon access, intoxication, agitation, or medical instability] (2–5 sentences. Use objective, behaviorally anchored language. Include direct quotes for threats or refusals.)

Sources of Information

• [Patient interview: method and setting]
• [Clinician observations during evaluation]
• [Collateral contacted: name/relationship, contact method, summary of information] (If collateral not obtained, document attempts and reason.)
• [Records reviewed: facilities, dates, document types]

[Reliability and limitations of information: intoxication, psychosis, language barrier, refusal, agitation, time constraints] (When assessment elements are limited, document "Unable to assess: [reason]" rather than leaving blank.)

History of Present Illness

[Chronological narrative of onset, course, and acuity of current symptoms and behaviors precipitating evaluation] [Precipitating stressors or triggers] [Recent behavioral dyscontrol: self-harm, threats, assaults, weapon acquisition] [Treatment adherence changes and recent care contacts] [Substance use proximate to event: type, quantity, route, timing] [Current available supports and protective factors] (Attribute each element by source: "Patient reports…," "Collateral states…," "Record review indicates…," "Observed by clinician…". Use direct quotes for suicidal/homicidal statements, refusal statements, key delusions, command hallucinations, and statements demonstrating inability to care for self.)

(Optional focused summary if risk-specific details not fully integrated above:)

• Suicide/Self-Harm: [Ideation: passive vs active], [Plan], [Intent], [Timeframe], [Means access], [Preparatory acts], [Prior attempts with dates, methods, lethality], [Protective factors]. Quote statements of intent: "[Exact words]"
• Violence: [Target], [Plan], [Intent], [Weapon access], [Stalking/threatening behaviors], [Past violence and escalation]. Quote threats: "[Exact words]"
• Grave Disability: [Ability to obtain/use food and hydration], [Ability to obtain and use shelter safely], [Ability to obtain essential medical care], [Unsafe behaviors due to psychiatric symptoms], [Realism of available supports]. Quote statements demonstrating inability: "[Exact words]"

Background History

• Prior psychiatric diagnoses and hospitalizations: [Details or "Unable to obtain: reason"]
• Suicide history: [Number of attempts, methods, medical lethality, most recent timing, consequences]
• Violence history: [Past assaults/threats, legal outcomes, restraining orders]
• Substance use history: [Primary substances, pattern, last use, treatment history, withdrawal risk]
• Psychiatric medications: [Current medications with doses], [Adherence], [Recent changes]
• Medical history: [Chronic conditions, allergies, pregnancy status if applicable]
• Housing and baseline functioning: [Housing status], [ADLs/IADLs], [Employment/education]
• Supports: [Family/friends, outpatient providers, community resources] [Realistic availability today]
• Dependents/caregiver responsibilities: [Details]
• Lethal means access: [Firearms, medications, other] [Storage/security]
• Legal status: [Open charges, probation/parole, protective orders]

(Document "Unable to obtain: [reason]" for any element that cannot be assessed.)

Medical Screening and Examination

• Vital signs: [BP] / [HR] / [RR] / [Temp] / [SpO2] (Include source/time.)
• General appearance and exam: [Level of consciousness], [Distress], [Signs of intoxication/withdrawal], [Injuries], [Relevant physical findings]
• Diagnostics reviewed: [Toxicology], [BAL], [Metabolic panel], [Other] with results

Medical stability statement: [Medically stable for psychiatric hospitalization/transfer / Requires further medical workup due to: specific findings]

Mental Status Examination

• Appearance/Behavior: [Grooming/hygiene], [Dress], [Cooperation], [Eye contact], [Abnormal movements], [Agitation/restlessness]
• Psychomotor: [Retardation / Agitation / Normal], [Tremor/EPS]
• Speech: [Rate], [Volume], [Prosody], [Spontaneity]
• Mood/Affect: Mood: "[Patient-stated mood in quotes]"; Affect: [Range, intensity, congruence, stability]
• Thought Process: [Linear / Goal-directed / Circumstantial / Tangential / Flight of ideas / Disorganized]
• Thought Content: [Suicidal ideation], [Homicidal ideation], [Delusions], [Preoccupations] (Use direct quotes for threats, suicidal/homicidal statements, and delusional content.)
• Perceptions: [Hallucinations: auditory/visual/other], [Command hallucinations: content and response in quotes]
• Cognition: [Orientation], [Attention], [Memory] (State methods used; if limited, document what was attempted and observed.)
• Insight: [Description with examples]
• Judgment: [Description with examples]
• Impulse Control: [Current capacity to inhibit harmful or risky behavior]

(Never auto-populate normal defaults for suicidal ideation, homicidal ideation, or capacity. If elements cannot be assessed, write "Unable to assess: [reason]".)

Risk Assessment

Suicide and Self-Harm Risk

• Current ideation: [Passive / Active / Denied / Unable to assess: reason] (Include direct quotes.)
• Plan: [Description / None / Unable to assess: reason]
• Intent and timeframe: [Description / None / Unable to assess: reason]
• Means access: [Firearms], [Medications], [Other]; [Secured / Unsecured]; [Location]
• Preparatory behaviors: [Description / None]
• Past attempts/self-harm: [Methods], [Dates], [Medical lethality], [Triggers]
• Acute risk factors: [Intoxication, agitation, recent loss, psychosis, non-adherence, isolation, medical illness, legal problems]
• Protective factors: [Supports, reasons for living, treatment engagement, responsibility to others]
• Assessed risk level: [Low / Moderate / High] — Basis: [Concise rationale]

Violence Risk

• Current violent/homicidal ideation: [Present / Denied / Unable to assess: reason] (Include direct quotes for threats.)
• Target specificity: [Identified person/group / Non-specific / None]
• Plan and intent: [Description / None / Unable to assess: reason]
• Weapon access: [Firearms], [Knives], [Other], [Access details]
• Stalking/threatening behavior: [Description / None]
• Past violence: [Incidents], [Injuries caused], [Legal outcomes]
• Acute contributors: [Intoxication, withdrawal, psychosis, personality factors, situational stressors]
• Assessed risk level: [Low / Moderate / High] — Basis: [Concise rationale]

Grave Disability

• Food and hydration: [Ability/inability to obtain and use safely; observed behaviors; quoted statements]
• Shelter and safety: [Ability/inability to obtain and use shelter safely; environmental hazards]
• Essential medical care: [Ability/inability to obtain and adhere to necessary treatment; consequences]
• Cognitive/disorganization factors: [Disorganization, confusion, psychosis impacting self-care]
• Supports: [Availability and realism of supports to mitigate deficits today]

Overall Risk Formulation

[Synthesis distinguishing acute vs chronic risk across suicide, violence, and grave disability] [Why risk is not manageable in a less restrictive setting today, or why it is manageable with specific conditions] [Direct link to recommended disposition]

Capacity Assessment

(Include when legal status determination depends on the patient's refusal or impaired decision-making.)

Decision at Issue: [Capacity to consent to voluntary psychiatric admission / Capacity to refuse hospitalization / Other]

• Communicates a choice: [Consistent / Inconsistent / Unable] (Quote refusals: "[Exact words]")
• Understands information: [Able / Unable] — [Understanding of diagnosis, risks/benefits, alternatives]
• Appreciates consequences: [Able / Unable] — [Application of information to personal situation]
• Reasons about options: [Coherent / Illogical] — [Comparison of risks/benefits]

Conclusion: [Has capacity / Lacks capacity / Indeterminate: reason]. [Link to legal pathway chosen.]

Legal Criteria Analysis

Jurisdiction and Authority

[Jurisdiction], [Hold/petition type], [Initiated by], [Time/date initiated], [Expiration if applicable]

Criteria Evaluation

• Danger to Self:
  • Supporting facts: [Specific behaviors, statements in quotes, observed impairments]
  • Factors against: [Protective or mitigating factors]
  • Conclusion: [Criterion met / Criterion not met] — [Rationale]
• Danger to Others:
  • Supporting facts: [Specific behaviors, threats in quotes, weapon access]
  • Factors against: [Mitigating factors]
  • Conclusion: [Criterion met / Criterion not met] — [Rationale]
• Grave Disability:
  • Supporting facts: [Objective inability to provide for food, clothing, shelter, or medical care; unsafe behaviors]
  • Factors against: [Realistic supports, functioning]
  • Conclusion: [Criterion met / Criterion not met] — [Rationale]

Least Restrictive Alternative Analysis

• Voluntary admission: [Offered / Not offered] — [Patient response with quote if refused: "[Exact words]"] — [Why insufficient if refused]
• Crisis residential/respite: [Considered / Not available] — [Why insufficient]
• Intensive outpatient/partial hospitalization: [Considered] — [Why insufficient]
• Family/friend supervision with safety plan: [Considered] — [Why insufficient]
• Shelter/community resources: [Considered] — [Why insufficient]
• Detox/SUD treatment: [Considered] — [Why insufficient]

Patient Notification

[Patient informed of hold status and reason, rights explained, written notice provided] (Or document why notification was not possible and plan to notify.)

Diagnostic Impression

• [Primary psychiatric diagnosis] [Provisional if appropriate]
• [Substance-related diagnoses if applicable]
• [Medical/neurologic differentials if relevant]

[Brief formulation linking diagnoses to current dangerousness or grave disability and to capacity findings]

Disposition and Safety Plan

Disposition: [Recommended level of care], [Voluntary / Involuntary status], [Receiving facility/service if known], [Transfer method]

Safety Precautions: [Observation level], [Environmental precautions], [Elopement precautions], [Contraband search], [Sitter/security] (Until disposition executed.)

Handoff: [Key risk drivers communicated], [Required precautions relayed], [Receiving clinician contacted: time/date]

(If criteria not met and discharge recommended: Document why criteria not met, safety planning completed including lethal means counseling, follow-up arranged with dates/times, crisis resources provided, and who will supervise the patient with confirmation of feasibility.)

Attestation

[Electronic signature], [Credentials], [Date]

Total clinician time: [Minutes] (Include preparation, evaluation, counseling, collateral contacts, documentation.)