What This Document Is
This is a blank Patient Referral Form and accompanying criteria used by Stephens County Hospital’s Senior Behavioral Health Unit. It’s designed to standardize the information provided when a patient is referred for psychiatric assessment and potential admission. The form collects essential details about the patient’s presenting issues, medical history, and current functional status.
Why This Document Matters
This form is critical for healthcare professionals – physicians, nurses, social workers, and other providers – who are considering referring a patient to Stephens County Hospital’s Senior Behavioral Health Unit. Accurate and complete referrals ensure the receiving team can quickly assess the patient’s needs and determine the appropriate level of care. It streamlines the intake process and supports informed clinical decision-making. It is also important for facilities needing to document the referral process and maintain patient records.
Common Limitations or Challenges
This document is a *form* for collecting information; it does not provide diagnostic guidance or treatment protocols. It relies on the referring provider’s clinical judgment to accurately identify the patient’s needs and complete the form appropriately. It also doesn’t include details about the hospital’s specific admission criteria beyond the listed reasons for referral.
What This Document Provides
The full document includes:
* Sections for patient demographics and contact information.
* A checklist of common reasons for referral (e.g., dementia with behavioral changes, suicidal ideation).
* Areas to document ambulation needs, medical conditions, and medication lists.
* Specific data requests, including recent lab results and nursing notes.
* A psychiatric symptom assessment worksheet with a list of potential symptoms to consider.
* Information regarding legal status, guardianship, and discharge planning.
* Contact information for the Senior Behavioral Health Unit (phone and fax).
This preview *does not* include completed examples, detailed admission criteria, or the full psychiatric assessment worksheet. It is a blank form intended to be filled out by a healthcare professional.
