Psychiatric Assessment at Admission Checklist
Comprehensive psychiatric admission assessment including mental status examination, suicide/violence risk assessment, and initial treatment planning.
- Industry: Healthcare
- Frequency: At admission
- Estimated Time: 45-60 minutes
- Role: Psychiatric Nurse/Psychiatrist
- Total Items: 31
- Compliance: Joint Commission BHC Standards, CMS Psychiatric Hospital CoP, State Mental Health Regulations
Legal Status Verification
Admission documentation
- Legal status documented?
- Commitment papers in order (if involuntary)?
- Consent for treatment obtained?
- Patient rights explained?
Psychiatric History
Mental health history
- Chief complaint documented?
- Previous psychiatric hospitalizations documented?
- Outpatient treatment history obtained?
- Current psychiatric medications documented?
- Substance use history obtained?
Mental Status Examination
MSE components
- Appearance documented?
- Behavior documented?
- Speech characteristics documented?
- Mood and affect documented?
- Thought process documented?
- Thought content (delusions, obsessions)?
- Perceptual disturbances (hallucinations)?
- Cognitive function assessed?
- Insight and judgment assessed?
Risk Assessment
Safety evaluation
- Suicide risk assessment completed?
- Suicide risk level documented?
- Homicide/violence risk assessed?
- Self-harm history documented?
- Elopement risk assessed?
Safety Planning
Initial safety measures
- Observation level ordered?
- Contraband search completed?
- Belongings inventoried and secured?
- Environment assessed for safety hazards?
Treatment Planning
Initial treatment plan
- Preliminary diagnosis documented?
- Initial treatment goals identified?
- Medication orders placed?
- Therapy referrals placed?
Related Healthcare Checklists
- Palliative Care Assessment Checklist
- Physical Therapy Initial Evaluation Checklist
- Occupational Therapy Initial Evaluation Checklist
- Speech-Language Pathology Evaluation Checklist
- Pediatric Weight-Based Medication Dosing Checklist
- Rapid Response Team Activation Checklist
- Organ/Tissue Donation Referral Checklist
- Newborn Nursery Assessment Checklist
Related Health Services Checklists
- Home Health Start of Care Assessment Checklist - FREE Download
- Palliative Care Assessment Checklist - FREE Download
- Physical Therapy Initial Evaluation Checklist - FREE Download
- Occupational Therapy Initial Evaluation Checklist - FREE Download
- Speech-Language Pathology Evaluation Checklist - FREE Download
- Social Work Assessment Checklist - FREE Download
- Dietary/Nutrition Screening Assessment Checklist - FREE Download
- Chaplain/Spiritual Care Assessment Checklist - FREE Download
Why Use This Psychiatric Assessment at Admission Checklist?
This psychiatric assessment at admission checklist helps healthcare teams maintain compliance and operational excellence. Designed for psychiatric nurse/psychiatrist professionals, this checklist covers 31 critical inspection points across 6 sections. Recommended frequency: at admission.
Ensures compliance with Joint Commission BHC Standards, CMS Psychiatric Hospital CoP, State Mental Health Regulations. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the Psychiatric Assessment at Admission Checklist cover?
This checklist covers 31 inspection items across 6 sections: Legal Status Verification, Psychiatric History, Mental Status Examination, Risk Assessment, Safety Planning, Treatment Planning. It is designed for healthcare operations and compliance.
How often should this checklist be completed?
This checklist should be completed at admission. Each completion takes approximately 45-60 minutes.
Who should use this Psychiatric Assessment at Admission Checklist?
This checklist is designed for Psychiatric Nurse/Psychiatrist professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.
Can I download this checklist as a PDF?
Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.