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Release or Detention of Voluntary Admission (2.1.14)

Release or Detention of Voluntary Admission (2.1.14) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer

2.1.14


UW HEALTH CLINICAL POLICY 1
Policy Title: Release or Detention of Voluntary Admission – Psychiatric Patient
Policy Number: 2.1.14
Category: UW Health
Type: Inpatient
Effective Date: December 18, 2015

I. PURPOSE

To establish guidelines for discharge or detention of patients admitted to the hospital voluntarily.

II. POLICY ELEMENTS

A. It is the physician's responsibility to make the decision w hether to discharge or detain a psychiatric patient
admitted to the hospital voluntarily.
i. Section 51.10(5) (a) Wisconsin S.S. provides that at the time of their admission to an inpatient
facility, voluntary patients shall be informed, orally and in w riting, of their right to leave upon
submission of a w ritten request to the staff of the facility, except w hen the director or his/her
designee f iles a statement of emergency detention w ith the Court by the end of the next day in
w hich the Court transacts business (Refer to UW Health clinical policy 1.2.1, Emergency Detention
– State Mental Health Act).
ii. Voluntary patients shall be discharged upon request unless the treatment director or his/her
designee:
a. Has reason to believe that the patient is dangerous to him/herself or others; and
b. Files a statement of emergency detention under Wisconsin S.S. 51.15(10) w ith the Court
by the end of the next day in w hich the Court transacts business. The patient shall be
notif ied immediately w hen such a statement is to be f iled.
iii. Sec. 51.10(5)(c) Wisconsin S.S. provides that prior to f iling the statement of emergency detention,
or director's emergency detention, the patient may be detained only long enough for the staff of the
facility to evaluate the individual's condition and f ile the statement. The time may not exceed the
end of the next day in w hich the court transacts business. Once a statement is f iled, a patient may
be detained. Unless a hearing is held under Wisconsin S.S. 51.20(7) (involuntary commitment) or
under Wisconsin S.S. 55.06(11)(b) (protective services), the patient may not be detained more than
72 hours exclusive of Saturdays, Sundays and holidays.
B. The statutes allow the hospital to refuse discharge to those voluntary patients w ho are being evaluated for
emergency detention or commitment for the period to the end of the next day in w hich the Court transacts
business. If the patient does not meet the requirements for emergency detention, there should be no delay
in discharge of a voluntary psychiatric patient. Delay is permissible only for evaluation and for f iling
emergency detention. The physician may complete Discharge Against Medical Advice form w hen
appropriate (refer to UWHC policy #4.19, Discharge Against Medical Advice/Elopement from Hospital).

III. PROCEDURE

Action taken should be recorded in the patient's medical record.
The Nursing Coordinator is notif ied w hen detention action is initiated or w hen patient is discharged against
medical advice.

IV. FORMS
Discharge Against Advice, UWH #335
Statement of Emergency Detention by Law Enforcement Officer
Statement of Emergency Detention by Treatment Director (State of WI forms available on Inpatient
Psychiatry)

V. COORDINATION

Author: Nurse Manager, Inpatient Psychiatry
Senior Management Sponsor: SVP, Patient Care Services and CNO
Review ers: General Counsel; Director, Psychiatric Services
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: November 16, 2015




UW HEALTH CLINICAL POLICY 2
Policy Title: Release or Detention of Voluntary Admission – Psychiatric Patient
Policy Number: 2.1.14

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Jeff Grossman, MD
UW Health CEO

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

Section 51.10 of the Wisconsin Statutes – Voluntary admission of adults
UW Health clinical policy #1.2.1, Emergency Detention – State Mental Health Act
Section 51.15 of the Wisconsin Statutes – Emergency detention
Section 51.20 of the Wisconsin Statutes – Involuntary commitment for treatment
Section 55.06 of the Wisconsin Statutes – Protective services and protective placement; eligibility
UWHC policy #4.19, Discharge Against Advice/Elopement from Hospital

VIII. REVIEW DETAILS
Version: Revision
Next Revision Due: December 18, 2018
Formerly Know n as: Hospital Administrative policy #10.18