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Confidential Psychiatric Admissions and Notification of Release (2.1.20)

Confidential Psychiatric Admissions and Notification of Release (2.1.20) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer

2.1.20


UW HEALTH CLINICAL POLICY 1
Policy Title: Confidential Psychiatric Admissions and Notification of Release
Policy Number: 2.1.20
Category: UW Health
Type: Inpatient
Effective Date: September 29, 2016

I. PURPOSE

To establish standards for confidentiality of admission and notification of release for B6/5 psychiatric patients
at the University Hospital (600 Highland Avenue).

II. POLICY ELEMENTS AND PROCEDURE

A. Informing Callers and Visitors of Psychiatric Inpatients. UW Health has adopted the following standards for
informing callers and visitors of the presence of a psychiatric patient on B6/5.
i. Upon admission to inpatient psychiatry unit, every patient will be presented with the Authorization
for Consent to Information Disclosure (UWH #3405) by the admitting Nursing Staff member. In
compliance with Wis. Stat. § 51.30, the nursing staff member will inform the patient of his right for
confidential admission.
ii. If patient (and/or guardian or agent under activated health care power of attorney if the patient has
one) signs the Consent of Information Disclosure, the staff of UW Health will acknowledge the
presence of the patient in the hospital to visitors or callers. The Consent of Information Disclosure
may be revoked at any time, but any revocation will not apply to disclosures made prior to the
revocation. The Consent of Information Disclosure will expire upon the patient’s discharge from the
inpatient psychiatry unit.
iii. If the patient (and/or guardian or agent under activated health care power of attorney if the patient
has one) refuses or is unable to sign the Consent of Information Disclosure:
a. Notify the Information Desk of the patient’s desire for confidential admission. In this case,
the information desk personnel, as well as the inpatient psychiatric unit staff, would
respond to inquiries regarding the patient with a statement similar to, “We have no room
number listed for that person.”
b. The Information Desk personnel, as well as the staff of the inpatient psychiatric unit, will
flag the patient’s record as confidential.
c. It is the responsibility of the patient to notify friends and/or family of his/her presence in
University Hospital.
d. The patient will be informed by Admissions staff that selection of confidential admission
will result in the return of gifts, and flowers sent to patients.
e. Patients will be informed that if they wish to have visitors, they must arrange for the visit
with staff, often by meeting the visitor at the door of inpatient psychiatric unit.
f. Disclosure can be made without the patient’s consent in circumstances where the law
authorizes or requires such disclosure. Questions concerning when such disclosure can
be made should be directed to the UW Health Legal Department and/or Privacy Officer.
iv. Confidentially admitted patients may choose to sign the Consent of Information disclosure at any
time.
B. Patient Consent to Notify Persons of Patient’s Release. UW Health, pursuant to Wis. Stat. § 51.10(9), must
offer the patient, upon admission, an opportunity to consent to notifying the patient’s parent, child, spouse or
any other adult, of the patient’s request for release.
i. Upon admission, the inpatient psychiatry admitting nursing staff member must offer the patient
orally and in writing the opportunity to consent to notification of one of the above mentioned
persons of the patient’s request for release.
ii. The patient should be offered the Consent for Notification of Release Form (UWH#4008501) upon
admission.
iii. If the patient consents and signs the form, the inpatient psychiatry staff shall notify the person
specified as soon as possible after the patient requests release.

III. FORMS

Authorization for Consent of Information Disclosure UWH #3405
Consent for Notification of Release Form UWH #4008501




UW HEALTH CLINICAL POLICY 2
Policy Title: Confidential Psychiatric Admissions and Notification of Release
Policy Number: 2.1.20

IV. COORDINATION

Author: Nurse Manager, Inpatient Psychiatry
Senior Management Sponsor: SVP, Patient Care Services and CNO
Reviewers: General Counsel; Director of Hospital Psychiatry Services
Approval committees: Nursing Patient Care Procedures Committee; UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: September 19, 2016

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.

V. APPROVAL

Peter Newcomer, MD
UW Health Chief Medical Officer

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

VI. REFERENCES

Wisconsin Statutes section 51.30 – Records
Wisconsin Statutes section 51.10 – Voluntary Admission of Adults
Wisconsin Administrative Code DHS section 92.03(2) and (3) – General Requirements—Disclosure of
Patient Status in Response to Inquiries and Informed Consent

VII. REVIEW DETAILS
Version: Revision
Next Revision Due: September 2019
Formerly Known as: Hospital Administrative policy #10.15