UW HEALTH CLINICAL POLICY 1
Policy Title: Admission and Discharge of Patients to and from the Inpatient Psychiatric
Policy Number: 2.1.23
Category: UW Health
Effective Date: May 1, 2017
To ensure the use of a uniform policy when patients are admitted to and discharged from Inpatient
II. POLICY ELEMENTS
Patients are admitted to inpatient psychiatry voluntarily or involuntarily with acute psychiatric conditions that
cannot be managed in the community. The patient must be at least 18 years of age.
A. Admission Criteria
i. Inclusion Criteria: Severe psychiatric illness with one or more of the following consequences:
a. Deterioration in function.
b. Assaultive/Threatening behavior.
c. Lack of cooperation with treatment with deterioration or reason to believe deterioration will
d. Recent suicide attempt or thoughts about suicide that indicate a risk for a future suicide
e. Safety Needs: the person is at risk of harming themselves or others or is grossly incapable
of meeting the ordinary demands of life, such as the need for food or shelter.
ii. Exclusion Criteria:
a. There is violence beyond what can be safely managed on the unit.
b. There are medical needs beyond what staff are able to manage such as some level II
medications, or monitoring is required which is unavailable such as telemetry.
c. Patient is likely to be disruptive to the therapeutic milieu and/or to interfere with the safe
and therapeutic care of other patients on the unit.
d. Patient is unlikely to benefit from psychiatric hospitalization.
B. Discharge Criteria
i. Does not require intensity of observation available in hospital.
ii. Improvement of level of function.
iii. Medication management is stable enough to transfer to outpatient treatment.
iv. Psychiatric illness is not causing a significant risk of dangerous behavior to self or others.
v. Medically stable enough to transfer to outpatient care or another appropriate treatment facility.
vi. Will not benefit from further hospitalization.
Author: Nurse Manager, Inpatient Psychiatry
Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: Director, Hospital Psychiatry Services; Director Inpatient Psychiatry
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: April 17, 2017
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.
UW HEALTH CLINICAL POLICY 2
Policy Title: Admission and Discharge of Patients to and from the Inpatient Psychiatric Unit
Policy Number: 2.1.23
Peter Newcomer, MD
Chief Clinical Officer
J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee
VI. REVIEW DETAILS
Last Reviewed: May 1, 2017
Next Revision Due: May 2020
Formerly Known as: Hospital Administrative policy #10.22