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Adult Patient Acknowledgement of Voluntary Inpatient Psychiatric Admission and Alternative Procedures (3.1.2)

Adult Patient Acknowledgement of Voluntary Inpatient Psychiatric Admission and Alternative Procedures (3.1.2) - Policies, Clinical, UW Health Clinical, Medical Records and Communication, Consent


Policy Title: Adult Patient Acknowledgement of Voluntary Inpatient Psychiatric
Admission and Alternative Procedures
Policy Number: 3.1.2
Category: UW Health
Type: Inpatient
Effective Date: December 18, 2015


To outline a procedure for obtaining adult patient (and/or guardian) consent for an inpatient psychiatric
admission and for advising the patient of his/her rights.


Ensure that all patients voluntarily admitted to the Inpatient Psychiatric Unit have given consent to the
admission, evaluation and treatment and have been advised of their rights.


A. Voluntary Admission
i. The voluntary admission form should be signed by the patient upon admission to the hospital. In
the case w here the court has appointed a legal guardian, both the patient and the guardian must
consent to admission. The admitting physician should make every effort to obtain the signature(s)
upon admission. The voluntary admission forms are available in the Emergency Department and at
the nurses’ station on the Inpatient Psychiatric Unit.
ii. The patient is considered voluntarily admitted w hen the follow ing tw o qualif iers have been met:
a. Patient signs the voluntary Admission form.
b. Patient crosses the threshold onto the B6/5 Inpatient Psychiatry unit.
iii. Upon admission, the patient shall be informed orally and in w riting of his/her rights under sec.
51.61, Stats. The complete section is available upon request.
iv. Copies of the statement of rights shall be posted in each patient area and made available to the
patient's immediate family and any guardian.
B. Alternative Procedures If the patient (and/or guardian w hen applicable) refuses or is unable to sign the
voluntary form, there are f ive options:
i. Consider initiation of the Emergency Detention process, if the patient is refusing admission and
treatment and there is indication for required detention and treatment. UW Health clinical policy
#1.2.1 - (Emergency Detention-State Mental Health Act).
ii. Do not admit the patient if the patient does not meet criteria for admission.
iii. Request the medical director to temporarily admit the patient under sec. 51.10(7), Stats., if there is
reason to question the competency of the individual. The director shall then apply to the court for
appointment of a guardian w ithin 48 hours of admission (excluding Saturdays, Sundays, and
holidays). The individual may be held pending appointment of a guardian.
iv. For passive, voluntary patients, use the procedure for patients presumed to consent under sec.
5l.l0 (4m). If the patient refuses or is unable to sign the application for admission but does not
indicate a desire to leave the facility, and a physician certif ies in w riting (before tw o w itnesses) that
the physician has advised the patient orally and in w riting (before such w itnesses):
a. Of the benefits and risks of treatment;
b. The right to least restrictive form of appropriate treatment;
c. That the facility w ill provide such treatment;
d. Of the patient's rights under s. 5l.61 and his/her right to request discharge in w riting, to
have w riting materials to request discharge and to be discharged unless an emergency
detention is f iled; the patient is presumed to consent to admission and may be held as a
voluntary patient for up to 7 days if the court is notif ied on the f irst court day follow ing
admission. The court w ill appoint a guardian ad litem w ithin 24 hours of receiv ing the
notice, w ho shall visit the facility w ithin 48 hours to determine if the patient's rights have
been respected. Unless the patient signs a voluntary admission form w ithin the 7 days, the
court w ill decide on discharge. A physician on the Inpatient Psychiatric Unit staff w ithin the
7 days may initiate procedures for involuntary commitment.
v. For a patient w ho cannot or w ill not sign the application for admission but w ho is competent and
w ho orally states he/she w ishes to be admitted (the active voluntary patient), the patient may be

Policy Title: Adult Patient Acknow ledgement of Voluntary Inpatient Psychiatric Admission and Alternative
Policy Number: 3.1.2

admitted to the unit for a maximum of 24 hours (see C.iii. below ).
C. If option number iii, iv, or v above w as chosen, then the follow ing should occur:
i. Physician Responsibilities:
a. The psychiatry physician should notify the Inpatient Psychiatric Unit Nursing Staff.
b. The psychiatry physician should Document on the admission note the reasons the patient
did not sign the voluntary admission form and on w hat basis the patient is being admitted.
ii. Nursing Staff Responsibilities:
a. Communicate through shift-to--shift handoff that the patient has not signed the voluntary
admission form.
b. Discuss w ith other team members at the follow ing day's treatment team’s meeting the
issue of the unsigned voluntary admission form and the options available and chosen.
c. The health unit coordinator w ill review charts of all new admissions to determine if the
voluntary admission form has been signed. If the voluntary admission form has not been
signed, the health unit coordinator w ill notify the nurse manager.
iii. If option v w as chosen, and w ithin the 24 hours, a patient still refuses to sign a voluntary admission
form, other alternatives should be sought w hich may include seeking Emergency Detention if the
patient meets the criteria. In most cases, a patient should not remain on the unit after 24 hours
w ithout his/her acknow ledged w ritten consent to treatment or court proceedings. Exceptions may
arise in circumstances such as w hen the patient is physically unable to sign or is unw illing to sign
but expresses w illingness to be treated on the Inpatient Psychiatric Unit. Exceptions must be
approved by the Medical Director during w eekdays or by the on-call faculty during on-call hours.
The exceptional circumstances must be documented in the chart by the Medical Director or on call
faculty w ith 2 w itnesses' signatures.
iv. Weekend Staff Responsibilities:
a. On w eekends and holidays, the nursing staff w ill try to obtain the signature for the
voluntary form. If the signature cannot be obtained, the nurse w ill immediately notify the
physician on call.
b. Each admitting physician on call during the w eekend should coordinate obtaining the
necessary signature w ith the next on-call physician.
c. The on-call physician must come to the unit to see the patient, review the situation, and
attempt to obtain the signature. If after 24 hours the voluntary form has not been signed
nor appropriate legal measures taken, the on-call physician w ill contact the attending staff
on call. If the decision is made to discharge the patient, the attending staff w ill evaluate the
patient prior to discharge.


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

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.


Jeff Grossman, MD
UW Health CEO

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

Policy Title: Adult Patient Acknow ledgement of Voluntary Inpatient Psychiatric Admission and Alternative
Policy Number: 3.1.2


Section 51.61 of the Wisconsin Statutes – Patient rights
UW Health clinical policy #1.2.1, Emergency Detention – State Mental Health Act
Section 51.10 of the Wisconsin Statutes – Voluntary admission of adults

Version: Revision
Next Revision Due: December 18, 2018
Formerly Know n as: Hospital Administrative policy #10.13