Uniform Preadmission Screening and Report Form

Uniform Preadmission Screening and Report Form
Data Elements Reference Sheet for the Preadmission Screening Form

Uniform Preadmission Screening and Report Form

QUESTION : Prior to Section I, what does “Case/TDO#” refer to?

ANSWER : If a TDO is issued, the number assigned to the TDO should be put in that box.

QUESTION : Section 1 – Are there prescribed values for “Sex,” “Race,” and “Hispanic Origin”?

ANSWER : If your CSB will use the form to capture information for CCS data reports, you should limit what you put in these fields to the values listed in the attached “CCS Data Elements Reference Sheet for the Preadmission Screening Form.”

QUESTION : In general – Are there required CCS data elements that are not included on the form?

ANSWER : Yes. If your CSB uses this form to collect CCS data elements, there are other CCS data elements that are required to be collected during an emergency services event. . CSBs that use the form to collect CCS data elements may want to record these data elements on the form. These include the individual’s home “CityCountyCode” in Section 3 and “Pregnant Status” for inclusion in Section 10, the medical section. The CCS codes are included in the attached “CCS Data Elements Reference Sheet for the Preadmission Screening Form.”

QUESTION : Section 2 – What does WRAP stand for?

ANSWER : WRAP stands for “Wellness Recovery Action Plan”. One element of a WRAP is “crisis planning”. Information about the elements of a crisis plan in a WRAP may be found here. If the individual’s WRAP plan is available at the time of the assessment, it could serve as an excellent resource for identifying what may help ameliorate the situation.

QUESTION : Section 2 – What does MOT stand for?

ANSWER : MOT stands for “Mandatory Outpatient Treatment”. “Under MOT” should be checked if the individual is subject to a Mandatory Outpatient Treatment Order.

QUESTION : Section 3 – What should be put in Local Use?

ANSWER : The Local Use section can capture anything that would be helpful for your particular region/locality. Some Boards use the section for data collection, or to answer other questions specific to the locality.

QUESTION : Section 7 – Why doesn’t the risk assessment section include whether or not the person is homicidal or suicidal? There are lots of variables to consider in assessing risk, why aren’t there check boxes for things like hopelessness or access to weapons?

ANSWER : This section is designed to be a place to document the outcome of your clinical risk assessment, based on the new criteria language in the Code. There are places to specifically describe information regarding recent acts or behaviors that would be harmful to self or others and the risk of homicide or suicide should be noted within these parameters.

For example, the risk of homicide would be considered as part of the assessment of a risk of serious physical harm to others. Document a risk of homicide as follows:

Check “There is a substantial likelihood of serious physical harm to”, check “others”, and check any other applicable box(es) that identify recent behavior with respect to, causing, attempting or threatening to harm someone. If the individual had access to weapons, for example, check “means” and describe these facts on the following lines.

A risk of suicide would be considered as part of the assessment of a risk of serious physical harm to self. A clinical evaluation which found, for example, that the individual exhibited hopelessness could be documented in the section, “Other relevant information, if any”.

The Uniform Preadmission Screening Form Workgroup (which included ES Managers) considered the development of a standardized, prescribed universal risk assessment tool that would be completed and attached as a Supplemental Form to the prescreening form. The workgroup did not support this idea so it was not pursued.

QUESTION : Section 7 - Why is there an asterisk next to the criteria: “There is a substantial likelihood that, as a result of mental illness, in the near future he/she will suffer serious harm due to a lack of capacity to protect him/herself from harm or to provide for his/her basic human needs?”

ANSWER : The asterisk refers to the statement at the end of the section “Not applicable under Virginia Code §19.2-169.6, 19.2-176, and 19.2-177.1” These code sections are related to forensic commitments. The 2008 General Assembly specifically decided not to include this “suffer serious harm” criterion for detention and commitment of jail inmates under those sections of the Code.

QUESTION : Section 8 - What does the boxed note “If a TDO is not recommended you must inform the petitioner and on-site treating physician” refer to? Who is the petitioner at this point? What if the physician or petitioner is unavailable?

ANSWER : The new language in the Code, § 37.2-809 K related to this reminder is as follows: “The employee or designee of the community services board who is conducting the evaluation pursuant to this section shall, if he recommends that the person should not be subject to a temporary detention order, inform the petitioner and an on-site treating physician of his recommendation.” It is true that in some situations there may not be an identified petitioner requesting the evaluation. However, in situations in which there is a known petitioner, that person should also be notified if a TDO is not issued. In any case where there is an on-site treating physician, every effort should be made to notify the physician if a TDO is not recommended so that he/she may exercise the option to contact the magistrate directly or take other action as needed.

QUESTION : Section 9 – What is an “advance directive”?

ANSWER : In Virginia, advance directives are used to document in written form a person’s specific instructions or preferences regarding medical treatment in certain circumstances. It is not expected that the prescreening clinician will develop a directive with the individual. However, if an individual has such a document and it is available during the time of the assessment, such information may assist in the development of the least restrictive treatment plan in accordance with the individual’s wishes.

QUESTION : Section 9 – Do all psychiatric hospitalizations need to be listed?

ANSWER : No, under “2b” the form specifically asks the name of the last hospital from which the individual was discharged. There is an optional comments section to add whatever additional information regarding mental health treatment history that may be of note.

QUESTION : Section 10 – Isn’t it a violation of disclosure laws to attach a medical addendum?

ANSWER : It is permissible to share medical information that will allow, and is necessary for, the person to obtain needed treatment. It is optional to add an addendum, so if there is no pertinent information to share, it may not be appropriate. For example, if there is information regarding toxicology reports or liver functioning, that may be important information to share. However, information about certain illnesses (some STDs, for example) may not be appropriate or necessary to share.

QUESTION : Section 14 – Can this be filled out by the prescreener at the time of the evaluation for the temporary detention order?

ANSWER : Yes, it can be, but §37.2-809 H. of the Code also states “The duration of temporary detention shall be sufficient to allow for completion of the examination required by § 37.2-815, preparation of the preadmission screening report required by § 37.2-816, and initiation of mental health treatment to stabilize the person's psychiatric condition to avoid involuntary commitment where possible, but shall not exceed 48 hours prior to a hearing.” . Thus, Section 14 may also be completed later, especially if the pre-detention and pre- hearing recommendations may change. Also, the recommendation and identification of providers for mandatory outpatient treatment would likely not be possible at the time of detention.

QUESTION : Section 14 – Is this not the same as what the independent examiner does?

ANSWER : §37.2--816 specifically requires that a preadmission screening report by the community services board be submitted to the court and include “whether the person is in need of involuntary inpatient treatment, whether there is no less restrictive alternative to inpatient treatment, and the recommendations for that person's placement, care, and treatment including, where appropriate, recommendations for mandatory outpatient treatment.” Section 14 is the CSB report to the Court, which is separate and distinct from the independent examiner’s report, §37.2-815. It is true, however, that the elements of the evaluations share many similarities.

QUESTION : Section 14 – Why is “Mental Retardation” listed and not “Intellectual Disabilities”?

ANSWER : The Code has not specifically changed the term to intellectual disabilities. This name change will be voted on again during the next General Assembly session.

QUESTION : Section 14 – What are trauma informed services?

ANSWER : As noted on SAMSHA’s National Mental Health Information Center: “The goal is to develop a sensitivity to the centrality of trauma and its ongoing role in the lives of consumers and survivors seeking services. Trauma-informed management is important not only in providing effective services, but also to ensure that survivors and consumers are not further traumatized in their efforts to break out of the isolation of trauma and move ahead in the healing process”. Further information regarding trauma informed services can be found here: http://mentalhealth.samhsa.gov/nctic/

QUESTION : Is this form to be used for juveniles?

ANSWER : Yes. As of July 1, 2008, the previous preadmission screening form should not be used. We recognize that while the criteria for temporary detention are the same for adults and juveniles, the criteria for commitment are different for juveniles. DMHMRSAS will be working on a way to address the unique needs of juveniles in this process.

QUESTION : Is this form to be used prior to recommitment hearings as well?

ANSWER : Yes. The Code makes no differentiation between commitment and recommitment hearings. This form has been approved by the Attorney General’s office and no other forms have been approved for use in this process.

QUESTION : Can this form be faxed or e-mailed to another CSB if they will be attending the hearing?

ANSWER : Yes, the following language is taken directly from § 37.2 - 817B “Where a hearing is held outside of the service area of the community services board that prepared the preadmission screening report, and it is not practicable for a representative of the board to attend or participate in the hearing, arrangements shall be made by the board for an employee or designee of the board serving the area in which the hearing is held to attend or participate on behalf of the board that prepared the preadmission screening report. The community services board that prepared the preadmission screening report shall remain responsible for the person subject to the hearing and, prior to the hearing, shall send the preadmission screening report through certified mail, personal delivery, facsimile with return receipt acknowledged, or other electronic means to the community services board attending the hearing. Where a community services board attends the hearing on behalf of the community services board that prepared the preadmission screening report, the attending community services board shall inform the community services board that prepared the preadmission screening report of the disposition of the matter upon the conclusion of the hearing. In addition, the attending community services board shall transmit the disposition through certified mail, personal delivery, and facsimile with return receipt acknowledged, or other electronic means.”

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Data Elements Reference Sheet for the Preadmission Screening Form

City/County Codes: Click here for City/County Codes

Sex (Gender):
01 Female
02 Male
97 Unknown
98 Not collected

Race:
01 Alaska Native
02 American Indian
03 Asian or Pacific Islander*
04 Black or African American
05 White
06 Other
13 Asian
23 Native Hawaiian or Other Pacific Islander
31 American Indian or Alaska Native and White**
32 Asian and White**
33 Black or African American and White**
34 American Indian or Alaska Native and Black or African American**
35 Other Multi-Race**
97 Unknown
Hispanic Origin
01 Puerto Rican
02 Mexican
03 Cuban
04 Other Hispanic
05 Not of Hispanic Origin
06 Hispanic - Specific origin not specified
97 Unknown

CSB Agency Codes:
001 Alexandria
003 Alleghany-Highland
005 Arlington County
007 Central Virginia
009 Chesapeake
011 Chesterfield
013 Colonial
015 Crossroads
017 Cumberland Mountain
019 Danville-Pittsylvania
020 Dickenson County Behavioral Health Services
021 Eastern Shore
023 Fairfax-Falls Church
025 Goochland-Powhatan
027 Hampton-Newport News
029 Hanover County Community Services Board
031 Harrisonburg-Rockingham Community Services Board
033 Henrico Area
035 Highlands
037 Loudoun County Community Services Board
039 Middle Peninsula-Northern Neck
041 Mount Rogers
043 New River Valley
045 Norfolk Community Services Board
047 Northwestern
049 Piedmont Regional
051 Planning District I
053 District 19 Community Services Board
055 Portsmouth
057 Prince William County Community Services Board
059 Rappahannock Area Community Services Board
061 Rappahannock-Rapidan Community Services Board
063 Region Ten Community Services Board
065 Richmond
067 Blue Ridge Behavioral Healthcare
069 Rockbridge Area Community Services
071 Southside Community Services Board
073 Valley Community Services Board
075 Virginia Beach Community Services Board
077 Western Tidewater Community Services Board

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Uniform Preadmission Screening and Report Form