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How to IVC Patients At HBH

How to place a patient on IVC petition

AKA How to keep patients in the hospital using hospital police

In an effort to protect patients/staff, conserve PPE, and reduce spread of COVID-19, CL psychiatry (ie, Consults) will be moving to a primary liaison model and minimizing face-to-face interactions. As a result, primary providers may be asked to fill out IVC paperwork to allow police to keep a patient in the hospital. To place a patient on petition for IVC, you must fill out two forms, the Petition and 1st Qualified Physician Exam (QPE). The 2nd QPE is completed on inpatient psychiatry and “completes” the petition for IVC. Both documents are submitted to hospital police. The first document (Petition) needs to be signed in the presence of hospital police or a notary. The second does not need to be. If a police notary is not available, please contact Donna Withrop (patient relations) or Shannon Medlin (admin assistant). We are working on the proper workflow in the event that a notary is not available. Please call hospital police at 5-2073 if you need their assistance. Please follow the instructions below to complete these forms. If you have any questions, please contact the CL psychiatry team at 347-1238 and we can walk you through it:

Petition (AFFIDAVIT AND PETITION FOR INVOLUNTARY COMMITMENT)

  • This document has ONE provider signature, but it MUST be signed in front of hospital police / notary
  • “COUNTY”: for the hospital (ORANGE), NOT patient’s home county.
  • “IN THE MATTER OF”: Fill in Demographic Information
  • Patient Name, Address, and Date of Birth (required)
  • SSN, Drivers License, and State (Optional / Leave Blank)
  • Below the demographic information, select the relevant boxes regarding dangerousness and use the free text box to add information justifying commitment.
  • MUST Select: #1 “has a mental illness and is dangerous…”
  • CAN Select: subset “in addition to having a mental illness” only if patient has an Intellectual Disability
  • DO NOT select: #2 even if patient has a substance use disorder. This checkbox is primarily used for outpatient substance abuse commitment and not keeping someone in the hospital.
  • With free text, emphasize facts demonstrating dangerousness. For example, if the patient is requesting AMA discharge, emphasize their predictable risk of injury to self or death by refusing further medical treatment and their impaired judgement.
  • Can be copied and pasted into the second document, the QPE (see below)
  • “Name and Address of Nearest Relative/Guardian”: Optional if this individual exists.
  • Patient Facesheet in Epic can be a good source of information.
  • “Name and Address of Person Other Than Petitioner”: Optional. Most often left blank
  • “SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME” (bottom left section): Do NOT fill out
  • This is for notary / police
  • “Signature of Petitioner” (bottom right): Do NOT sign UNTIL you are with the notary
  • Must be signed in their presence
  • “Name and Address of Petitioner” (bottom right):
  • Name / Address: Your name / hospital address
  • Relationship to Respondent: PHYSICIAN
  • Home Telephone No: Leave blank
  • Business Telephone No: 984-974-4131 (hospital operator)
  • “PETITIONER’S WAIVER OF NOTICE OF HEARING” (page 2)
  • Not necessary, can leave blank.

QPE (FIRST EXAMINATION FOR INVOLUNTARY COMMITMENT) - This document has TWO provider signatures, but neither need to be done in front of hospital police / notary - Upper right box: County (ORANGE), Client Record # (leave blank), File # (leave blank) - Demographic Information - Complete Patient Name, DOB, Age, Sex, Race, Marital Status (M.S.), home address (street #, city, state, zip, county, and phone if homeless, can list street # as “Homeless”) - “Legally responsible person”: optional if applicable. Often left blank. Usually spouse, parent, or adult child. Include their relationship and address Facesheet in Epic can be helpful. - Petitioner Information: Petitioner listed on “Petition” above - Name: Likely yours. If comes into the ED under petition, please use the name and information for the petitioner (listed in the lower right corner). - Relationship: PHYSICIAN - Address: UNC Hospital, not your home address - EXAMINATION INFORMATION - “Conducted on”: When you last examined the patient - “Included in the examination” - MUST check box for #1 - DO NOT check box for #2 even if they have a substance use disorder. This is used primarily for outpatient substance abuse treatment petitions. - SECTION I - CRITERIA FOR COMMITMENT - ONLY select boxes in the first column “Inpatient” - You MUST check all three unless you are releasing a patient - “An individual with a mental illness” - “Dangerous to:” - “Self” and/or “Others” - Can Check: - “In addition to having a mental illness is also intellectually disabled” If applicable - “None of the above” If releasing patient from IVC - Can ignore “Outpatient” and “Substance Abuse” sections - SECTION II – DESCRIPTION OF FINDINGS - “Clear description of findings”: AKA why you think they are a danger to themselves/others and cannot leave. - Can be copy/pasted from the Petition (see above) - Emphasize dangerousness. See above item 3 section d for more information - “Impression / Diagnosis”: Reason for their dangerousness. May be psychiatric (MDD, bipolar disorder, schizophrenia, etc) or medical (delirium, TBI, encephalopathy, etc) - HEALTH SCREENING - This section is long and does not apply for patients at UNC. It was developed to allow ancillary mental health clinics to IVC someone. - You only need to fill out the first portion. - Check “Check box & sign to attest that the health screening is being replaced by a medical evaluation”. - Sign and print your name, credentials (MD/DO), date, and time. - Skip to Section III leave the rest blank. - SECTION III – RECOMMENDATIONS FOR DISPOSITION - If placing/keeping a patient on petition (AKA, you want them to stay). - Check “Inpatient Commitment” and enter “7” under the number of days. - Petitions outside psychiatric units are only good for 7 days and must be resubmitted (petition AND QPE) every 7 days to remain active. - If releasing a patient from petition (AKA, they can leave). - Check “Respondent was held at first evaluation site pending placement at a 24-hour facility and no longer meets criteria for inpatient commitment”. - Check “Terminate proceedings and release respondent”. - Sign the form: Does NOT need to be done in presence of a notary/police. - Signature - Name - Credentials (defaulted to MD/DO) - Address: hospital, defaulted to UNC Hospital-Chapel Hill