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Admission Checklist
Authorization and Consent
Authorization for Use of Image
Authorization for Use or Release of Information
Belongings List
Consent for Ordinary and Routine Medical and Dental Care
Consent For Services
Consent for Treatment
Geriatric Depression Scale
Inpatient Certificate
Intake Questionnaire
Legal Notice to Patients
Notice Regarding Rights of Recipients
Observation Record
Patient Phone and Visitation Restriction Sheet
Petition For Involuntary/Judicial Admission
Psychiatric Medical Clearance Checklist
Psychotropic Medication Notice and Consent
Rights Receiving Mental Health Services
Suicide Safety Plan
Unit Rules
Sign Forms
Generate Forms
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Belongings List
Patient
Directions: Complete form and obtain signature from Patient or Significant Other (SO)
Apparel
Coat;
Jacket;
Shirt;
Blouse;
Dress;
Skirt;
Nightwear;
Shoes;
Boots;
Slippers;
Sweater;
Hat;
Pants;
Slip;
Robe;
Socks;
Hose;
Belt;
Underwear;
Other:
Disposition
Patient
Family
Lost & Found/(Security)
Other
Jewelry
Earring(s);
Necklace(s);
Ring(s);
Watch;
Bracelet(s);
Other:
Disposition
Patient
Family
Lost & Found/(Security)
Other
Personal Effects
Glasses;
Contacts;
Denture-Upper;
Denture-Lower;
Hearing Aid;
Key(s);
Wallet/Contents;
Purse/Contents;
Wheelchair;
Cane;
Walker;
Cell Phone;
I-Pod;
MP3;
Laptop;
Computer;
Other:
Disposition
Patient
Family
Lost & Found/(Security)
Other
Money
Disposition
RCH Safe
Patient chooses to keep at own risk
Sent home with:
Medications
None
Refer to Med Reconciliation Form
Disposition
Locked Cabinet on Unit
Sent home with:
Room Transfer
From Room:
To Room:
Discharge
Personal Medications Returned
Money Returned from Hospital Safe
Death
All Belongings Checked Above were
Returned
Sent to Morgue (Security)
Remove