Final Week: Education for Legal Professionals Regarding Mental Health Records in Florida

Welcome to our final week! This post will wrap up our series by sharing common forms which are included in mental health records. This applies to adults being treated in acute inpatient mental health units (crisis stabilization/Baker Act receiving facilities).

Admission Form:

  1. Voluntary Admission Form (signed by patient) or
  2. Involuntary Admission Form
    • Baker Act (completed by police or designated healthcare provider) or
    • Ex-Parte Order (ordered by the Court)

Psychiatric Evaluations to Determine Need for Inpatient Treatment and Competency Status

  1. Patient continues voluntary treatment or
  2. Patient is deemed in need of involuntary treatment
    • Patient is incompetent and needs an appointed guardian for decision making, or
    • Patient is competent and can make treatment decisions for self (excluding being discharged)

Ensure the involuntary commitment forms (if applicable) are sent by the facility to the Court to be filed.

  1. There will be a date and time stamp on this document and
  2. Person sending the document is listed

Consent forms for medications signed by either

  1. Voluntary or competent patient or
  2. Appointed guardian (often called a Health Care Surrogate)

If restraints are used (to include manual holds), then they must be documented in detail per policy.

Screening questionnaires:

  1. Risk for suicide
  2. Alcohol or substance abuse
  3. Risk for harm to self or others

Other documents:

  • Patient rounding sheets
  • Treatment team documents

This is only a partial list but should assist you in determining which documents should be included, and how they apply. Feel free to contact me for additional information or explanations regarding mental health records and forms used in Florida.

If you have questions about legal matters, please consult an attorney.


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