Medical Evaluation of Patients Prior to a Psychiatric Hospitalization: A Clinical Pathway Approach

At present, there is no consensus in the literature regarding the appropriate medical evaluation of the patient with a psychiatric chief complaint in the emergency department (ED). There is agreement in the literature that the evaluation should include obtaining a history, performing an appropriate physical and mental status examination, and performing medical tests as needed. However, controversy exists as to the components of the evaluation, the proper documentation of the process, and the need to perform tests on patients presenting with behavioral or psychiatric chief complaints. There are no clear established guidelines or standards to guide the clinician in the emergency room in determining how extensive an evaluation is needed. Some patients may be receiving an unnecessary workup while others may not be receiving adequate medical clearance. The lack of clear evidence-based standards often leads to disagreement between ED clinicians and psychiatrists about the “medical clearance” of a patient. The purpose of this paper is to review the available literature on the topic and to suggest guidelines to help structure the medical clearance of a psychiatric patient in the emergency room.