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OBH 1 Physicians Emergency Certificate

The document is a Physician's Emergency Certificate from the Louisiana Department of Health, allowing for the observation, diagnosis, and treatment of a patient for a maximum of 15 or 28 days due to mental illness or substance abuse. It requires detailed patient information, examination findings, and the physician's opinion on the patient's need for immediate psychiatric treatment. The certificate also provides legal authority for the patient's transportation to a treatment facility.

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stephanie.provo98
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68 views1 page

OBH 1 Physicians Emergency Certificate

The document is a Physician's Emergency Certificate from the Louisiana Department of Health, allowing for the observation, diagnosis, and treatment of a patient for a maximum of 15 or 28 days due to mental illness or substance abuse. It requires detailed patient information, examination findings, and the physician's opinion on the patient's need for immediate psychiatric treatment. The certificate also provides legal authority for the patient's transportation to a treatment facility.

Uploaded by

stephanie.provo98
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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OBH-1 (PEC) Complete Prior

Rev. 05/2017 to Admission


STATE OF LOUISIANA
LOUISIANA DEPARTMENT OF HEALTH – OFFICE OF BEHAVIORAL HEALTH
PHYSICIAN’S EMERGENCY CERTIFICATE
For observation, diagnosis, and treatment at a treatment facility for a period not to exceed 15 days, or 28 days, for substance abuse (Title 28:52.4). See
Louisiana Revised Statutes, Title 28, Sections 53 and 63. These directives must be fulfilled in order for this certificate to be valid.

NAME OF EXAMINING PHYSICIAN: EXAMINATION DATE: EXAMINATION TIME:

ADDRESS OF EXAMINING PHYSICIAN:

NAME OF PATIENT

ADDRESS OF PATIENT

RACE SEX DATE OF BIRTH BIRTHPLACE


PATIENT MARITIAL STATUS
M F
MILITARY STATUS RELIGION
DATA
S M D W SEP VETERAN NON-VETERAN
NAME OF NEAREST RELATIVE, FRIEND, OR GUARDIAN RELATIONSHIP

ADDRESS PHONE NUMBER

CHECK:
Mental Illness or Substance Abuse (15 Day) Substance Abuse (28 Day) 1 st 2nd Order For Protective Custody Date: ________________

FINDINGS OF EXAMINATION
HISTORY OF PRESENT ILLNESS (REASONS FOR ADMISSION, INCLUDING BEHAVIOR, ACTS, THREATS, ETC.)

PHYSICAL FINDINGS (MEDICAL HISTORY, CURRENT MEDICATIONS, ETC.)

MENTAL CONDITION (ORIENTATION, MOOD, THOUGHT CONTENT, AFFECT, ANY HALLUCINATIONS OR DELUSIONS)

PREVIOUS PSYCHIATRIC TREATMENT DATE OF TREATMENT PLACE, IF KNOWN

INPATIENT OUTPATIENT
IS PATIENT CURRENTLY:
SUICIDAL HOMICIDAL VIOLENT
I am of the opinion that the above person named is in need of immediate psychiatric treatment in a treatment facility because he/she is seriously
mentally ill or suffering from substance abuse so that he/she is (check where appropriate in both 1 & 2):
1. Dangerous to self Dangerous to others Gravely disabled
2. Unwilling Unable to seek voluntary admission
SIGNATURE OF EXAMINING PHYSICIAN LA MEDICAL LICENSE NUMBER DATE SIGNED TIME SIGNED

Completion of above certificate shall constitute legal authority to transport patient to the following facility:

1. ______________________________________________________________________________________________________________

2. ______________________________________________________________________________________________________________

To be transported by: ______________________________________________________ Relationship to patient: ____________________________

ORIGINAL TO HOSPITAL – ONE COPY TO EXAMINING PHYSICIAN

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