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    MRMHA C Confirmation or Revocation

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    prabha
    This document is either a confirmation or revocation of a treatment order under the Mental Health Act 2009 for a patient. It contains sections for identifying the patient, examining the patient and either confirming an existing Level 1 treatment order or community treatment order, or revoking an existing Level 1, 2, or extended treatment order. If confirmed, the examining psychiatrist or authorized medical practitioner must make a statement of reasons for the confirmation as soon as practicable using another form. If revoked, copies must be given to the patient and appropriate others as soon as possible.

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    MRMHA C Confirmation or Revocation

    Uploaded by

    prabha
    63 views2 pages
    This document is either a confirmation or revocation of a treatment order under the Mental Health Act 2009 for a patient. It contains sections for identifying the patient, examining the patient and either confirming an existing Level 1 treatment order or community treatment order, or revoking an existing Level 1, 2, or extended treatment order. If confirmed, the examining psychiatrist or authorized medical practitioner must make a statement of reasons for the confirmation as soon as practicable using another form. If revoked, copies must be given to the patient and appropriate others as soon as possible.

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    This document is either a confirmation or revocation of a treatment order under the Mental Health Act 2009 for a patient. It contains sections for identifying the patient, examining the patient and either confirming an existing Level 1 treatment order or community treatment order, or revoking an existing Level 1, 2, or extended treatment order. If confirmed, the examining psychiatrist or authorized medical practitioner must make a statement of reasons for the confirmation as soon as practicable using another form. If revoked, copies must be given to the patient and appropriate others as soon as possible.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    63 views2 pages

    MRMHA C Confirmation or Revocation

    Uploaded by

    prabha
    This document is either a confirmation or revocation of a treatment order under the Mental Health Act 2009 for a patient. It contains sections for identifying the patient, examining the patient and either confirming an existing Level 1 treatment order or community treatment order, or revoking an existing Level 1, 2, or extended treatment order. If confirmed, the examining psychiatrist or authorized medical practitioner must make a statement of reasons for the confirmation as soon as practicable using another form. If revoked, copies must be given to the patient and appropriate others as soon as possible.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    You are on page 1of 2

    1a.

    Affix patient identification label in this box


    䢇
    CONFIRMATION or
    Hospital: ...........................................................................................

    REVOCATION of a
    UR No: ............................................................................................. 䢇
    TREATMENT ORDER
    Surname: .........................................................................................
    Given Name: ...................................................................................
    (MRMHA-C) Second Given Name: ....................................................................
    䢇
    D.O.B: .................................................... Sex: ............................

    Mental Health Act 2009 – Section 10, 21, 25


    䢇
    1b. PERSON ADDRESS DETAILS (if not on or different from patient label above)
    䢇
    Address: .............................................................................................................................................................................................................
    Suburb/town: ............................................................................................................................................... Postcode: ___ ___ ___ ___
    䢇
    2. EXAMINATION OF PERSON
    I have examined the above named person on:
    䢇
    __ __ /__ __ / 20 __ __ at __ __ : __ __ (24-hour clock)

    Location of examination: .................................................................................................................................................................................


    Please specify: emergency dept, ward and hospital, community mental health site, GP clinic or residence.
    䢇
    3. CONFIRMATION OF A LEVEL 1 TREATMENT ORDER
    䢇
    I have examined the person and am satisfied that the grounds for the making of the
    □ Level 1 community treatment order, or
    䢇
    □ Level 1 inpatient treatment order

    Made on __ __ /__ __ / 20 __ __ continue to exist.


    䢇
    I hereby confirm the order.

    OR

    CONFIRMATION OR REVOCATION OF A TREATMENT ORDER MRMHA-C


    4. REVOCATION OF A TREATMENT ORDER

    I have examined the person and am not satisfied that the grounds for the
    □ Level 1 community treatment order made, or
    □ Level 1 inpatient treatment order made, or
    □ Level 2 inpatient treatment order made, or
    □ Level 2 inpatient treatment order extended

    On __ __ /__ __ / 20 __ __ continue to exist.

    I hereby revoke the order.

    5. PSYCHIATRIST or AUTHORISED MEDICAL PRACTITIONER REVIEWING THE ORDER


    Full Name (Please print):
    Psychiatrist □ Authorised Medical Practitioner □

    Signature:
    __ __ /__ __ / 20 __ __ at __ __ : __ __ (24-hour clock)

    Health service/agency (Please print):

    Office of the Chief Psychiatrist Inquiries: (08) 8226 1091 Act Forms Fax: (08) 8115 5551
    SA Health Internet: www.chiefpsychiatrist.sa.gov.au Act Forms Email: HealthOCPMHLO@sa.gov.au

    Created Sensitive: Medical (When completed) - I2 - A2


    May Please turn over—continued over the page

    Page 1 of 2
    2017 Please use black ballpoint pen when completing this form
    1a. Affix patient identification label in this box

    CONFIRMATION or
    Hospital: ...........................................................................................

    REVOCATION of a
    UR No: .............................................................................................

    TREATMENT ORDER
    Surname: .........................................................................................
    Given Name: ...................................................................................
    (MRMHA-C) Second Given Name: ....................................................................
    D.O.B: .................................................... Sex: ............................

    6. STATEMENT OF REASONS
    The psychiatrist or authorised medical practitioner confirming a level 1 treatment order must make a statement of
    reasons describing the reasons for the confirmation of the order. The statement of reasons must be made as soon as
    practicable using Form MRMHA-E.

    7. HEALTH SERVICE / AGENCY OBLIGATIONS


    The person must be given a copy of the revocation of a treatment order as soon as practicable.
    The guardian, substitute decision maker (medical agent), relative, carer or friend must be given a copy of the
    revocation of a treatment order (if appropriate) as soon as practicable.
    Note: Copies of the confirmation of an order do not need to be given to the patient or a guardian, substitute decision
    maker (medical agent), relative, carer or friend.
    The Chief Psychiatrist must be sent a copy of page 1 of this form within 1 business day.
    The reasons for the confirmation or revocation of an order, the provision of copies and making of notifications must be
    noted in the person’s medical records and/or casenotes, whether electronic or paper-based.

    Thi
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    ase ge
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    Office of the Chief Psychiatrist Inquiries: (08) 8226 1091 Act Forms Fax: (08) 8115 5551
    Internet: www.chiefpsychiatrist.sa.gov.au Act Forms Email: HealthOCPMHLO@sa.gov.au

    Sensitive: Medical (When completed) - I2 - A2


    Page 2 of 2

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