5 Universal Intake Set

This chapter defines the minimum intake set that prevents safety and medical misses. Most useful at first contact or when restarting care.

Purpose. Create a minimum, repeatable intake set for every patient. Catch safety, medical, and substance issues early. Normalize cross-cutting context so it is not lost under time pressure.

5.1 Minimum Intake Set (every patient, every time)

Safety: suicide/self-harm, violence risk, self-neglect, exploitation risk.
Medical/neurologic red flags: acute confusion, head injury, seizures, infection signs.
Substance/medication review: intoxication, withdrawal, recent changes, iatrogenic effects.
Sleep/circadian: insomnia, hypersomnia, circadian shift, nightmares.
Pain/fatigue: severity, duration, functional impact.
Function: work/school, relationships, self-care.
Trauma/stress exposure: recent threats, ongoing safety concerns.
Social determinants: housing, food security, legal issues, access to care.
Supports and strengths: relationships, coping skills, protective factors.

Red flags

Acute confusional state or rapidly fluctuating cognition. [E0/U3]
Severe intoxication, withdrawal, or medication reaction. [E0/U3]
Imminent self-harm or harm to others. [E0/U3]
Inability to care for basic needs without support. [E0/U3]

Documentation Output. Presenting problem line. Safety screen outcome. Rule-out triggers noted. Context and supports snapshot.