Form 4.1 and 4.2 (British Columbia - First and Second Medical Certificate for Involuntary Admission)

Patients need not always be admitted involuntarily for psychiatric disorders. If a patient is willingly coming into the hospital, they can be admitted in one of two ways:

1. Under British Columbia's Hospital Act, which does not require the use of mental health forms. In routine clinical practice, this is the most common way of admitting voluntary patients as there is no paperwork required.
2. Or, a patient could also be admitted voluntarily under British Columbia's Mental Health Act, but this would require giving the patient a Form 1 (Request for Admission) and Form 2 (Consent for Treatment) In routine clinical practice, this is rarely done except for individuals under age 16.

Police officers have powers under Section 28 of the MHA to take an individual into custody and to transport them to a designated facility for assessment by a physician who will determine the need for further treatment. The criteria used by the police are:

1. If the person is acting in a manner likely to endanger that person's own safety or the safety of others; and
2. If the person is apparently a person with a mental disorder.

Upon arrival, police must keep the person in their custody until the individual is examined by a physician.

In order for an individual to be admitted involuntarily, all of the following four criteria must be met; a physician must be of the opinion that an individual:

1. Is suffering from an apparent mental disorder that seriously impairs their ability to react appropriately to his or her environment or to associate with others;
2. Requires psychiatric treatment in or through a designated facility
3. Requires care, supervision, and control in (or through) a designated facility to prevent the person's substantial mental or physical deterioration, or for the person's own protection, or for the protection of others; and
4. Is not suitable as a voluntary patient

If all of the above criteria is met, a Form 4.1 must be completed by a physician or nurse practitioner licensed to practice medicine in British Columbia. The physician does not need to be a psychiatrist. A resident physician (i.e. - with an educational license) is not legally allowed to complete a Form 4.

• The physician or nurse practitioner should complete a Form 4.1 as soon as possible after the examination/assessment of the patient, collection of collateral information and completion of necessary investigations to determine that the patient meets the criteria for treatment under the Mental Health Act.
  • Admission and treatment can then occur under the Form 4.1.
  • Nurse practitioners are able to issue a Form 4.1 but a Form 4.2 can only be completed by a physician.
• However, a Form 4.1 does not have to be issued immediately – for example, if additional collateral information is needed, a physician has up to 14 days from the date which they have examined the patient to decide whether they want to initiate the Form 4.1.
• If a physician has filled out a certificate, and the patient cannot be located, the certificate is still valid for 14 days starting from the time it was filled out.
  • Thus, a Form 4.1 can also be used to recall a previously voluntary patient who has left hospital, and have police take them back to a designated hospital facility if there is concern about the patient harming themselves or others.

• Once a patient is involuntarily admitted to hospital by a Form 4.1, a second physician's examination and Form 4.2 must be completed within 48 hours.
  • This must be a different physician from the Form 4.1
• The Form 4.2 continues the involuntary hospitalization for up to 1 calendar month starting from the date of involuntary admission (see section below for further clarification).
• If a Form 4.2 is not completed within 48 hours, the patient must be discharged or admitted as a voluntary patient.
• A Form 4.2 must also be co-signed by a Director/Delegate to continue the involuntary admission (depending on the institution, this could be a physician, nurse practitioner, head nurse, nurse or patient care manager).

The following Forms must be completed immediately on admission, regardless of the length of a patient's involuntary admission:

• Form 4.1 (First Medical Certificate)
  • This Form sets out why the patient can be involuntarily admitted for up to 48 hours, and must be completed immediately following the psychiatric assessment.
  • A Form 4.1 must be co-signed by a Director/Delegate to initiate involuntary admission (depending on the institution, this could be a physician, nurse practitioner, head nurse, nurse or patient care manager).
• Form 5 (Consent for Treatment)
  • This Form sets out the proposed psychiatric treatment, and either the patient or director must consent before any psychiatric treatment, including observation, restraints, seclusion, class of medications begins.
• Notification and Nomination Forms (Form 13, 15, and 16)
  • These should be done as soon as possible after Form 4.1, within 24 hours
  • Form 13 (Notification of Rights)
    • This Form provides information about patient’s rights and must be read to the patient and a copy provided to them
    • If a patient is not capable of understanding the Form 13 on admission, the Form must be provided again once patient is capable of understanding. The physician should document that the patient was not capable of understanding the Form 13.
  • Form 15 (Nomination of Near Relative)
    • This Form allows a patient to nominate a near relative to be notified of admission and detention
  • Form 16 (Notification to Near Relative)
    • This Form notifies the near relative of the patient’s admission, detention and rights. If there is no known near relative, form is sent to Public Guardian and Trustee.

• The 'date of involuntary admission' is the key date from which all future periods of involuntary hospitalization are derived.
  • This is the date on which an individual has been admitted to a designated facility with a Form 4.1
  • Thus, this is not necessarily the date that the patient arrived at the hospital! (e.g. - they may have been voluntary for a period time before being on a Form 4.1)
  • It is also not necessarily the date that a Form 4.1 was completed either! (e.g. - the patient may have been seen in an outpatient office, and the physician may have issued a Form 4.1 the same day, but the patient did not arrive and become admitted at the hospital until 3 days later)
• There can often be confusion and misunderstanding by clinicians over what constitutes the date of involuntary admission.