CON Writer (MPA)
©2023
Ben Smith, MD, FACEP
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About
This tool generates a TN Certificate of Need for involuntary psychiatric commitment.
This is an in-browser PDF generator, no PHI is stored or transmitted.
No patient-specific information typed in here is sent to the web.
Destination, Transport method, and County will be logged.
MPA Phone, County, Transport Method, and Destination will be stored in your browser for the next time you visit this page.
This use of this tool does not constitiute any form of medical advice.
Patient Name
MPA Name
MPA Phone
County
Anderson
Bedford
Benton
Bledsoe
Blount
Bradley
Campbell
Cannon
Carroll
Carter
Cheatham
Chester
Claiborne
Clay
Cocke
Coffee
Crockett
Cumberland
Davidson
Decatur
DeKalb
Dickson
Dyer
Fayette
Fentress
Franklin
Gibson
Giles
Grainger
Greene
Grundy
Hamblen
Hamilton
Hancock
Hardeman
Hardin
Hawkins
Haywood
Henderson
Henry
Hickman
Houston
Humphreys
Jackson
Jefferson
Johnson
Knox
Lake
Lauderdale
Lawrence
Lewis
Lincoln
Loudon
Macon
Madison
Marion
Marshall
Maury
McMinn
McNairy
Meigs
Monroe
Montgomery
Moore
Morgan
Obion
Overton
Perry
Pickett
Polk
Putnam
Rhea
Roane
Robertson
Rutherford
Scott
Sequatchie
Sevier
Shelby
Smith
Stewart
Sullivan
Sumner
Tipton
Trousdale
Unicoi
Union
Van Buren
Warren
Washington
Wayne
Weakley
White
Williamson
Wilson
Transport Method
Friends/Family
Ambulance
Sheriff/Law Enforcement
Destination
Psychiatric Facility
Telehealth Location
Evaluation Location
Face to Face
Telehealth Exam
Sign here
Clear
1) Has a mental illness or serious emotional disturbance...
Has a history of depression, now with suicidal ideation and a plan.
Has a history of bipolar disorder, now presents with acute mania.
Has a history of schizophrenia, now has symptoms of acute psychosis.
Unknown history of mental illness, now presenting with active symptoms of psychiatric disorder.
2) Poses a high likelihood of harm...
Has attempted suicide.
Has serious thoughts of suicide with a clear plan.
Has threatened homicide and serious injury to others.
Disorganized thoughts put the patient and others at substantial risk of harm.
Active symptoms of psychiatric disorder.
3) Describe what makes treatment necessary...
Needs intensive inpatient psychiatric care.
Lack of inpatient care will likely result in harm to others.
Lack of inpatient care will likely result in harm to the patient.
4) List alt Tx considered and rational for rejection...
Not appropriate for outpatient management.
The patient cannot contract for safety.
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