Medical clearance (psychiatric)
Formal Definition
The ED-initiated medical evaluation performed to identify and address acute medical conditions that may be contributing to, or co-occurring with, a patient's psychiatric presentation — historically used as a precursor to psychiatric admission or transfer, with significant variation in what "clearance" requires across institutions and consulting psychiatrists; modern consensus favors a focused, evidence-based workup rather than the historical shotgun approach of "rule out everything."
How It's Used on the Ward
"Medically clear" or "med-cleared" — what the ED writes when they have evaluated a psychiatric patient, ruled out acute medical causes of the presentation, and decided the patient is stable for psychiatric admission or transfer; historically involved large batteries of tests; recent evidence suggests that for patients with known psychiatric history and a normal or near-normal exam, targeted testing is sufficient.
Example
""34-year-old with schizophrenia and bipolar disorder, brought in by family for increased agitation and refusing medications for 3 days. Family reports he stopped his depakote and risperidone. Vitals stable, T 37.2, glucose 88, mild tachycardia (HR 108, likely from agitation). Exam: alert, oriented x2 (imprecise on date), audible pressured speech, tangential, no focal neuro deficits, no trauma. Toxicology screen pending. Medical workup: CBC, BMP negative for infection or metabolic cause, no acute findings. Diagnosis: psychiatric decompensation from medication non-adherence. Documented: "Medically cleared from an acute medical standpoint; primary issue is psychiatric; recommend psychiatric admission for medication restart." Psychiatry consulted; admission accepted.""
Clinical Context
Historical vs. current practice: historically "clearance" meant CBC, CMP, urine tox, alcohol level, TSH, B12, folate, ammonia, ESR/CRP, head CT, neuroimaging, countless other tests — low yield for most patients, high cost, long ED stays. Modern evidence: focused workup, based on history and exam. Higher-yield testing when: (1) age >50 with new psychiatric symptoms (consider delirium, stroke, mass lesion). (2) history not previously diagnosed with psychiatric illness (consider first-episode mania vs. medical cause). (3) any focal neuro deficit. (4) immunosuppressed or unstable vitals. (5) toxidrome signs on exam. (6) head trauma, fall, or seizure. The phrase itself is increasingly avoided because it implies false certainty; more accurate: "no acute medical cause identified; primary issue is psychiatric" or "medically stable for psychiatric admission pending tox screen."