Psychiatric Admission Note (Basic Outline)
DANIEL CARLAT, MD
PATIENT NAME
DATE OF ADMISSION
IDENTIFYING INFORMATION
ADMISSION LEGAL STATUS
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST PSYCHIATRIC HISTORY
- Prior psychiatric admissions:
- Past medication trials:
- History of suicide attempts:
- Trauma history:
SUBSTANCE USE HISTORY
OUTPATIENT TREATERS
- Prescriber:
- Psychotherapist:
- Primary care physician:
- Others:
PAST MEDICAL HISTORY
OUTPATIENT MEDICATIONS
ALLERGIES
CODE STATUS
PHYSICAL EXAMINATION
LABORATORY DATA
SOCIAL HISTORY
FAMILY PSYCHIATRIC HISTORY
MENTAL STATUS EXAM
(Can report in paragraph form or in categories such as below)
Appearance
Level of consciousness
Orientation
Behavior
Attitude
Speech/thought process
Mood
Affect
Thought content (SI, HI, AH, delusions)
Cognitive functioning (eg., formal mental status exam assessing memory/concentration)
Insight
Judgment
ASSESSMENT
DIAGNOSES
TREATMENT PLAN
Published on 4/13/2020. Copyright 2020 Inpatient Psychiatry Today.