Admission Note Guidelines – Inpatient Psychiatry Today

Guidelines for Admission Documentation

In general: Keep the H and P short, concise, and to the point. The H and P is to serve as a succinct summary of why the patient is hospitalized, their mental status, the diagnosis, and your initial treatment plan. It should generally be no longer than 1000 words.

Please include all the bolded sections below in the listed order.

PATIENT NAME

DATE OF BIRTH

MEDICAL RECORD #

DATE OF ADMISSION

DATE OF SERVICE

The date of service, or date of the evaluation, is important for our billing because it is often the day after the actual admission.

IDENTIFYING INFORMATION

Snapshot to give quick idea of demographics, and the presenting clinical issue. Generally includes age, marital status, ethnicity, gender, work status, underlying diagnosis and immediate reason for admission.

ADMISSION LEGAL STATUS

Either Conditional voluntary (Sections 10/11) or Involuntary (Section 12b)

CHIEF COMPLAINT

Usually a statement in the patient’s own words, in quotes, that encapsulates/illustrates the patient’s major issues/pathology.

HISTORY OF PRESENT ILLNESS

Keep it succinct. Focus on the events leading to the hospitalization including exactly how the patient ended up in the emergency room. It should generally start with brief statement of the baseline context, moving on to a description of what seems to have happened to destabilize the patient.

EG: The patient has a history of chronic schizophrenia with baseline auditory hallucinations which are generally adequately blunted by medications. She is generally adherent to medications and is able to manage fairly well in a group home. Her last admission was 5 months ago, and she was doing reasonably well until a week before this admission when she met an old friend who had some cocaine—leading to a week of drug use, noncompliance with meds, and decompensation. Two nights ago, she arrived at the group home late at night intoxicated and agitated. Group home staff called 911 and she was BIBA to the ED, where she required 4 point restraints initially but calmed after being medicated with IM Haldol, Ativan, and benadryl. Her urine tox screen was positive for cocaine, fentanyl and THC. She remained in the ED for two nights during a bed search before being admitted to the hospital.

Do: Synthesize information from the ED and other places to tell a concise story of the admission.

Don’t: Copy and paste material from other sources, such as ED or nursing or mental health tech notes.

Don’t: Include information about past hospitalizations or past events unless they relate directly to the current admission.

PAST PSYCHIATRIC HISTORY

Prior psychiatric admissions
Past medication trials
History of suicide attempts
Trauma history

OUTPATIENT MEDICATIONS

OUTPATIENT TREATERS (include phone numbers if possible)

Prescriber
Psychotherapist
Primary Care Physician
Others (eg., DMH case workers etc)

SUBSTANCE USE HISTORY

Substances used (focus on most recent use, including amount of daily use and time since last use)
Treatments engaged in (eg., rehabs, MAT, AA)

PAST MEDICAL HISTORY

ALLERGIES

PHYSICAL EXAMINATION

You can choose to summarize the PE performed in the ED, or you can simply state: “Hospitalist consulted to perform a standard physical examination upon admission; refer to hospitalist progress note for details.”

LABORATORY DATA

Specify when and where labs were drawn…typically they are from the referring ED. You may choose to list only the abnormal labs and summarize normal labs in a format like “CBC was unremarkable”.

SOCIAL HISTORY

Cover topics such as upbringing, current residence, family, relationships, education, employment/income source, military history, legal history, leisure activities, typical day.

FAMILY PSYCHIATRIC HISTORY

MENTAL STATUS EXAM

You may write or dictate a brief narrative in paragraph form or, alternatively, you can note findings under each heading below.

Appearance
Level of consciousness and 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 regarding mental illness/substance use and treatment
Judgment

ASSESSMENT

What are the patient’s main problems, why are they admitted, what are the treatment/disposition/legal challenges going to be?

DSM-5 DIAGNOSES (Note: do not use the multi-axial system as this is no longer a part of DSM)

(List numerically, start with DSM-5 diagnoses followed by any current and relevant medical diagnoses. Do not use the multi-axial system as this is no longer a part of DSM.)

EG:

Bipolar disorder, recurrent, depressed, severe without psychosis.
Alcohol use disorder, moderate.
Hepatitis B
Hyperlipidemia

PLAN

List numerically. Avoid using a template of boiler plate generic plans; instead create a plan specific to each patient. Depending on the patient, plans may include some or all of the following elements:

Information gathering to clarify the diagnosis and history of prior treatment, such as obtaining release of information from prior hospitals and contacting outpatient caregivers.
Obtaining laboratory data, such as screening labs that were not drawn in the ED, or medication levels such as lithium or Depakote.
Medication treatment—which may include resuming outpatient medications and/or starting new medications or adjusting dosages.
Follow-up specific medical issues, in conjunction with the hospitalist.
Legal procedures, such as planning for civil commitment for patients on section 12, initiating Rogers guardianships etc….
Aftercare planning, such as in coordination with social work.

EG:

Obtain and review medical records from prior psychiatric admission at Bournewood two months ago
Obtain collateral history from the patient’s outpatient psychiatrist, Dr. Smith, at 111-111-1111
Add Abilify 5 mg to current antidepressants for augmentation
Discontinue Benadryl and start trial of trazodone for insomnia
Meet with parents to coordinate care
Consider referral to partial hospitalization program post discharge

ATTESTATION

The attending psychiatrist spent over <30/50/70> minutes during this clinical encounter, with greater than 50% devoted to counseling and coordination of care including review of records pertinent lab data and studies, as well as discussing diagnostic evaluation and workup, planned therapeutic intervention, and further disposition of care.

(This attestation statement is helpful in case of an audit. For the vast majority of our admissions, we spend at least 70 minutes on direct care and coordination.)