Psychiatric Admission Note, Extended Template
PATIENT NAME:
DATE OF BIRTH:
MEDICAL RECORD #:
DATE OF ADMISSION:
DATE OF THIS EVALUATION:
IDENTIFYING INFORMATION:<patient name> is a <age> year old <employment status> <race> <gender><living status> with a history of <diagnoses, any drug use>, admitted from the Melrose-Wakefield Hospital Emergency Department / <medical unit> / <other facility> for assessment and treatment of xxx.
ADMISSION LEGAL STATUS: Conditional voluntary (Sections 10/11) / Involuntary (Section 12b)
CHIEF COMPLAINT: “<exact quote from patient of why they believe they are here>”
HISTORY OF PRESENT ILLNESS: The patient had last been well <weeks/months ago>, and was <working/receiving treatment>. <Three weeks ago>event occurred leading to <describe how patient was brought to emergency ED report: <ED staff observations and assessments, reports by family / friend / police / EMTs>room>
Life stressors:
In the first meeting with the attending psychiatrist / NP, events and symptoms leading to admission were reviewed. <describe presentation, observations, other info including patient’s report that may contradict or clarify ED reporting>
PAST PSYCHIATRIC HISTORY:
- Past Psychiatric Admissions:
- Past Suicide Attempts:
- Medication trials:
- Trauma history:
SUBSTANCE USE HISTORY: Patient denied current or prior tobacco, drug, or significant alcohol use / <or describe substance history, including first and most recent use, withdrawal complications, detox’s and other treatments and programs>
OUTPATIENT MEDICATIONS:
OUTPATIENT TREATERS:
- Prescriber:
- Psychotherapist:
- Primary Care Physician:
- Other:
PAST MEDICAL HISTORY: Unremarkable / Remarkable for <list of current/past pathologies, surgeries, injuries>
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION:
Hospitalist consulted to perform a standard physical examination upon admission; refer to hospitalist progress note for details.
LABORATORY DATA: Unremarkable; or remarkable for:
SOCIAL HISTORY:
Residence: Homeless on street or in shelter / Group home / Own home / Lives with xxx
Family: <describe, including deaths and other relevant info, such as being adopted>
Relationships: Single / Married / Divorced / Widowed <details> with no / <number> children <details such as contact>. <describe other relationships, such as romantic partnership>
Education: <describe, including diagnosed learning or other problems>
Employment/income source: Employed as xxx / Unemployed but previously worked as xxx /collects SSI/SSDI for <diagnosis>
Legal history: Denies any arrests or legal involvement/ On probation; was incarcerated; has hearing scheduled for; has restraining order.
Military history: Patient denies military history / served from <date> to <date> in <branch>, seeing / not seeing action, with honorable / non-honorable discharge <other info, such as emotional effects of serving, reason for non-honorable discharge>
FAMILY PSYCHIATRIC HISTORY: Patient denied that any family member has known clinical mental illness or substance use issues / <describe pathologies, suicides, etc.>
MENTAL STATUS EXAM:
Patient was alert, oriented, and cooperative. Speech was of normal rate and rhythm. Mood good. Full range of affect. Linear thought process. No delusions. No auditory or visual hallucination. No suicidal or homicidal ideation. Insight and judgment were fair. Alert and oriented x3.
Appearance. Hospital scrubs / Own attire, groomed / unkempt; well-nourished / undernourished / obese looks [older than / younger than] chronological age
Level of consciousness. Fully alert / Drowsy / Lethargic, with average / intermittent / poor / intensive eye contact
Orientation. Alert and oriented to name, date, location, and reason for hospitalization and treatment / <describe deficits>
Behavior. Average movements and activity / Psychomotor agitation / Psychomotor retardation / Pacing / Catatonia /
Disorganized / <other details>. Appropriate / Intermittent / Poor eye contact
Attitude: Pleasant and cooperative / Limited cooperation / Guarded / Uncooperative/Hostile
Speech. Rate average / slowed / rapid / pressured; Volume average / low / high; Articulation average / poor / heavy accent, Spontaneity average / decreased / increased; Easily redirectable / Challenging to redirect; Normal prosody
Mood. “<exact patient quote>”
Affect. Euthymic / Flat / Irritable / Dysthymic / Anxious / Angry / Expansive; with full / restricted /no range
Thought process. Reasonably organized and linear / somewhat disorganized / circumstantial / tangential / flight of ideas
Attention, Concentration, Executive functioning: Able / Difficulty naming calendar months backward from August to the previous August.
Memory: Able / unable to register 3 pairs of words <describe any problem>; Able / unable to recall all 3 one minute later
Alternative:
Memory and concentration: Absent gross deficits in memory and concentration observed
Knowledge: Able / unable to name the current and previous 4 presidents
Thought content. Denies delusions or other psychotic symptoms, symptoms of mania/hypomania, obsessions or perseverations, or frank depression / paucity of expressed thought / <other: describe remarkable content>
Hallucinations. Patient denied / Auditory with / without commands / Visual / Tactile
Suicidal ideation: Patient denied / Passive / Active with / without plan
Homicidal ideation: Patient denied / Generalized / Active toward <target>
Insight. Reasonable / Limited/Poor regarding understanding the nature and severity of <mental illness>, and need for treatment
Judgment. Reasonable / Limited / Poor regarding seeking and accepting help, and regarding safety
Reliability as reporter: Strong / Limited/ Poor or inconsistent
ASSESSMENT:
DSM-5 DIAGNOSES:
Common Diagnoses:
Major depressive disorder (recurrent, moderate / severe with / without psychosis)
Persistent depressive disorder (Dysthymia)
Unspecified depressive disorder
Bipolar I disorder (current or most recent episode manic / depressed)
Bipolar II disorder
Unspecified bipolar and related disorder
Schizophrenia
Brief psychotic disorder
Schizoaffective disorder (bipolar / depressive type)
Unspecified schizophrenia spectrum and other psychotic disorder
Social anxiety disorder (Social phobia)
Panic disorder
Generalized anxiety disorder
Unspecified anxiety disorder
Posttraumatic stress disorder
Obsessive compulsive disorder
Borderline personality disorder
Antisocial personality disorder
Oppositional defiant disorder
Intellectual disability
Major or mild neurocognitive disorder due to <see DSM-5 for list>
Autistic spectrum disorder (Asperger’s)
Alcohol use disorder
Opioid use disorder
Stimulant use disorder (mild / moderate /severe, Cocaine)
Tobacco use disorder
INITIAL TREATMENT PLAN:
- Obtain collateral history …
- Medications…
- Medical issues…
- Aftercare planning….
NOTE: The attending psychiatrist spent over 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.
Published on 4/13/2020. Copyright 2020 Inpatient Psychiatry Today.