Psychiatric Admission Note
PATIENT NAME:
DATE OF BIRTH:
MEDICAL RECORD #:
DATE OF ADMISSION:
DATE OF THIS EVALUATION:
IDENTIFYING INFORMATION:
ADMISSION LEGAL STATUS: Conditional voluntary
CHIEF COMPLAINT:
“ ”
HISTORY OF PRESENT ILLNESS:
PAST PSYCHIATRIC HISTORY:
- Past Psychiatric Admissions:
- Past Suicide Attempts:
- Medication trials:
- Trauma history:
OUTPATIENT MEDICATIONS:
OUTPATIENT TREATERS:
- Prescriber:
- Psychotherapist:
- Primary Care Physician:
- Other:
SUBSTANCE USE HISTORY:
PAST MEDICAL HISTORY:
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:
SOCIAL HISTORY:
FAMILY PSYCHIATRIC HISTORY:
MENTAL STATUS EXAM:
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
Judgment
ASSESSMENT:
DSM-5 DIAGNOSES:
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.