BH Initial Psychiatric Consultation Note Template PDF

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Format of notes for psychiatric consultation...

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BH Initial Psychiatric Consultation Note Patient:

MRN:

FIN:

Age: Sex: DOB: Associated Diagnoses: Author: Visit Information DATE: REFERRING PHYSICIAN: CONSULTING PSYCHIATRIST: REASON FOR CONSULTATION: CHIEF COMPLAINT: " HISTORY OF THE PRESENT ILLNESS: COLLATERAL HISTORY: PAST PSYCHIATRIC AND TREATMENT HISTORY: Past Hospitalizations: Most recent Admission: Past suicidality/self-injurious behaviors: Past medication trials: Current Prescriber: Outpatient Treatment: Psychiatrist: Therapist: PSYCHIATRIC ROS: Depression: Recent mood: Mania: increased energy: Psychosis: AH/VH: Anxiety: rumination: PTSD: Flashbacks:

Sleep: risky behaviors:

paranoid thoughts: delusions: Feelings of anxiousness: panic attacks: Nightmares: Racing thoughts: trauma:

PAST MEDICAL HISTORY: PAST SURGICAL HX: FAMILY HISTORY: ALLERGIES: MEDICATIONS: Home: Inpatient: SOCIAL HISTORY: Social and Developmental History: Marriage/Family: Housing: Education: Highest level: Occupation: Legal: Trauma History: SUBSTANCE ABUSE AND TREATMENT HISTORY: Alcohol: Drugs: -Past: -Present:

Interests: Guilt: Energy: manic episodes :

Concentration:

Appetite: Psychomotor Changes: SI:

FAMILY PSYCHIATRIC HISTORY: ROS: A full ROS was completed and was negative with the exception of pertinent positives noted in the history of the presenting illness (HPI). PHYSICAL EXAMINATION: Vital Signs : HR: BP: RR: MENTAL STATUS EXAM: Appearance: General: Behavior/demeanor:

T:

Appears/doesn’t appear stated age, wearing:

, level of self care :

Psychomotor: No psychomotor agitation or retardation. No tics or tremors noted. Eye contact: good Speech: volume: Rate: Rhythm: Mood: “ Affect: Range: Thought Process: Thought Content: No overt evidence of Paranoia or Delusions. Denies SI/HI Perception: not overtly responding to internal stimuli; denies AH/VH Cognition: alert and oriented*3 Insight: Judgment: RESULTS REVIEW: RELEVANT LABS/IMAGING: IMPRESSION AND PLAN: Inpatient Psychiatric hospitalization is **** at this time. DSM- 5 Diagnoses: 1.

Severe,

Recurrent

2. Degree: Opioid use disorder, severe, in sustained remission RECOMMENDATIONS: 1. 2. Current risk of suicide is thought to be ****, ****Recommend 1:1 sitter at this time Thank you for allowing us to participate in this patient's care. Psychiatry will continue**** to follow. Please feel free to contact the Psychiatry consult service (4-3376) with any questions or concerns. Case discussed with: Attending**** Recommendations cortexted to***Dr. Who requested Consult Note prepared with the help of John Foley, MSIV Resident**** MD/ DO Department of Psychiatry, PGY**** Pager #99030...