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Initial Psychiatry Consultation Note

This initial psychiatry consultation note documents a patient's chief concern, history, mental status examination, assessments, risks, and treatment plan. The note records the patient's presenting symptoms, psychiatric history, social history, medical issues, medications, and examination results. It then provides differential diagnoses, global assessment of functioning score, risk factors, and treatment recommendations.

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Stephan Carlson
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97 views2 pages

Initial Psychiatry Consultation Note

This initial psychiatry consultation note documents a patient's chief concern, history, mental status examination, assessments, risks, and treatment plan. The note records the patient's presenting symptoms, psychiatric history, social history, medical issues, medications, and examination results. It then provides differential diagnoses, global assessment of functioning score, risk factors, and treatment recommendations.

Uploaded by

Stephan Carlson
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

INITIAL PSYCHIATRY CONSULTATION SERVICE NOTE

We were asked to see this patient by _ from the _ service to address the question of/
The request for consultation is documented by Dr._ in note dated_

Chief Concern: _

HPI/Symptoms: _

Past Psych Hx:


Inpatient:
Outpatient:
Medication Trials:
Suicide Attempts:
Drug/Etoh:
History of Violence:

Social History:
Housing:
Relationships:
Education:
Financial:
Legal Problems:

Family History: _

Medical History: _

Allergies: _

ROS:
Constitutional: _ Gastrointestinal: _
Cardiovascular: _ Genitourinary: _
Respiratory: _ Ears/Mouth/Nose/Throat: _
Endocrine: _ Heme/Lymph: _
Neurological: _ Integumentary: _
Eyes: _ Allergy/Immunologic: _
Musculoskeletal: _ [_] Unless otherwise indicated, blank items are all negative

Current Medications _

Outpatient Medications _

Mental Status Examination


Appearance:
Behavior/Activity:
Speech:
Thought Form:
Thought Content:
Mood:
Affect:
Suicidal Ideation:
Homicidal Ideation:
Orientation:
Memory:
Judgment/Insight:
Attention/Concentration:
Other:

Vital Signs:_

Lab Findings: _

Assessment/Medical Decision Making (number of possible diagnoses considered) note problems,


management options, dangerousness/risks including risk factors.
Formulation: _
Differential Diagnoses: _
Axis I: (Major Diagnoses) _
Axis II: (Personality Diagnosis) _
Axis III: (Relevant Medical Conditions) _
Axis IV: (Psychosocial Stressors) _
Axis V: (Global Assessment of Function Score) _

Risk Factors
[_] harm to self/others [_] suicidal ideation/plan [_] homicidal ideation [_] grave disability
[_] substance [_] co-morbid medical [_] delirium/cognitive [_] pain
abuse/withdrawal conditions impairment
[_] impulsivity [_] psychosis [_] anxiety [_] other

Treatment Recommendations & Plan (management options considered) _

For Involuntary Patients:


[ ] Case and treatment plan discussed with:
[ ] ER Nursing
[ ] ER MD
[ ] ER Social Work
[ ] Psychiatry Nursing
[ ] Primary Medical Team
[ ] Primary Medical Team Social Work
[ ] Primary Medical Team Nursing

[ ] I have observed and evaluated this patient and have determined that he/she cannot be released from
involuntary treatment to accept treatment on a voluntary basis.

[ ] Patient will be converted to voluntary legal status

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