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Psychiatry Progress Note Template

This psychiatry consult progress note documents a patient evaluation, including a mental status examination and assessments of appearance, behavior, speech, thought processes, mood, affect, and orientation. The note records the patient's medications, lab findings, and vital signs, and provides diagnoses and treatment recommendations. For involuntary patients, it indicates whether the case and treatment plan were discussed with emergency room and primary medical team staff, and whether the patient will remain under involuntary treatment or be converted to voluntary status.

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anmolmani20003190
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135 views1 page

Psychiatry Progress Note Template

This psychiatry consult progress note documents a patient evaluation, including a mental status examination and assessments of appearance, behavior, speech, thought processes, mood, affect, and orientation. The note records the patient's medications, lab findings, and vital signs, and provides diagnoses and treatment recommendations. For involuntary patients, it indicates whether the case and treatment plan were discussed with emergency room and primary medical team staff, and whether the patient will remain under involuntary treatment or be converted to voluntary status.

Uploaded by

anmolmani20003190
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
  • Psychiatric Consultation Overview

PSYCHIATRY CONSULT PROGRESS NOTE

Date: / /

Interval History/Chief Concern: _

Pertinent Review of Systems (ROS):

Mental Status Examination


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

Medication:

Lab Findings:

Vital Signs:

Medical Decision Making (Note new problems, management options, dangerousness risks)
Assessment: _
Diagnoses: _
Recommendations: _

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

PSYCHIATRY CONSULT PROGRESS NOTE Date: / / Interval History/Chief Concern: _ Pertinent Review of Systems (ROS): Mental Stat

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