Psychiatry Admission Note Template (For Beginners- a reference):

ID: ___ yr old Caucsian/African/Indian American domiciled, single, employed male self presented to our ED with thoughts of wanting to jump of the roof.

Urine TOX: positive for cannabinoids

BAL: <10. 

HISTORY OF PRESENT ILLNESS: 

Pt presented with recent thoughts of hopelessness and helplessness surrounding his recent divorce. Pt reports that he has been having a difficult time concentrating at work and states, “ I just stare at the screen all day and realize that I did not get anything done.” Thankfully it is still early but my boss has not noticed. I was wondering If I should quit. 

When asked what patient – Pt reports that he had been married for two years but…

Ask about sleep and appetite

In regards to sleep and appetite, pt reports that he has been oversleeping. As soon as he comes from work around 6 pm, he just loiters and sits on the couch, uses his phone and then goes to bed at 8 pm. He does report eating but has been eating whatever.  Pt states,” it will be three pm, and I would realize that I had forgotten about eating. I then go to the cafeteria and eat a slice of pizza and thats about it.” WHen i come home I have around two beers. 

Pt reports it has been two months since he has been feeling this way…

Pt reports being having thoughts of wanting to die for two weeks with consistent thoughts of jumping off he roof for the last two days. He denies any auditory or visual hallucinations. Pt denies any homicidal

(Since this is your initial interviews or in case of time constraints, you may go as little or as much in detail as time permits)

Psychiatry Review of Symptoms

For example, if these are the headings you would like to go into:

Past Psychiatric History:

Diagnosis:

Past medication trials: Which medication, What dose, how long was the trial, any side effects, response??

Hospitalizations: when and for what

Psychiatry Providers- the Psychiatrist, the therapist

Case Manager

DMH worker

Suicide Attempts:

Thought of it, planned it and actually dit and stopped, and then attempted and somebody else had to stop all showcase a different level of severity and desperation. 

It also important to keep in mind, that impulsive attempt vs a long drawn attempt have different implications on our approach to the patients. 

Homicidal attempts:

Trauma:

PTSD:

Adverse childhood experiences

Adverse Adulthood experiences: 

Substance use History:

While ideally you would like to know last use, current withdrawal symptoms if any, any overdose, withdrawal seizures or DTs with alcohol. 

In more detail, you  would like to daily amount of use, when did the patient start, have they tried to stop, is this a way they use to cope with insomnia, anxiety, sadness

But that’s a lot of information for one setting, withdrawal especially alcohol or benzodiazepines would be the most important considering they can be life threatening. Opiate use as well as if it is still in the system, you don’t want to start a suboxone taper as it will put them in withdrawal.

Cannabis

Alcohol

Tobacco: 

Stimulants – cocaine, amphetamine

Opiates

Hallucinogens. 

Family History:

Mental illness and substance use in the family and also suicide attempts (family history of suicide is linked ot higher suicide risk in our patient)

It may also help to know which medications the family has used and what has been effective for them. 

Social History:

A lot of this is important for aftercare planning and understanding the level of functioning the person is able to maintain. 

Developmental/Childhood: Where was he born, by biological parents?, divorced, siblings. Is patient in touch, is family a support. 

Employment: is patient able to maintain employment and function in what capacity. I had a supersmart patient on the schizophrenia spectrum. 

Education:

Income: Is patient struggling with basics of survival (a safe place to live, food and water). Surprisingly 

Relationships and Kids. 

Legal History: Psychiatry is one of the few medical specalities that has so many legal aspects. 

What we want to know is if they have any active warrants, cases ongoing or have been arrested in the past, for what and hwat was the outcome. 

(I had a patient who in their state of mania put their own house on fire )

Review of symptoms:

You do want to ask general physical symptoms and do a physical exam. Will elaborate on this a later date. 

HEENT: No symptoms reported

Respiratory: No symptoms reported

Cardiac: No symptoms reported

Abdominal: No symptoms reported

Extremities: No symptoms reported

Genital: No symptoms reported

Urinary: No symptoms reported

Skin: No symptoms reported

Endocrine: No symptoms reported

Hematologic/Lymphatic: No symptoms reported

Allergy/Immunologic: No symptoms reported

Physical Exam:

General Appearance: alert, oriented x3

Cardiovascular: normal heart sounds, regular rate, regular rhythm

Respiratory: normal breath sounds, no respiratory distress

Abdominal: normal bowel sounds, soft, non-tender

Musculoskeletal: full range of motion, No visible abnormalities

Skin: warm, dry

Neuro: follows commands, normal strength and normal sensation to light touch

Cranial Nerves:

 Normal Right Pupil Reactive to Light (ll)

 Normal Left Pupil Reactive to Light (ll)

 Normal Visual Fields (ll)

 Normal Extra Ocular Movements (lll, lV, Vl)

 Normal Facial Sensation to Light Touch (V),

 Normal Facial Muscles Symmetric, Hearing Normal to Rubbing Fingers (Vll)

 Normal Movement of Pallet, Phonation (lX, X)

 Normal Shoulder Shrug, Head Turn (Xl)

 Normal Movements of Tongue (Xll)

MENTAL STATUS EXAM*- needs a separate lecture. (DM if you want it)

Appearance: well-groomed

Attitude: cooperative

Orientation: time, place, person, situation

Behavior: appropriate eye contact

Gait: normal gait

Speech: normal rate, normal rhythm, normal volume

Mood: euthymic

Affect: congruent

Muscle Strength and Tone: normal muscle strength

Motor Activity: within normal limits

Thought Process: linear, organized, goal directed

Thought Content: unremarkable

Perception: normal

Suicidal Ideas: denies

Homicidal Ideas: denies

Insight: full

Judgement: good

Memory: intact

Intelligence: average

Assessment and Plan: example-

50 year old domiciled, single, unemployed male on SSDI presented with disorganized behaviour, running on the street naked. Past history revels chronic schizophrenia previously stabilized on perphenazine 8 mg PO TID. Psychosocial stressors include….

Recommendations:

Admit to inpatient??

Medication recs

Staff Informed.