Psychiatry Evaluation

Psychiatric Evaluation Patient Name DOB MRN
Review of Systems Chief complaint/Reason for consult Start Time Stop Time Date
Review of Systems Yes No
Constitution
Fatigue or Malaise
Fever or chills History of Present Illness Patient is Nonverbal. History obtained from Family Medical records
Appetite changes
Eyes Suicidal ideation Yes No Plan formed Yes No Patient has the means to carry out the plan Yes No
Conjunctivitis Homicidal ideation Yes No Plan formed Yes No Patient has the means to carry out the plan Yes No
Eye pain
Vision changes
ENT/mouth
Sore throat
Epistaxis
Rhinorrhea
Respiratory
Dyspnea
Cough
Wheeze
Cardiovascular
Chest pain
Ankle edema
Palpitations
Gastrointestinal
Nausea or vomiting
Weight changes Allergies and Medications
Abdominal pain
Medications reviewed Medications reconciled with Nursing Home or Hospital data
Genitourinary
Hematuria
Dysuria
Allergy List reviewed No drug allergies No food allergies History of life threatening allergic response to
Urethral discharge

Musculoskeletal
Myalgias Past Medical History, Social History and Family History
Arthralgias Yes No Arrhythmias Yes No HIV/AIDS Yes No Thyroid disease
Joint swelling Yes No Asthma Yes No Kidney disease Yes No Tuberculosis
Skin/Breasts Yes No Coronary Artery Disease Yes No Liver disease Yes No Malignancy
Masses
New skin lesions
Yes No COPD Yes No Porphyria
Rash
Yes No Diabetes Yes No Seizures Yes No Neuroleptic Malignant Syndrome
Neurologic Yes No Heart Failure Yes No Syphilis Yes No Malignant Hyperthermia
Headaches
Seizures Past Surgical History
Paresthesias
Endocrinologic
Hair loss Past Psychiatric History
Polydipsia Yes No Anxiety Yes No Hospitalizations for psychiatric illnesses
Tremors Yes No Bipolar disorder
Heme/Lymph Yes No Depression Yes No History of Electroconvulsive Shock Therapy
Bleeding gums Yes No Mania
Unusual bruising Yes No Psychosis Yes No Prior Suicide attempts
Swollen lymph nodes
Yes No Schizophrenia
Allergy/Immunology
Nasal congestion
Yes No Personality disorder
Psychiatric Yes No Other
Agitation Social History / Risk factors
Hallucinations Denies Yes Ever smoker ___ # Packs X ____ # Yrs Denies Yes Alcohol use ___ Drinks per day week
Depressed mood Denies Yes Chews tobacco Denies Yes Felt the need to cut down on drinking?
Insomnia Denies Yes Quit tobacco use Quit date _________ Denies Yes Annoyed by others criticizing drinking?
Hypersomnia Denies Yes Guilt associated with drinking?
Altered concentration
Denies Yes Feels safe at home or work Denies Yes Eye opener needed?
Denies Yes Tattoos
Feels worthless
Denies Yes High risk sexual behavior
Grandiose ideas
Denies Yes Recreational drug use Inhalational Injectable Ingestible
Compulsions
Denies Yes Prescription Drug dependence Narcotics Benzodiazepines
Believes they have
special powers
Family Medical History
New / increased
substance abuse Asthma CHF COPD Coronary Artery Dis Pancreatitis Peripheral Artery Disease Renal Dysfunction
Thalassemia Thrombotic disorder Thyroid Disease Malignancy Other

Anxiety disorder Bipolar disorder Depression Schizophrenia Suicide or Suicide attempts
©MB and RR 2006-2010 e-medtools.com Revised 2Dec09 Health Care Provider Initials or Signature
Exam To qualify as a comprehensive exam: Document every all of the bullets in Constitutional (including at least 3 vital signs) and the Psychiatric sections AND at least
one bullet in the Musculoskeletal section.
Vitals Constitutional ( 3 vitals) Body habitus and Grooming required of General Multisystem but not Organ System Exam
Height _____ in cm x General Appearance Well nourished Cachectic Obese
Grooming Appropriate Unkempt Deformities None noted Present as follows
Weight _____ lb kg
Temperature _____ Musculoskeletal

x Strength & Muscle tone Within normal limits Increased Decreased Flaccid Cogwheel Atrophy
Pulse Rate _____ x Gait & Station Within normal limits Ataxia Wide based gait Shuffle
Rhythm Regular Irregular
Patient leans Rt Lt Forward Backward
Blood Pressure
Psychiatric
x Speech (Describe Rate, Volume, Articulation, Coherence, Spontaneity and include abnormalities)
________ Sitting Standing Lying
________ Sitting Standing Lying
Respiratory Rate _____

x Thought processes (Describe Rate, Content, Abstract reasoning and Computation)
Labs
\____/ ____ / ____ / ____ /

/ \ \ \ \
x Associations Intact Loose Tangential Circumstantial
Radiology
x Thoughts Within normal limits Illogical Hallucinations Obsessions Preoccupation with violence
Homicidal ideation Suicidal ideation
Additional Exam Findings x Judgment and Insight
Mental Status
x Orientation Oriented to Person, Time, and Place NOT oriented to Person Time Place
x Recent & Remote Memory
x Attention Span & Concentration
x Language
x Fund of Knowledge
x Mood & Affect Within normal limits Agitated Anxious Depressed Hypomanic Labile
Data Reviewed Impression
ER Notes
Labs Axis I
Radiology data
Pathology
ECHO and/or ECG Axis II
EEG
Pulmonary Function Test
Axis III
Nursing Notes/Vitals log
Primary Care Physician records
Psychiatry records Axis IV
Other past medical records
Care Coordinated with
Patient
HCPOA or Surrogate
Primary Care Physician
Consultant(s)
Case Management or Social Worker
Pharmacy
Nursing
Recommended Diagnostics
12-lead ECG
Echocardiogram
Computed Tomography
Magnetic Resonance Imaging

CBC with differential
PT, PTT, INR
Arterial Blood Gas
Basic Metabolic Panel (with calcium)
Complete Metabolic Panel
HIV
Hepatitis panel
Serum Porphyrin
RPR
TSH, T3, and Free T4 levels
Urinalysis

Toxicology panel
Blood alcohol level
Urinary catecholamines
Recommended Actions
Smoking cessation aids
Substance Abuse Counseling Physician Signature
cc
Antidepressant therapy
Antipsychotic therapy Code Status
Counseling Patient is currently ABLE UNABLE to understand their current health condition AND the consequences of
Other treatment options (including no treatment)
Pneumonia vaccine FULL CODE DO NOT ATTEMPT RESUSCITATION

Influenza vaccine
Patient has an advanced health care directive. HCPOA is _______________________________________

Psychiatry Evaluation

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Psychiatry Evaluation

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Psychiatric Evaluation Patient Name DOB MRN

Temperature _____ Musculoskeletal

________ Sitting Standing Lying

Respiratory Rate _____

\/ / / /

Additional Exam Findings x Judgment and Insight

x Recent & Remote Memory

x Attention Span & Concentration

Pneumonia vaccine FULL CODE DO NOT ATTEMPT RESUSCITATION

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Psychiatry Evaluation

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Psychiatry Evaluation

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Доступные форматы

Psychiatric Evaluation Patient Name DOB MRN

Temperature _____ Musculoskeletal

________ Sitting Standing Lying

Respiratory Rate _____

\____/ ____ / ____ / ____ /

Additional Exam Findings x Judgment and Insight

x Recent & Remote Memory

x Attention Span & Concentration

Pneumonia vaccine FULL CODE DO NOT ATTEMPT RESUSCITATION

Вам также может понравиться

________ Sitting Standing Lying

\/ / / /

Pneumonia vaccine FULL CODE DO NOT ATTEMPT RESUSCITATION