WOMEN & INFANTS HOSPITAL
Psychiatry Consultation/Liaison
Rotation Guide
C/L Rotation Guide
Rotation Goals & Objectives
Psychiatry Call Manual
Day Hospital Rotation Guide
WBH Clinical Services
WIH Phone Numbers
Cerner EMR Guide
Psychiatry Note Templates
Common Abbreviations
Resources for Medications & Referral Options
Updated 10/7/15
pages 2-3
page 4
pages 5-9
page 10
pages 11-12
page 13
page 14
pages 15-17
page 18
pages 19
1
Rotation Guide for Women & Infants Psychiatry Consult Service
Welcome to your PGY-2 psychiatry consultation-liaison rotation at Women & Infants Hospital! We are
excited to have you join us, and hope you will enjoy learning about women’s mental health during your
time with us. The manual provides a lot of valuable information about your experience here, so please
be sure to review it prior to the start of your rotation.
Before the Rotation:
1-2 weeks before rotation, call 274-1122 x41925 OR e-mail fniang@wihri.org, to contact Fran Niang for
the necessary documentation for your rotation and to get a computer log-on and Cerner access. You
will get a welcome email several weeks prior to the start of your rotation reminding you of this. Please
also be sure to read this guide in its entirety prior to your first day of the rotation.
General Info
Computer: Cerner is the electronic medical record. See Cerner guide below for more details. There are
templates for the consult note and follow up note if you choose to use them.
Food: ABP on the ground floor, and cafeteria in the basement. ABP and RIH cafeteria through the
tunnels. 2 Dudley Street also has a café on the first floor.
Locations: Consult office located in the Department of Medicine Suite on the third floor of the main
hospital. Code to enter office area is 1884* the DOM suite is down the corridor to the left.
WBH (outpatient) in 1st floor Coop building (2 Dudley Street) Day hospital 1st floor Coop building (2
Dudley Street)
Phone Numbers: see WIH phone numbers list on page 13
Codes:
Triage Entry Code: 0101
Social Work Office entry code: 4321 (consult office key kept next to printer) (make sure we still have
access to this office)
3rd floor code: 1884*
Amion code for W&I: wihri (www.amion.com)
Consult Service Basics
Attendings:
Carmen Colomer, MD
Pager: 401-582-4581
Email: ccolomer@wihri.org
Cell: 617-459-1210
Laura Hollar-Wilt, MD
Pager: 401-582-4410
Email: lhollarwilt@wihri.org
Cell: 717-903-6786
Neha Hudepohl, MD
Pager: 401-582-9416
Email: nhudepohl@whiri.org
Cell: 513-659-8559
Updated 10/7/15
2
HT Kao, MD
Pager: 401-582-7461
Jessica Pineda, MD
Pager: 401-582-4532
Email: jpineda@wihri.org
Cell: 513-532-4889
Women’s Mental Health Fellow:
Nina Gonzales, MD (2015-16)
Pager: 401-582-2157
Email: ngonzales@wihri.org
C/L Social Worker:
Erin Hunt, LICSW
Pager: 401-582-0312
Email: ehunt@wihri.org
Cell: 505-795-6263
Cell: 401-440-1277
Showtime: On your first day, 8AM @ Department of Medicine Suite on 3rd floor of main hospital. You
will meet with Fran Niang initially to complete housekeeping requirements followed by a brief
orientation and tour of the main hospital with the C/L Social Worker at 9am. Subsequently, your day
will begin at 8am unless otherwise specified by the team.
What to expect: You will be expected to carry the consult pager and will most likely be the first point of
contact for all consult calls. Expect to initially evaluate most consults either on your own or with the C/L
SW as appropriate. It is important to talk with nursing staff/social work and obtain collateral
information whenever indicated. You will write your initial consult evaluation (save but do not sign
without reviewing with attending.) You will present patients to your attending during “table rounds”
and you and your attending will round on patients together during “bedside rounds”. You will also be
expected to see follow ups whenever needed and to communicate psychiatry recommendations to the
primary teams. Expect to be available to see consults until 5PM unless it is a didactics/clinic day. Also,
please try to see all follow ups before 12:30PM.
Service Schedule: Plan to check in with the C/L team at 8am unless otherwise specified. You will spend
your mornings seeing new and follow-up consults. If there are no new or pressing follow-ups , plan to
spend your morning in the Day Hospital. Check in with the Day Hospital attending and let her know if
there are pending consult follow-ups so you can best plan your time.
On your didactic/clinic days, you will check in with your attending at 11am prior to leaving. On your full
days, plan to round with your team at 2pm unless otherwise specified. Generally, the daytime team will
accept new consults until about 4pm, and later if there is an emergency. Consults called later than that
will either be saved until the next day, or if absolutely necessary, seen by the on- call physician. This
decision will be determined by the attending.
C/L Team Structure: The WIH C/L Team is comprised of an attending physician, resident, and psychiatric
social worker. The C/L Social Worker serves as an anchor for the team by triaging cases, assisting with
coordination of behavioral treatment, and evaluating patients as needed. At times there may also be a
women’s mental health fellow on the team.
Updated 10/7/15
3
Consult Rotation Goals & Objectives






To demonstrate understanding of the unique needs of the perinatal population,
including diagnostic assessment and treatment modalities.
To develop a framework for approaching clinical decision making in the pregnant and
breastfeeding patient.
To develop an initial understanding of basic attachment patterns and disrupted
attachment, as well as the implication of maternal mental illness on child development.
To acquire expertise in liaison work in the setting of a specialty hospital.
To expand knowledge on the application of non-pharmacologic evidence-based
interventions for perinatal mental illness.
To review details about perinatal mental illnesses, including postpartum depression,
postpartum psychosis, perinatal-onset OCD, trauma-related illnesses, and psychiatric
disorders in the gynecologic-oncology population.
Updated 10/7/15
4
Call Manual for Women & Infants Hospital
As the only psychiatry consultation service at a specialty women’s hospital, we provide a significant
amount of expertise in dealing with psychiatrically ill patients at Women & Infants Hospital. Both our
academic and community referral sources rely on our expertise in the care of their patients. To that
end, we strive to be readily available both during the workday and after hours to help care for these
patients.
General Information:
Weekday call: Begins Monday at 5PM and ends Friday at 8AM (weeknight call is 5pm-8am nightly during
the week).
Weekend call: Begins Friday at 5PM and ends Monday at 8AM.
During your PGY-2 rotation, you will take 1 week of call (usually Monday at 5pm – Monday at 8am).
Prior to coming on call you must be sure that your Cerner password is active. Please check with the
chief resident for WIH (Brian Theyel MD) regarding your Cerner login/password. Most of you should
already have this access from your C/L rotation in the past. If you had access in the past but need to
update your password, contact Butler computer support at 921-1000 or the WIH Helpdesk at 274-1122
ext. 48777. You should check your Cerner access while at Butler Hospital (under the CNErgy Cerner
icon) in advance of your call. You are expected to refresh or familiarize yourself with this system prior
to being on call. You must be free of other call responsibilities including other moonlighting and
jeopardy call.
While you are on call you will be supervised by an attending. You will receive a call schedule distributed
in advance by the chief resident as well as an email reminder at the start of your call. You can also check
AMION (www.amion.com password = wihri) for the backup attending information. It is your
responsibility to know when you are on call and who your backup attending is.
You will be emailed any relevant consult sign-out to your Brown email accounts, but will be sent via
encrypted email with “PHI” in the subject line.Please be sure to provide relevant information regarding
the consult service in sign out to the primary team via secure email.
Weeknight and Weekend Call:
Consult requests can be reviewed with your backup attending prior to coming into the hospital, unless it
is a clear emergency. Many, but not all, consults may be seen or evaluated by a social worker prior to
you being called, unless it is a psychiatric emergency.
Due to the untimed nature of obstetrics, patients may not come to the attention of either SW or
psychiatry until over the weekend. Because these patients are likely to be discharged home over the
weekend it is our policy to evaluate consults called in on the weekends. Often social work will have
seen these patients first, but sometimes the primary team will call the psychiatry team directly
especially if there is a question related to medications or safety. As a general rule, all consults must be
seen and completed within 24 hours of consultation request.
If you are called on a consult that can be pushed until the primary team returns (the following morning),
please email or page the psychiatry resident or attending covering consults for the next morning by
Updated 10/7/15
5
8:00AM with the information including patient name, room number, DOB, and any other pertinent
information
Consultation Requests:
There are important psychiatric emergencies that necessitate having to come in. When in doubt, we
err on the side of coming in to evaluate patients. The following list constitutes what our service
generally considers to be emergent:
 Acute onset of delirium in patients who are not responsive to the initiation of the Delirium Care
Plan
 Acutely agitated, behaviorally dysregulated, or actively suicidal/homicidal patients on the
medical or obstetrical floors
 Patients where there is a high index of suspicion for post-partum psychosis. These patients must
be evaluated rapidly!
 Substance abuse patients in active withdrawal that cannot be managed by current protocols at
WIH
 Capacity assessments where there is a high degree of risk for death or injury to patient or fetus,
or a significant change in care or assessment due to refusal of recommended care, or desire to
leave AMA.
 Patients in Triage
Any other patient for which the primary team is requesting an urgent consult.
Transfer Protocols for Women & Infants:
Pa ent evaluated in triage by
primary psych team or on call
resident – decision is made for
inpa ent treatment
Once pa ent medically cleared…
Fax clinical informa on, demographics,
& med list to Butler PAS @
401-455-6532.
Call Butler PAS @ 401-455-6346 within
30 minutes to discuss bed availability
& transfer
No fy WIH Staff to facilitate MD:MD &
nurse:nurse
Obtain Precer fica on from insurance
& no fy PAS
Transfer Policy –Triage
Updated 6/23/14
If pa ent is too agitated to be managed by
WIH staff, WIH staff to transfer to a secure
facility/D-POD RIH. Call D-POD resident @
401-444-3640. Follow steps as detailed
below
If Bed @
Butler not
available
Contact D-POD resident to inquire if
space is available-401-444-3640.
.
If no room, call other
facili es & WIH to hold pt
un l a bed is found. Follow
protocols for transfer as
requested by accep ng
facility. Pa ent to be kept
at WIH un l bed available.
D pod able to accept pa ent
Call D-POD resident.
If pt accepted, call RIH Access @ 401-444-3000 to provide
demographics for pre-registra on.
Fax clinical informa on & med list to 401-444-9866.
Facilitate nurse:nurse @ 401-444-3640.
No fy WIH staff to facilitate ambulance transfer
No fy WIH staff to arrange ambulance
transport & provide paperwork to
send with pa ent
Updated 10/7/15
6
Pt evaluated by primary
psychiatry team or on call
resident – decision is made for
inpa ent admission
Once pa ent is medically
cleared…
Fax clinical informa on,
demographics, & med list to Butler
PAS @ 401-455-6532. Call Butler PAS
@ 401-455-6346 within 30 minutes to
discuss bed availability & transfer.
Pa ent cannot be transferred
to a lower level of care (LOC)
Eg. RIH ER/D-POD
Transfer Policy—WIH
Main Floors
Updated 6/23/14
If pa ent is agitated
Manage agita on with primary providers,
psychiatry C/L team, & security
No fy WIH staff to facilitate MD:MD &
Nurse:Nurse
Obtain Precert & No fy PAS
No fy WIH staff to coordinate
ambulance transport & provide
paperwork to send with pt
Updated 10/7/15
When pt stabilized
Follow protocol for IP admission, if
deemed necessary
7
Calls for other reasons:
The backup attending covers any calls from outpatient attendings on weeknights and weekends. If you
are called on an outpatient in Women’s Behavioral Health, have the answering service call your backup
attending.
If you are called about an active Day Hospital patient or a Project Link patient, then refer the caller to
the therapist on call for these respective programs (can be found in AMION). The answering service
should also have a list of who is on call for these programs.
Emergency Slots:
One emergency slot is available for patients over the weekends that need immediate follow-up
evaluation and/or care. This slot is primarily available to pregnant or postpartum women. The slots are
scheduled on Mondays at 8:30AM (Or Tuesdays at 8:30AM if there is a holiday on Monday). These are
60-90 minute slots with a psychiatric clinician who will have backup from a psychiatrist if it is clinically
warranted. The patient should be directed to Women’s Behavioral Health at 2 Dudley Street, First floor
and given the number (401) 453-7955.
As the on-call psychiatry resident, you will be responsible for managing the use of this emergency
appointment. Remember, there is only 1 slot and once filled, it is no longer available. The social
workers should contact you if they have a patient they would like to refer to that slot, but it is ultimately
your decision how that slot is utilized.
Please notify the following individuals about a patient booked in an emergency slot. Please provide the
patient’s name, DOB, contact phone number as well as a brief description of the clinical circumstances.
Margaret Howard (mhoward@wihri.org)
Judy Randall (jlrandall@wihri.org)
Erin Hunt (ehunt@wihri.org)
Please use a secure email address to send this information.
Consult Documentation:
Women and Infants Hospital has an electronic medical records system (Cerner) and all consult notes are
to be written in Cerner. Prior to coming on call you must be sure you have your Cerner access active.
Please check with the WIH Chief Resident Brian Theyel MD regarding your Cerner login/password if
you are uncertain of it.
Consultation notes are within the “Clinical Notes” section and should be documented in the same
fashion as a standard psychiatric consultation note or H&P. Please see the Consult Note Templates
below for further details. Please contact either the WIH Chief Resident or your supervising attending if
you have any questions about documenting in Cerner. We encourage you not to wait until the start
date of call to do this. Please add any new consults seen/called to the “WIH BH Consults” list in Cerner
(see Cerner guide for more details).
Attending Contact Information:
Carmen Colomer, MD
Pager: 401-582-4581
Email: ccolomer@wihri.org
Cell: 617-459-1210
Thamara Davis, MD
Updated 10/7/15
8
Pager: 401-582-0144
Cell: 401-663-5590
Email: thamara.davis.md@gmail.com or familyinstitute@gmail.com
Laura Hollar-Wilt, MD
Pager: 401-582-4410
Email: lhollarwilt@wihri.org
Cell: 717-903-6786
Margaret Howard, PhD
Pager: 401-582-4618
Email- mhoward@wihri.org
Cell: 401-368-2180
Neha Hudepohl, MD
Pager: 401-582-9416
Email: nhudepohl@whiri.org
Cell: 513-659-8559
HT Kao, MD
Pager: 401-582-7461
Jessica Pineda, MD
Pager: 401-582-4532
Email: jpineda@wihri.org
Cell: 513-532-4889
Lawrence Price, MD
Home: 401-245-9246
Email: lprice@butler.org
Cell: 401-523-4315
On Call Telephone Tree:
Call your listed backup attending
I
I
(If unavailable after 15 minutes, try backup attending again – consider alternate number)
After 2 tries or 30 minutes
I
V
Call Neha Hudepohl MD, Medical Director, Women’s Behavioral Health
AND/OR
Margaret Howard PhD, Division Director, Women’s Behavioral Health
I
(If unavailable after 2 tries or 30 minutes)
I
I
V
Call Lawrence Price MD
Chief of Psychiatry, Women & Infants Hospital
Updated 10/7/15
9
Rotation Guide for Women & Infants Day Hospital
While you are on service at Women & Infants, the psychiatry consultation/liaison service is your primary
clinical responsibility; however, you will often have free time during the mornings and can participate in
clinical care at the Day Hospital. This is a unique experience and will help expose you to women’s
mental health and perinatal psychiatry in a partial hospital setting using the concept of a mother-baby
unit. While participating in the Day Hospital, you will attend groups, rounds and participate in individual
patient care. Residents have found this to be a very valuable experience and a great introduction to the
care of pregnant and postpartum women.
Location: 2 Dudley Street, Co-Op Care Center, First floor . There is signage pointing you in the right
direction.
Phone: 401-274-1122 ext. 42870
Schedule:
8:30-9:00AM First Rounds – discuss new admissions, potential discharges, and other patientrelated issues for Day Hospital patients
9:00-10:15AM Morning IPT Group
10:15-10:30AM Brief Rounds
10:45-11:30AM Morning Skills Group/Individual sessions with patients
11:45AM-12:15PM Lunch
12:15-12:45PM Relaxation Group
1:00-2:15PM Afternoon Skills Group
2:15-2:30PM Wrap Up
What to expect: You will attend group whenever possible, participate in rounds and be asked to see
patients for individual sessions for either psychotherapy or a medication evaluation. At times, you will
also be asked to evaluate newly admitted patients on their first day and present to the psychiatrist.
When possible, you may also be involved in intake appointments (evaluating patients prior to admission
to the Day Hospital).
Showtime: First rounds begin at 8:30AM, but remember that consults are your first priority.
Documentation: At this time, the Day Hospital uses paper charting. Initial evaluations (the “7 page”
form), interim evaluations (the “4 page” form), and progress notes are available from the secretary.
When medication changes are made or at the initial or discharge evaluation, a medication reconciliation
must be completed in Cerner (see Cerner guide).
Updated 10/7/15
10
Women’s Behavioral Health Clinical Services
Division Director: Margaret Howard, PhD
Medical Director: Neha Hudepohl MD
Associate Division Manager: Judy Randall
Psychiatry Inpatient Consultation/Liaison Service:
Pager # 582-4404
Social Worker: Erin Hunt, LICSW
Attending Psychiatrists: Carmen Colomer, MD
Laura Hollar-Wilt, MD
Neha Hudepohl, MD
Women’s Behavioral Health (outpatient):
Ann Back Price PCNS, IAAP
Laura Chalk CNM, PCNS
Carmen Colomer, MD
Shannon Erisman, PhD
Aimee Grause, PCNS
Jane Hesser, LICSW
Laura Hollar-Wilt, MD
Margaret Howard, PhD
Neha Hudepohl, MD
Erin Hunt, LICSW
Jessica Pineda, MD
Alpha Roca, LCDP (case manager)
Kristen Wedel, LCSW
Main # 453-7955
Day Hospital (partial hospitalization program):
Main # 274-1122 x42870
Clinical Director: Shannon Erisman, PhD
Attending Psychiatrists: Carmen Colomer, MD
Laura Hollar-Wilt, MD
Neha Hudepohl, MD
Clinical Staff: Ann Back Price PCNS, IAAP
Laura Chalk, CNM, PCNS
Aimee Grause, PCNS
Kristen Wedel, LCSW
Brown Clinical Psychology Resident
Case manager: Alpha Roca, LCDP
 Partial hospitalization program for pregnant and postpartum women with mood and
anxiety disorders focused on IPT/attachment issues and women are encouraged to bring
their babies. Admit up to 1 year PP.
Research:
Research Psychologist: Cynthia Battle PhD
Women’s Mental Health Fellowship:
Program Director: Neha Hudepohl, MD
Updated 10/7/15
11
Associate Program Director: Margaret Howard, PhD
Research Director: Cynthia Battle, PhD
Fellow 2015-16: Nina Gonzales, MD
Fellowship Coordinator: Fran Niang
Updated 10/7/15
12
Important WIH Phone Numbers
**must dial 4 before 4-digit extension**
Main #WIH
Main # WIH
Shuttle
Computer Help
274-1100 (for operator)
274-1122 (automated when you know your extension)
x41635
x48777
CL work room 3rd floor
Social work main desk
Day Hospital
Women’s Behavioral Health
Francois Niang
Judy Randall
x42360
x41360
x42870, x42878
453-7955, backline x42788, x42755
x41925
x42710
Admissions
Ambulatory Surgery
LDR
PACU
Triage
ACU (4 North & South)
4 East
4 West
5 East
5 East Nursery
6 East
6 East Nursery
6 West
6 West Nursery
NICU 2 North & South
NICU 3 North & South
WPCC East
WPCC West
MFM
Gyn Onc work room
x41422 x41423
x41300
x41400
x41500
x41520 x41750
x43400
x41512
x41812
x41810
x41801
x41507
x41506
x41503
x41502
x43200
x43300
x42785
x42793
x42354
x41279
Updated 10/7/15
13
Cerner (EMR) Guide
The “List”
To get the WBH Consult Patient list:
-log on, click on Patient List on the tool bar
- click on button that looks like a wrench in upper left corner, it is called “list maintenance”
-click “new,” then click “care team”
-scroll down to team called “WIH BH Consults,” press finish
-it should be in your “available list” column, click the right handed arrow to move it to “active
list,” press ok
Add patient to the list:
-within your WBH Consult Patient List screen, click on icon that is a person with a sparkle aka
“Add a patient”
-look patient up by name, MR or location
-select the active encounter for current admission, and hit “Add”
The Chart—Double-click on the patient; this will take you to the summary screen. There is a tab on the
left side of the screen called “Menu – Inpatient” that if you click on it will give you the following tabs:
-Summary screen: is exactly that, a summary, has current meds, vitals, recent labs, allergies
-Patient info: Click on Visit list -- you can see if they have ever seen Women’s Behavioral Health
or the Day program. If so, call Tina x2870 and have her fax the intake/discharge
summary
-Results Review: labs/x-rays/nursing assessments (includes agitation, CIWA, etc). On the central
blue stripe that has a clinical date range listed, right click to change the dates so you can see the
whole hospital stay or look for labs that were done before the admission
-Clinical notes: All notes written on the patient. Double click to open each folder. First,
Right click on the central blue stripe that has a clinical date range listed, change the
initial day to 1/1/2003, which is when the hospital went electronic OR just change the
year of the date listed to 2000.
-Consultation notes have social work consults and psychiatric consults
-Emergency Department notes have why they were admitted
-Progress notes for what is going on here and now. THIS INCLUDES F/UP CONSULT
NOTES.
-History and Physical sometimes they have this separate entry, tons of info
-PowerOrders: then click on consults, so you can see who ordered the consult and why
-eMar : electronic MAR, helpful to see what meds they actually got and when
Writing Notes—
-click into “Clinical Notes” tab from the Menu – inpatient menu
-click on the button in upper left that looks like a paper with a sparkle aka “add”
-in the new screen that pops up, in the “type” drop down box, right click and click on “document
type list” then click on “complete”
-then in “type” drop down box, scroll to “psychiatric consult” or “psychiatric progress note”
-click on button in upper left that looks like a stamp aka “template”
-click on the type of template you want, and then click insert
-now just type the info you want into the note!
Updated 10/7/15
14
Psychiatry Initial Consult Note Template
Initial Psychiatric Consultation
(Date)
Reason for Consultation: (Please also list who is requesting the consult—generated by SW, primary
team, specialty service)
Chief Complaint: “ “
Identifying Information: -include age, demographics, G/P status if pregnant/postpartum, age of
gestation if pregnant, reason for hospitalization
HPI:
-note that you reviewed the chart
-that you saw the patient, where and who was present
-planning to breastfeed?
-pregnancy planned? Reaction to pregnancy? Partner’s reaction? How did pregnancy go?
-psychiatric review of systems (depression, mania, psychosis, anxiety disorders)
Past Psychiatric History: Any inpatient, partial, IOP treatment? Any outpatient treatment? Previous
suicide attempts? Previous medication trials?
Should we include Past Reproductive History?
Substance Abuse History: Include pertinent negatives – nicotine, caffeine, alcohol, cannabis, other
drugs. Ask about taking non-prescribed prescription medications.
PMH: Include whether hx of TBI, seizures, asthma, headaches, relevant past surgical history
Medications: Copy and paste active inpatient meds from Summary tab in Cerner
Allergies: Include reaction
Family History: Include any Fhx suicide
Social History: refer to social work note for complete history. Living situation? History of interpersonal
violence? Education level? Employment or source of income? Relationship with FOB if relevant? Other
children in the home, previous DCYF involvement? Developmental history?
O:
Vital Signs: Most recent set of vitals - Copy and paste from Summary tab in Cerner
MSE:
Appearance:
Eye Contact/Behavior:
Speech:
Mood:
Updated 10/7/15
15
Affect:
Thought Process:
Thought Content: evidence of delusions/paranoia, any intrusive thoughts?
SI/HI: any SI/HI/thoughts of dying/harming infant thoughts etc?
Perceptual:
Orientation:
Cognitive exam: include MOCA/MMSE if relevant
Insight/Judgment:
Labs: last 100 results reviewed/any abnormalities noted OR labs reviewed from past 3 months/12
months/etc.
Impression/Recommendations: “This is a …. “
Diagnosis:
Psychiatric Diagnosis:
Medical Diagnosis:
Psychosocial Stressors:
Recommendations:
-agree with social work involvement for __________ (support, liaison for housing, etc)
-no acute/imminent safety concerns (unless there are…then comment)
-other recommendations including medications, follow up, etc.
Thank you for the consult. Our team will/will not continue to follow while in the hospital.
Impression/recommendations communicated to PRIMARY ATTENDING.
(your name, PGY-?)
Psychiatry Follow Up Consult Note Template
Psychiatry Consult Service Follow Up Note
(date)
Events overnight: -include nursing reports
S: -patient’s report
Medications: Copy and paste active inpatient meds from Summary tab in Cerner
O: -add vital signs if relevant
MSE: Appearance:
Eye Contact/Behavior:
Speech:
Mood:
Updated 10/7/15
16
Affect:
Thought Process:
Thought Content: evidence of delusions/paranoia, any intrusive thoughts?
SI/HI: any SI/HI/thoughts of dying/harming infant thoughts etc?
Perceptual:
Orientation:
Cognitive exam: include MOCA/MMSE if relevant
Insight/Judgment:
-add labs if relevant
Impression/Recommendations: “This is a …. “
Diagnosis:
Psychiatric Diagnosis:
Medical Diagnosis:
Psychosocial Stressors:
Recommendations:
-agree with social work involvement for __________ (support, liaison for housing, etc)
-no acute/imminent safety concerns (unless there are…then comment)
-any changes/updates to plan or plan to continue previous recommendations
-follow up plans
Thank you for the consult. Please call with further questions OR Our team will continue to follow while
in the hospital. Impression/recommendations communicated to PRIMARY ATTENDING.
(your name, PGY-?)
Updated 10/7/15
17
Commonly Used Abbreviations
ACU = antenatal care unit
AMS = acute monitoring service
AVD = assisted vaginal delivery
BPP = biophysical profile
CSR = C-section recovery
CTX = contractions, ceftriaxone
EBL = estimated blood loss
EDD = estimated date of delivery
FHT = fetal heart tones
FOB = father of baby
G#P# = gravida/para
GBS = group B streptococcus
GDM = gestational diabetes mellitus
GTT = glucose tolerance test
IOL = induction of labor
IPV = intimate partner violence
IUD = intrauterine device
IUFD = intrauterine fetal demise
LDR = labor & delivery room
LEEP = loop electrosurgical excision procedure
LMP = last menstrual period
MFM = maternal-fetal medicine
MOB = mother of baby
OCP = oral contraceptive pill
PACU = post-anesthesia care unit
PCS = primary C-section
PEC = pre-eclampsia
PIH = pregnancy-induced hypertension
POC = products of conception
POD # = post-operative day #
PPD # = postpartum day #
PPTL = postpartum tubal ligation
PPROM = preterm premature rupture of
membranes
PROM = premature rupture of membranes
RCS = repeat C-section
REI = reproductive endocrinology & infertility
SS = social services
SS = social services postpartum
SVD = spontaneous vaginal delivery
TOF = tetralogy of Fallot
UDS = urine drug screen
US = ultrasound
VAVD = vacuum-assisted vaginal delivery
VBAC = vaginal birth after cesarean
WIH = Women & Infants Hospital
WPCC = Women’s Primary Care Clinic
NICU = neonatal intensive care unit
Updated 10/7/15
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Resources on Medications in Pregnancy and Breastfeeding
Through Care New England:
For side effects and risks for all medications in pregnancy and breastfeeding:
https://home.carenewengland.org/micromedex2/,DanaInfo=www.thomsonhc.com+librarian (OR link
through Micromedex on the Carenet Library page) and do a search for the medication in question.
Scroll to the bottom of the results list and click on the "reproductive risk" section.
We usually use the "Reprotox" reference of the choices given. Click on that and it will have a recent
summary of all known info on the drug in pregnancy and breastfeeding. It also covers some herbs and
supplements. When appropriate, you can often print a copy and give it to the patient.
For trainees who want access to Reprotox from home or sites without access, you can get a free
subscription: www.reprotox.org
Free resource for lactation only (LACTmed): http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Another helpful resource for patient friendly information/printouts on medications is
www.mothertobaby.org
Other Resources:
Toxicology and Teratology:
Motherrisk www.motherisk.org/prof/index.jsp
Organization of Teratology Information Specialists – OTIS - www.mothertobaby.org
Postpartum Psychiatric Disorders:
MedEdPPD - www.mededppd.org
Professional education, a peer-reviewed site
Postpartum Support International – www.postpartum.net
Addiction and Pregnancy:
National Advocates for Pregnant Women - www.advocatesforpregnantwomen.org
Guttmacher Institute - www.guttmacher.org/sections/pregnancy.php
Drug Policy Alliance Lindesmith Library - www.drugpolicy.org/library/
Smoking in Pregnancy in Rhode Island:
Quitworks RI: A free, evidence-based stop-smoking service developed by the Rhode Island Department
of Health.
http://quitworksri.org/ or Email: quitworksriinfo@jsi.com
Telephone: 1-800-TRY-TO-STOP (1-800-879-8678)
Fax: 1-866-560-9113
Updated 10/7/15
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