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: _
Cardiovascular: _
Respiratory: _
Endocrine: _
Neurological: _
Eyes: _
Musculoskeletal: _
Current Medications _
Outpatient Medications _
Mental Status Examination
Appearance:
Behavior/Activity:
Speech:
Thought Form:
Thought Content:
Mood:
Gastrointestinal: _
Genitourinary: _
Ears/Mouth/Nose/Throat: _
Heme/Lymph: _
Integumentary: _
Allergy/Immunologic: _
[_] Unless otherwise indicated, blank items are all negative
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
[_] substance
abuse/withdrawal
[_] impulsivity
[_] suicidal ideation/plan
[_] co-morbid medical
conditions
[_] psychosis
[_] homicidal ideation
[_] delirium/cognitive
impairment
[_] anxiety
[_] grave disability
[_] pain
[_] 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