Clinical Inpatient Record – Progress Note
Patient Name ________________________________________________
Physician _________________________________________________
Evaluation Date _____/_____/_____
Service Code ____________________
1. SUBJECTIVE FINDINGS
Appetite
Sleep
Normal
Good
Fair
Poor
Overeating
Medication Efficacy
Side Effects
Normal
Good
Fair
Poor
None
Tremors
Akathisia
Involuntary Movements
GI
Sexual
Appetite
Sedation
Other____________
Medication Compliance
Excellent
Good
Fair
Poor
Minimal
Excellent
Good
Fair
Poor
Minimal
Comments
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
2. OBJECTIVE FINDINGS
Orientation
Rapport
Person
Place
Time
Situation
Appearance
Appropriate
Hostile
Evasive
Distant
Inattentive
Poor Eye Contact
Mood
Appropriately Dressed
Appropriately Groomed
Poorly Dressed
Poorly Groomed
Disheveled
Body Odor
Affect
Euthymic
Depressed
Anxious
Angry
Irritable
Elated
Speech
Appropriate
Depressed
Expansive
Blunted
Flat
Labile
Coherent
Appropriate
Incoherent
Loose Associations
Circumstantial
Tangential
Poverty
Pressured
Loud
Soft
Perseveration
Clanging
Word Salad
Mute
Thought Content and Process
Appropriate
Goal-Directed
Delusional
Persecution
Reference
Thought Insertion
Broadcasting
Grandiose
Obsessions
Compulsions
Insight
Judgement
Excellent
Good
Fair
Poor
Grossly
Impaired
Excellent
Good
Fair
Poor
Grossly
Impaired
Phobias
Suicidal Ideation
Suicidal Plan
Homicidal Ideation
Homicidal Plan
Cognitive
Hopelessness
Worthlessness
Loneliness
Guilt
Self Depreciation
Hallucinations
Describe hallucinations below:
___ Auditory ___ Visual ___ Command
Psychomotor Activity
No Gross Cognitive Deficits
Concentration Problems
Concrete
Abstract
Easily Distracted
Normal
Restless
Retardation
Memory
Good
Fair
Impaired
Immediate
Recent
Past
Comments
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
3. ASSESSMENTS
Psychiatric condition is generally:
Improving
Unchanged
Deteriorating
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. PLAN
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Are serum levels needed?
Medication Name
Yes
No
Date Drawn
Labs WNL?
Serum Level
Yes
No
(If no, describe below.)
Pertinent Lab Data
Physician Signature___________________________________________________________________________
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Clinical Inpatient Record – Progress Note
(Cont.)
COMPLETE THIS SECTION IF PATIENT IS AN ALGORITHM CLIENT
Stage____________________
Weeks in this stage____________________
Patient education completed?
Yes
No
Primary Current Diagnosis
(check one)
MDD-NP
MDD-P
BPD-M
BPD-MX
BPD-D
SCZ-A (BP)
SCZ
SCZ-A
Other (specify)
______________
Use for all physician’s ratings below: (0 – 10) 0 = no symptoms 5 = moderate 10 = extreme. Leave blank if they do not apply.
Core Symptoms
____Mania
____Depression
____Positive Sx of Psychosis
____Negative Sx of Psychosis
Other Symptoms
____Irritability
____Mood Lability
____Insomnia
____Agitation
____Anxiety
____Appetite
____Level of Interest
____Energy Level
____Other____________________
Psychotropic Medication Information
Medication regimen unchanged from last assessment.
Document any new or
Please provide information on titration, dose, dose
discontinued meds or
frequency, duration the medication is to be taken, start and
changes (e.g. dose) to stop date (if applicable), and any other pertinent
Medication Name
established meds.
information describing this medication.
New Med
Change
No Change
Discontinue
New Med
Change
No Change
Discontinue
New Med
Change
No Change
Discontinue
New Med
Change
No Change
Discontinue
New Med
Change
No Change
Discontinue
New Med
Change
No Change
Discontinue
Indication
(Check all
that apply.)1
S
OS
SE
S
OS
SE
S
OS
SE
S
OS
SE
S
OS
SE
S
OS
SE
1
S = Medications targeted at core symptoms. OS = Medications targeted at other symptoms. SE = Medications for side effects of S or OS.
Deviation from the medication algorithm recommended?
Patient previously failed next step
Next step not medically safe for patient
Yes
Next step not acceptable
No options left
Patient Global – Self Report (0 – 10)
No
(If yes, check all that apply.)
Next step not available at this site
Other__________________________
0 = no symptoms 5 = moderate 10 = extreme
Symptom Severity__________
Side Effects__________
Clinical Rating Scales
MMSE_____
AIMS_____
POS SX_____
NEG SX_____
IDS-SR_____
IDS-CR_____
BDSS_____
Other_____
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