Follow-Up ED Consult
Hospital:
Patient consents to this evaluation by Telemedicine
Name: (Last)
Age:
(First)
SSN:
(MI)
Other ID:
Date of Last Consult:
Visit No (After Initial Consult:)
Reason for F/U Consult
Same as Previous reason for Initial Consult
Change in Sensorium
New Reason
Interval History
Mental Status Examination
Sensorium
Alert:
Appearance
Behavior
Oriented:
(if not, describe)
Cooperative:
(describe)
Guarded:
(describe)
Suspicious:
(describe)
Hostile:
(describe)
Other:
(describe)
None:
Psychomotor Abnormalities
Other:
Appropriate for Patient:
Attention:
(describe)
(if not, describe)
Intact:
(if not, describe)
Concentration: Intact:
(if not, describe)
Memory:
Judgment
Insight
Emotion
(describe)
Other:
Appropriate for Patient:
Mood:
Intact:
(if not, describe)
Good:
Fair:
Poor:
(describe)
Good:
Fair:
Poor:
(describe)
Euthymic:
(if not, describe)
Affect: Appropriate:
(if not, describe)
Thought Content
Hallucinations: No:
Yes:
(describe)
Delusions: No:
Yes:
(describe)
Thought Process
Logical/Goal directed:
Distractible:
LOA:
(*) Suicidal Ideation
No:
Yes:
(describe)
(*) Homicidal Ideation
No:
Yes:
(describe)
None:
Face:
Extremities:
Tics: No:
Other:
Lips/Tongue:
FOI:
Trunk:
(describe)
Yes:
(describe)
(describe)
Other
BAR CODE
SCDMH FORM
JAN. 09 (REV. SEPT. 09) DUKE - 02 Pg.1
(*) DSM-IV Diagnosis
(Must include both code and description)
Axis I
Axis II
Axis III
Axis IV
GAF
Explanation of diagnosis/thoughts
Recommendations
Psychiatric hospitalization not indicated at this time
Medication recommendations
Mental Health Medication
Dosage
Frequency
Amount
follow-up Psychiatric appt
follow-up substance abuse appt
follow-up medical appt
social services
community assistance
shelter
residential program
family supervision
safety precautions
emergency plan
legal
other
BAR CODE
SCDMH FORM
JAN. 09 (REV. SEPT. 09) DUKE - 02 Pg.. 2
Further evaluation needed
labs
consults
diagnostic tests
additional info
other
Psychiatric/substance abuse hospitalization indicated
voluntary
involuntary
Interim Management
Medication recommendations
Mental Health Medication
Dosage
Route
Frequency
environmental
social
other
Signature
Date
BAR CODE
SCDMH FORM
JAN. 09 (REV SEPT. 09) DUKE - 02 Pg. 3