|
Patient Name
|
|
|
DoB
|
Facility
|
|
Gender
|
Room Number
|
|
Race
|
|
|
Minutes Seen
|
|
|
Outstanding Psychiatric History
|
|
|
Anti-Dementia Medications
|
|
|
Results
|
|
|
LOC
• • •
|
Cooperative
• • •
|
|
Eye Contact
• • •
|
Psychomotor Abnormality
• • •
|
|
Affect: Appropriate?
• • •
|
Range
• • •
|
|
Intensity
• • •
|
Mood
• • •
|
|
Speech Spontaneous
• • •
|
Speech: Rate
• • •
|
|
Speech: Volume
• • •
|
Thought Process: Goal Directed?
• • •
|
|
Thought Content: Suicidal Ideation
• • •
|
Thought Content: Homicidal Ideation
• • •
|
|
Hallucinations
• • •
|
Perceptual Abnormalities
• • •
|
|
Delusions
• • •
|
Delirium
• • •
|
|
Judgement
• • •
|
Insight
• • •
|
|
Short Term Memory
• • •
|
Long Term Memory
• • •
|
|
Apraxia
• • •
|
Aphasia
• • •
|
|
Gait Disturbance
• • •
|
|
|
Appetite
• • •
|
Sleep Pattern
• • •
|
|
Orientation
• • •
|
|
|
Patient Is:
• • •
|
Patient Exhibits:
• • •
|
|
Grooming/Hygiene
• • •
|
|
|
A/P:
|
|
|
Notes and Recommendations
|
|
|
Signature
|
Date
|
