|
Date of service
|
Date of admission
|
|
Facility Name
• • •
|
|
|
Axis I
|
Axis II
|
|
CPT
|
|
|
STAFF REVIEW: Hours sleep:
|
|
|
Compliance
• • •
|
Group participation
• • •
|
|
Nutrition
|
Comments
|
|
Requiring redirection
|
Comments
|
|
Displaying psychotic symptoms
|
Comments
|
|
Inappropriate behaviour
|
Comments
|
|
Unstable affect/mood
• • •
|
Comments
|
|
Compared to initial presentation
|
Comments
|
|
Prn’s required
|
Comment
|
|
PHYSICAL STATUS
|
|
|
BP
/
|
pulse
|
|
Temp
|
Resp
|
|
Chronic medical problems
|
Comments
|
|
Acute medical problems
|
Comments
|
|
Latest orders/New Lab results
|
Comments
|
|
Current Medications
|
PSYCH MEDS
|
|
Date of medication adjustments
|
|
|
Medication Concerns per patient
|
Comments
|
|
Medication side effects evident
• • •
|
Comments
|
|
Patient Interview
|
|
|
Appetite
|
Comments
|
|
Sleep
|
Comments
|
|
The patient reports feeling:
• • •
|
Comments
|
|
Psychotic Symptoms
• • •
|
Comments
|
|
Patient’s awareness/insight
|
Comments
|
|
Somatic Concerns
|
|
|
Other concerns/issues:
• • •
|
Comments
|
|
MENTAL STATUS EXAM
|
|
|
Appearance
• • •
|
|
|
Speech
• • •
|
|
|
Behavior
• • •
|
Comments
|
|
Mood/Affect
• • •
|
Comments
|
|
Thought process/content
• • •
|
Comments
|
|
Judgment
• • •
|
Comemnts
|
|
Insight
• • •
|
Comments
|
|
Cognitive
• • •
|
Comments
|
|
Suicidal thoughts
• • •
|
Comments
|
|
PHYSICIAN’S ASSESSMENT
|
Comments
|
|
Affective Symptoms
• • •
|
Comments
|
|
Behavioral Symptoms
• • •
|
Comments
|
|
Altered Thoughts/Psychosis
• • •
|
Comments
|
|
Physical Status
• • •
|
Comments
|
|
GLOBAL ASSESSMENT
|
Comments
|
|
Patient seems
• • •
|
Comments
|
|
RATIONALE FOR CONTINUED STAY
• • •
|
Comments
|
|
PLAN OF TREATMENT
• • •
|
Comments
|
|
Discharge planning
|
Comments
|
|
Anticipated discharge date
|
Comments
|
|
NPs Statement
|
New Field
|
|
Providers
|
|
|
|
Comment
|
|
|
Comment
|
