|
Chief Complaint (reason for consult)
|
|
|
Chief Complaint:
• • •
|
HPI
|
|
|
|
|
HPI
|
|
|
Past Psychiatric History:
|
|
|
Past psych hospitalizations
|
Past SI/HI
|
|
Trauma hx:
|
Past Psych History
|
|
Psych. Dx:
• • •
|
Previous psych dx:
|
|
Psych meds
|
|
|
Psych meds
|
Psych. medications
• • •
|
|
|
|
|
Family/Social Hx:
|
|
|
Born/raise in
|
Marital status
• • •
|
|
Children
• • •
|
Religion:
• • •
|
|
Highest Education Level
• • •
|
Work Hx:
|
|
Law Enforcement Issues/DUI/DWI/Incarceration
• • •
|
Law Enforcement Issues+
|
|
Subst. use/tobacco/stimulant/cannabis/heroin:
• • •
|
Subst. use/tobacco/stimulant/cannabis/heroin:
|
|
Hobbies
• • •
|
Hobbies:
|
|
Military Service
|
|
|
Medical Hx:
|
|
|
Medical Dx:
• • •
|
Medical Dx:
|
|
Allergies
|
Allergies
|
|
Alerts:
|
Alerts:
• • •
|
|
|
|
|
MSE, PE, & ROS
|
|
|
Vital Signs
• • •
|
|
|
Appearance:
• • •
|
Gait:
• • •
|
|
Speech:
• • •
|
Behavior:
• • •
|
|
Affect:
• • •
|
Mood
|
|
Thought process:
• • •
|
Thought content:
• • •
|
|
Hallucinations:
• • •
|
Memory / Concentration
• • •
|
|
Language:
• • •
|
Insight
• • •
|
|
Judgement:
• • •
|
Abnormal Movement
• • •
|
|
ROS (new=10, est=2)
• • •
|
Care Coordinated:
• • •
|
|
|
|
|
Dx & Recommendations:
|
|
|
Dx:
• • •
|
|
|
Recommendations
• • •
|
Recommendations/Plan
|
|
Psychotropic monitoring
• • •
|
|
|
Referrals
|
|
|
Referrals
• • •
|
Referrals
|
