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Identifying Information
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Chief Complaints/Reason for Hospitalization
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Psychiatric History of Present Illness
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History of Psychiatric Disorders
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Substance Use Considerations
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Trauma/Adverse Life Events History
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Medical History
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Allergies/Adverse Drug Reactions
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Medical Conditions
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Family Medical and Psychiatric History
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Social History
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Developmental, Educational, Vocational History
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Reproductive History
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Guardianship
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Mental Status Examination
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Appearance
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Attitudes and Behavior
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Mood/Affect
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Speech/Language
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Perception
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Thought Process
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Thought Content
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Suicide/Violence Assessment
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Cognition
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Orientation
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Memory/Recall
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Attention/Concentration
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Intelligence
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Fund of Knowledge
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Judgment/Insight
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General [-]
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General
• • •
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General Comments
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Skin [-]
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Skin
• • •
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Skin Comments
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HEENT [-]
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HEENT
• • •
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HEENT Comments
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Neck [-]
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Neck
• • •
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Neck Comments
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Cardiovascular [-]
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Cardiovascular
• • •
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CV Comments
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Respiratory [-]
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Respiratory
• • •
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Resp Comments
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GI [-]
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GI
• • •
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GI Comments
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Urinary [-]
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Urinary
• • •
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Urinary Comments
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Periph. Vasc. [-]
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Periph. Vasc.
• • •
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Periph. Vasc. Comments
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MSK [-]
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MSK
• • •
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MSK Comments
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Neurological [-]
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Neurological
• • •
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Neuro Comments
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Endocrine [-]
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Endocrine
• • •
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Endo Comments
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Psychiatric [-]
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Psychiatric
• • •
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Psychiatric Comments
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General WNL
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General Abnormal
• • •
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General Comments
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HEENT WNL
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HEENT Abnormal
• • •
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HEENT Comments
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Skin WNL
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Skin Lesion
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Skin Comments
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Neck WNL
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Neck Abnormal
• • •
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Neck Comments
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Cardiovascular WNL
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Cardiovascular Abnormal
• • •
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Cardiovascular Comments
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Lungs WNL
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Lungs Abnormal
• • •
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Lungs Comments
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Abdomen WNL
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Abdomen Abnormal
• • •
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Abdomen Comments
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MSK WNL
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MSK Abnormal
• • •
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MSK Comments
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Neuro WNL
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Neuro Abnormal
• • •
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Neuro Comments
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Extremities WNL
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Extrem Abnormal
• • •
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Extrem Comments
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Psychiatric Formulation
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Psychiatric Diagnoses
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Medical Diagnoses
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Treatment Plan
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