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Type of Exam
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Date/Time
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Provider
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Facility
• • •
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Bed Number
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Consult Orders Reviewed
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Reason For Consult
• • •
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Reliability of History
• • •
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Chief Complaint
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Vital Signs
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HPI
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Past Psychiatric Treatment
• • •
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Past Psychiatric Med Treatment
• • •
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Psychiatric History
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Current Psych Meds from Chart
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Side effects to psych meds
• • •
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Medical Review
• • •
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Med Reconciliation
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Mental Status Exam:
• • •
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Other Medical Issues
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Mental Status Continued
• • •
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Lab
• • •
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Memory Testing
• • •
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Additional Lab
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Social History:
• • •
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OTHER INFORMATION
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Social History, Con't
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Family History of Med/Psych/Subs
• • •
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Psychiatric Diagnosis - Axis I
• • •
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Hx of substance abuse
• • •
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AXIS I Diagnoses
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Additional HIstory on Substance
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Axis II: deferred
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Psych Symptoms Review
• • •
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Axis III see record
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Sleep
• • •
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AXIS III, continued
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Appetite
• • •
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Axis IV
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Anxiety sxs
• • •
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Additional AXIS IV Stresses
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Mood sxs
• • •
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Axis V
• • •
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Suicide Assessment
• • •
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Psychosis
• • •
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Capacity
• • •
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Other Behavioral Symptoms
• • •
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Interactive Complexity
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Homocidal ideation
• • •
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TREATMENT PLAN
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Antipsychotics
• • •
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Education for Consent
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EDUCATION
• • •
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OTHER EDUCATION
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Return to Clinic
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