Follow-up Psych

Follow-up visit for [text name="visit" default=""].
Chart reviewed.  Labs reviewed.  Case discussed with staff.  
Patient seen and examined [checkbox name="variable_3" value="in hospital room on medical floor.|on unit.|on post-partum floor.| on rounds with Dr. Sharpe."]  [checkbox name="variable_5" value="Sitter is at bedside, but steps out for interview."]
Present during interview: [checkbox name="variable_6" value="Sitter|Security|RN|Care staff|Spouse|Family|Friend|Patient is alone"].

INTERVAL HISTORY:
[textarea name="IntervalHx" default=" "]

Appetite: normal/no problems reported           
Sleep: normal/no problems reported[_ ]     
Energy:  normal[_]
HI:  denies on interview, no evidence/report per discussion with staff
SI:  denies on interview, no evidence/report per discussion with staff
Aggression/Agitation: not currently[___]
AH/VH:   denies AH, denies VH
Delusions:   
Patient is: [___ able ___ not able to contract for safety ___N/A].          

Medication Side Effects (SE): [ ]
 
 MENTAL STATUS EXAM
Level of Consciousness: [Alert, drowsy, lethargic, non-arousable]
Appearance: [____________________________]  Gait:[ _______________________________________]
Manner:  [___ Cooperative   ___ Guarded   ___ Suspicious   ___ Irritable   ___ Hostile   ___Withdrawn   ___ Other ]
Psychomotor Activity: [ ___ Normal   ___ Agitation ___ Motor Retardation ___ Tremor  ___ Abnormal movement]
Musculoskeletal:  [ ___ Normal   ___ Rigidity ___ Cogwheel ___Flaccid   ___Tics/TD   ___ Other]   
Speech:                  [___ Normal   ___ Soft/Loud   ___ Slow/Pressured   ___ Dysarthric   ___ Incoherent   ___Other ]
Language:              [___ Normal   ___Expressive Aphasia ___Fluent Aphasia   ___ Other ____.  Appropriateness of conversation, rate of speech
(> 100 words per minute is normal; < 50 words per minute is abnormal), reading and writing appropriate to education level]
Fund of Knowledge: [_______Intact      ________Fair      ________ Poor      __________Other]
 Mood: [ ___ Euthymic ___ Depressed ___ Irritable ___Angry ___ Anxious ___ Fearful   ___ Apathetic ___ Euphoric ___Other]     
 Affect:    [ ___ Euthymic ___Depressed ___Blunted     ___Flat     ___Irritable     ___ Angry  ___Anxious    ___Labile   ___Expansive   ___Exaggerated   ___Other ]
Thought Process/Association:[ ___Normal           ___Tangential ___Circumstantial               ___Poverty of Thought       ___Concrete             ___Disorganized    ___Racing Thoughts    ___Flight of Ideas      ___ Loose             ___Other] 
Thought Contents: [___Normal      ___Hopelessness    ___Worthlessness    ___Hypochondriasness    ___Delusions     ___Paranoia    ___Ruminations     ___Confused            ___Obsessions/Compulsions    ___Other]
 Perception: [ ___ Normal, [  ___Hallucinations   ___Auditory    ___Visual   ___Olfactory   ___Tactle   ___ Command Hallucinations],[  ___Dissociation   ___Flashbacks   ___Other 
Attention/Concentration: [___Intact         ___Poor   ___Distractible   ___Redirectable   ___Other ]
Cognition: [___Intact     ___Impaired              Insight:   ___Intact   ___Fair   ___Limited]
Short Term Memory: [___Intact         ___Fair   ___Poor     Judgment:  ___Intact   ___Fair   ___Limited]
Remote Memory:[ ___Intact         ___Fair   ___Poor]      
 
PSYCHOTHERAPY/ COUNSELING: [ ___Therapeutic Interview ___ Supportive ___ CBT ___ Ongoing   ___Other] 

ASSESSMENT:  Patient is:[ ___ Well-controlled ___ Improving ___ Worsening ___ Other

DIAGNOSES: [ ]
 
TREATMENT/PLAN:
 [___ Continue Current Medications ___Continue Follow-Up ___Continue Labs ___ Other]
[Risks, benefits, Side Effects, Drug-to-Drug Interactions and Alternatives to treatment were discussed in my usual manner: ____ Yes ____No]
 
Reason for not reducing medication dose(s):    
[____N/A  ____ High risk of patient’s deterioration ___ Medication recently reduced    ___Prior Medication Dose Reduction Unsuccessful ____Other ]
 
Complexity Issues: 
[# of diagnoses or management options:  ____Limited   ____Multiple ]
 
[Problems: (gait, hearing, vision, etc.) effect on treatment and management:   ____Yes      ____ No]
 
[Risk of complications and/or morbidity or mortality: ____None    ____ Limited   ____ Moderate  ____  Severe]
 
[Coord. of Care  (e.g. with patient and/or family, social workers, nursing staff,  other doctors): 
____None   ____>50% of visit ____<50% of visit]
 
Topics discussed: 
___Nature of diagnosis and/or prognosis                                                          
___Aspects of aging process and relationship to the current problem              
___Nature of possible treatment options/drug drug interaction                        
___Risk of non-treatment                                                                                  
___Psychopharmacologic treatment options/possible benefits and risks          
___Nature of, reasons for and possible benefits from psychotherapy              
___Family and/or situational stressors                                                              
___Behavioral and/or environmental changed that might help
 

Additional considerations/activities:
___ Medical records reviewed
___Communication with patient’s Dr
___Communication with facility staff
___Communication with family/caregiver
___Referred for psychotherapy
___ Forms/reports filled out
___OtherFollow-up visit for [checkbox name="variable_1" value="suicidal ideation|suicide attempt|depression|anxiety|mood disorder|bipolar disorder|somatic symptoms|agitation|delirium|dementia|dementia with behavioral disturbances|AMS|psychosis|substance abuse|substance withdrawal|patient on 6404|patient on 6401|re-evaluation of capacity|re-evaluation of need for geripsych|re-evaluation of need for emergency psychiatric hospitalization"].
[checkbox name="variable_2" value="First time seeing patient, case discussed with handing off provider."]
Chart/labs/imaging/assessments reviewed.  Interval events discussed with staff.  [select name="variable_2" value="In the past 24 hours|In the past 48 hours|Since admission"], patient [select name="variable_3" value="has|has not"] required psychiatric PRNs [textarea name="variable_2" default="-"], [select name="variable_4" value="has|has not"] required restraints[textarea name="variable_3" default=""], [select name="variable_5" value="has|has not"] endorsed suicidal ideation [textarea name="variable_4" default=""], and [select name="variable_6" value="has|has not"] required involvement of security [textarea name="variable_5" default=""].

[select name="variable_1" value="Per nursing|Per tech| Per staff|Per report from primary team |Per case management|Per attending|Reportedly|Per review of interval notes"],[textarea name="variable_1" default=" today the patient has been appropriate, cooperative with care and treatment, eating/drinking OK, not agitated and not appearing to respond to internal stimuli."]