Psychiatry
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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."]
Follow-up visit for .
Chart reviewed. Labs reviewed. Case discussed with staff.
Patient seen and examined
Present during interview: .

INTERVAL HISTORY:


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 .

Chart/labs/imaging/assessments reviewed. Interval events discussed with staff. , patient required psychiatric PRNs, required restraints, endorsed suicidal ideation, and required involvement of security.

,

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