IdentifyingInfoPsych-1

The patient is a [text memo="age" size="2"]-year-old [checkbox value=" white| African-American| Hispanic| Asian|"] [checkbox value="female|male|transgender female|transgender male|gender non-binary individual"] [select name="variable_9" value="||with no past psychiatric history,|with history of |"] [checkbox value="depression|MDD|situational depression|anxiety|GAD|panic attacks|mood disorder|bipolar disorder|somatic symptoms|somatic symptom disorder|ADHD|PTSD|dementia|dementia with behavioral disturbances|OCD|psychosis|substance abuse|personality disorder|maladaptive personality traits|recurrent suicidal ideation|suicide attempt|schizoaffective disorder, bipolar type|schizoaffective disorder|schizophrenia|psychosis|unknown mental health diagnosis|severe persistent mental illness|psychiatric hospitalization|noncompliance with psychiatric medications/treatment"][textarea memo=" " rows="5"] and pertinent medical history of [textarea name="pertMedHx" default="sample text"], who [select value="initially presented to emergency department|initially presented to outside emergency department|was transferred here from outside facility|was directly admitted"][select value="|| alone| with family| with significant other| via EMS | already sedated and intubated| by police"] [select value=" |complaining of |for complaints of | due to report of | for higher level of care due to|for "][text memo="PRESENTING PROBLEM" size="20"].  [select name="variable_13" value="Per ED records,|Per outside records, |Per chart,|At time of admission,|Upon transfer and admission here,||"][select value="the patient reported |family reported |friend reported|EMS reported |staff at the facility reported|it was reported |outside records indicated |police reported|the patient was"][textarea memo="history of presenting complaints" rows="3"]  [select name="variable_13" value="In ED, work-up showed|At outside hospital,| Initial work-up showed|| "][textarea name="IntialWU" default=""]  [select name="variable_14" value="||No UDS results noted. |UDS at outside hospital reportedly|UDS was|"] [checkbox name="UDS" value="+amphetam/metham|+barbituates|+benzos|+cocaine|+opiates|+phencyclidine|+THC|+methadone screen"].  [select name="Druglevel1" value="||Acetominophen level less than 10.0 mcg/mL . |Acetominophen level high at X mcg/mL .|Salicylate level less than 10.0 mg/dl .|Salicylate level elevated at X mg/dl .|Lithium level therapeutic at X .|Lithium level low at X, not trough.|Lithium level low at X .|Lithium level high at X.|Depakote level high at X.|Depakote level low at X, not trough.|Depakote level low at X ."]  [select name="Druglevel2" value="||Acetominophen level less than 10.0 mcg/mL . |Acetominophen level high at X mcg/mL .|Salicylate level less than 10.0 mg/dl .|Salicylate level elevated at X mg/dl .|Lithium level therapeutic at X .|Lithium level low at X, not trough.|Lithium level low at X .|Lithium level high at X.|Depakote level high at X.|Depakote level low at X, not trough.|Depakote level low at X ."]  [select name="Druglevel3" value="||Acetominophen level less than 10.0 mcg/mL . |Acetominophen level high at X mcg/mL .|Salicylate level less than 10.0 mg/dl .|Salicylate level elevated at X mg/dl .|Lithium level therapeutic at X .|Lithium level low at X, not trough.|Lithium level low at X .|Lithium level high at X.|Depakote level high at X.|Depakote level low at X, not trough.|Depakote level low at X ."]  [select name="Druglevel4" value="||Acetominophen level less than 10.0 mcg/mL . |Acetominophen level high at X mcg/mL .|Salicylate level less than 10.0 mg/dl .|Salicylate level elevated at X mg/dl .|Lithium level therapeutic at X .|Lithium level low at X, not trough.|Lithium level low at X .|Lithium level high at X.|Depakote level high at X.|Depakote level low at X, not trough.|Depakote level low at X ."] 

Psychiatry consultation requested by 
 [text name="NameOfProv" default=""]for[select value="|| evaluation and management of | due to reports of |"][text memo="presenting psych problem" size="20"].