Psych Admission Notice

CHIEF COMPLAINT: [text default="" size=100]

HISTORY OF PRESENT ILLNESS: 
Patient is a [text default="" size=1]-year-old [select name="RACE" value="Caucasian|African American|Asian"], [select name="GENDER" value="male|female"], with PMH of [text default="" size=100], who [select name="ENTER" value="was brought|presented"] to TRMC on [date name="DATE" default=""][conditional field="ENTER" condition="(ENTER) .is('was brought')"] via EMT [/conditional][conditional field="ENTER" condition="(ENTER) .is('presented')"] with complaints of[/conditional][text default="reason + duration" size=100]. Patients UDS and Serum were [comment memo="UDS"][select name="UDS" value="negative|positive"][conditional field="UDS" condition="(UDS) .is ('positive')"] for [text name="DRUGS" default=""][/conditional][conditional field="UDS" condition="(UDS) .is ('negative')"] for any drugs[/conditional] and [comment memo="EtOH"][select name="UDS2" value="negative|positive"] for alcohol. The patient was admitted [text default="" size=100].

[comment memo="Story of what happened:"][textarea fillable="true"]Patient was in ****** normal state of health until ******.[/textarea]

[comment memo="DEPRESSION: (Sleep problems, interest, guilt, energy, concentration, appetite, psychomotor (agitation/retardation), suicidal thoughts)"][textarea name="DEP" default=""]

[comment memo="Psychotic Symptoms: (Hallucinations (visual/auditory), Delusions, Paranoia)"][textarea name="PsychoticSxs" default=""]

[comment memo="Mood:"][textarea name="Mood" default=""]

[comment memo="Suicidal intent/plan:"][textarea name="SI" default=""]

PAST PSYCHIATRIC HISTORY:  
• Past Psychiatric Diagnosis - [textarea name="1" default="Denies"]
• Previous hospitalization - [comment memo="(where and when)"][select value="There is no history of psychiatric hospitalizations|Patient has been psychiatrically hospitalized |"][textarea rows="2"]. [select value="Previous psychiatric/counseling services includes |Patient has no history of psychiatric/counseling|History of psychotherapy/counseling was not addressed due to symptomatic presentation|"][textarea rows="2"]. 
• Previous suicide attempts or injury - [select value="Patient has no history of thoughts of self-harm|History of thoughts of self harm include |"][textarea rows="2"].  [select value="There is no history of attempting to hurt themself|History of self-harm includes"][textarea rows="2"].
• Medications - [select value="Current psychiatric medications include: |Patient is unable to recall current psychiatric medications|"][textarea rows="4"]. [select value="Previous psychiatric medication trials include but may not be limited to: |The patient has no history of taking psychiatric medications|The patient denies any history of past psychiatric medications trials|The patient is unable to recall past psychiatric medication trials|"][textarea rows="1"].

PAST MEDICAL & SURGICAL HISTORY:
• [textarea name="PMHPSHX" default="Patient denies any significant PMH or Surgical history."]

SUBSTANCE ABUSE HISTORY: 
•[comment memo="When did they start, how often, last used"][textarea name="2" default=""]
•[comment memo="Any inpatient/outpatient addiction treatment program"][textarea name="23" default=""]
•[comment memo="How long, sobriety, rehab"][textarea name="234" default=""]
•[comment memo="Alcohol withdrawal (DT/seizures), when was last drink"][textarea name="2345" default=""]

LEGAL HISTORY: [comment memo="
jail/prison, probation/parole, charges or pending charges"]
• [textarea name="legal" default="Denies any current or past history of jail/prison, probation/parole, charges or pending charges."]
• [textarea name="legal2" default="Denies access to firearms."]

PERSONAL, FAMILY AND SOCIAL HISTORY: 
• Family – [comment memo="alive, mental health, substance abuse, suicide"][textarea name="FAMILY" default="Denies"]
• Abuse/trauma – [comment memo="Any subsequent flashbacks or nightmares"][textarea name="Abuse" default="Denies"]
• Education/employment – Highest level of education is [select value="highschool|an undergraduate degree in |a graduate degree in |some highschool|some college|currently in grade school|currently in highschool|currently in college studying |currently in graduate school studying |"][textarea rows="1"].
• Residence – [comment memo="Where/who do you live with"]Patient [select value="has no current housing concerns|is currently in an unstable housing situation related to |"][textarea rows="1"].
• Married/Kids – Patient has [select value="no|1|2|3|4|5|6|7|"] children.[textarea rows="1"] 
• Able to support self – [comment memo="Financial"]Patient is [select value="currently on disability due to mental health condition|currently on disability due to medical condition|currently employed |currently retired from |"][textarea rows="1"]. Patient's source of income is primarily [select value="disability|social security|unemployment|current employment|family support|"][textarea rows="1"]. 
• Social Support – Patient identifies [checkbox value="having no one|significant other|extended family|children|friends|church members"][textarea rows="1"] as social-support network. 
• Hobbies – [textarea name="Hobbies" default="Denies"]
 

TRAUMA HISTORY: 
• [select value="No history of head injuries or traumatic brain injuries|Past history of traumatic brain injuries resulting from |Patient has an underlying cognitive impairment from |"] [textarea rows="2"].  [select value="Denies history of trauma (sexual, emotional or physical)|Reported having a history of trauma but did not want to elaborate|Reported past traumatic experiences to include |"][textarea rows="2"].