Psychiatric Comprehensive Evaluation-PMHNP

Psychiatry & Psychology
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Psychiatric Comprehensive Evaluation-PMHNP

History: [textarea memo="Very pertinent history, otherwise leave blank" cols="31" rows="1"]

Chief Complaint: [textarea memo="In patient's own words" default="Auto-populated in EMR" cols="31" rows="1"]

Source of Information and their reliability:
[textarea default="Patient:\nAdmission Note:\nJail Records:" cols="51" rows="4"]

History of Present Illness:
[textarea memo="Look at Admission Note" default="Pull from AO" cols="51" Rows="4"]

ROS:
[textarea memo="Look at Admission Note" default="Pull from AO" cols="51" Rows="4"]

Physical Exam:
[textarea memo="Look at Admission Note" default="Pull from AO" cols="51" Rows="4"]

--Mental Status Examination--

Appearance/Behavior:
-general: [select value="Alert and oriented in all spheres|obtunded|disoriented|unknown"].[select value="Appears to be of chronological age|Appears younger than chronological age|Appears older than chronological age|unknown"].
-accessibility:[select value="cooperative|friendly|uncooperative|irritated but not to the level of anger|angry|hostile|alert|confused|hostile|silent|inappropriate boundaries|seductive|playful|ingratiating|evasive|guarded|sullen|manipulative|contemptuous|demanding|withdrawn|"][text].
-grooming: [select value="Average/WNL|well-groomed|poorly groomed|meticulously groomed|unknown"].
-clothing: [select value="clean|dirty|unkempt|neat|tidy|meticulous|worn out|skillfully applied|unconventional|fashionable|unknown|professional"],[select value="appropriate for season| inappropriate to season|unknown"],[select value="wearing issued sweatshirt and pants| inappropriately worn clothing|unknown"].
-hygiene: [select value="clean|unbathed|dirty|body odor|smells of alcohol|unknown"].
-Body habitus: [select value="average height|tall|short|unknown"],[select value="average weight|thin|overweight|obese|underweight|unknown"].
-facial expression: [select value="casual(normal)|bland|flat|mobile(rapid changes)|angry|unknown"]. Patient is [select value="wearing a a face mask|not wearing a face mask|"].
-Signs of distress: [select value="in no distress|in mild psychological distress|in moderate psychological distress|in acute psychological distress"].
-Eye contact: [select value="eye contact good|eye contact fair|eye contact avoidant|unknown"].
[text]

Psychomotor activity:
-abnormal movements: [select value="none|grimaces|tics|twitches|foot tapping|rocking back and forth|hand wringing|ritualistic behavior|mannerisms|posturing|nail biting|chewing movements|echopraxia|tardive dyskinesia|catatonic|unknown"].
-Rate/gait: [select value="normal|hyperactive|slow|retarded|agitated|hesitant|propulsive|shuffling|dancing|ataxic|uncoordinated|unknown"].
-Coordination: [select value="normal/no problems|awkward|clumsy|agile|falling easily|needed assistance|bed ridden|uses wheelchair|uses walker|unknown"].
-Posture: [select value="quietly seated|relaxed|stooped|combative|hyperactive|agitated|rigid|stiff|shaky|slouched|bizarre movements|posturing|crouching|erect|restless|unknown"].
[text]

Speech: [select value="normal rate and volume|pressured|monotonous|quiet|emotional|loud|forgetful|whispering|yelling|accented|impoverished|neologisms|aphasia|global aphasia|Broca's aphasia|Wernicke's aphasia|dysarthia|preservation|sterotypy"].
Speech - clarity: [select value="clear|slurred|mumbled|lisping|stuttering|inaudible|incoherent|long pauses"].
Speech - quantity: [select value="within normal limits|responds only to questions|scant|mute|verbose|repetitive"].

Mood/Affect:
-Reported mood: [text]
-Observed mood: [select value="euthymic|expansive|euphoric|anxious|depressed|tearful|labile|flat|happy|sad|irritated|angry|enraged|guilty|"].
-Affect: [select value="euthymic|full range of affect|broad|appropriate|constricted|blunted|flat|labile|anhedonic|blunted|emotional withdrawal|excited"].
[text]


Cognition/Memory
-overall functioning: [select value="within normal limits|grossly intact|below average|above average|short-term memory loss|long-term memory loss|amnesia|anterograde amnesia|retrograde amnesia| history of head trauma|transient global amnesia"]. [text]
-Orientation: [select value="orientated to person, place, time, and event|not orientated to person, place, time, and event|not orientated to place, time, or event|not orientated to time and event|not orientated to event|lethargic|obtundation|stupor|coma"].
-Abstraction: [select value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"].
-Attention & Concentration: [select value="Intact. Demonstrates the ability to focus and sustain their thoughts on a specific task/topic|Impaired. Unable to Demonstrates the ability to focus and sustain their thoughts on a specific task/topic"].
-Recent Memory:[select value="intact|impaired|Poor"].[text].
-Remote Memory:[select value="intact|impaired|Poor"].[text].

Thought Process: [select value="logical, relevant, and goal orientated|not logical, relevant, and goal orientated|past orientated|scattered|impoverished|racing thoughts|circumstantial|perservations|flight of ideas|illogical|hopeful|remorseful|enthusiastic|incoherent|neologism|distractable|tangential|overvalued ideas|excited|poverty of though|word salad|clang associations|slow reaction|rapid reaction|doubting|indecisive|blocking|spontaneous|pressured|"]. [text].

Perceptions: [select value="within normal limits|illusions|hallucinations|denationalization|derealization"]. [text]

Thought content: [select value="within normal limits|thought withdrawal|thought insertion|paranoia|thought broadcast|suspiciousness|grandiose delusions|somatic delusions|delusional guilt|nihilistic delusions|ideas of reference|ideas of inference|magical thinking"]. [text].

Insight: [select value="good|fair|poor"]. [select value=" |The patient demonstrates understanding and awareness of their current problems.|The patient does NOT demonstrate understanding and awareness of their current problems."][text].

Judgment: [select value="good|fair|poor"]. [select value=" |Demonstrates ability to make considerate decisions when performing a task based on their understanding of the current circumstances.|Does NOT demonstrate the ability to make considerate decisions when performing a task based on their understanding of the current circumstances."]
[text].


CAPACITY OF INFORMED CONSENT
Capacity of consent: [select value="|Has capacity|Does not have capacity|JA|AR"]


RATIONALE:
They [select name="variable_3" value="demonstrate|do NOT demonstrate"] the ability to communicate a choice, and can clearly indicate a preferred treatment option or deny treatment..
They [select name="variable_3" value="demonstrate|do NOT demonstrate"] the ability to understand the relevant information, and grasp the fundamental meaning of the information communicated to the patient regarding their medical condition and treatment.
They [select name="variable_3" value="demonstrate|do NOT demonstrate"] the ability to appreciate a situation and its consequences, and they acknowledge the medical condition and likely consequence of proposed treatment options and alternatives.
They [select name="variable_3" value="demonstrate|do NOT demonstrate"] the ability to reason rationally, and they are able to engage in a rational process of manipulating the relevant information.

Thus, the patient does [select name="variable_4" value="appear|NOT appear"] to have capacity to consent to medical treatment

---ASSESSMENT---
BEHAVIORAL RISK ASSESSMENT
1. Harm to others
Homicidality/bodily injury towards others: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, no current plan or intent|current ideation and plan, no current intent|current ideation, plan, and intent"]. Patient is currently assessed to be at [select value="no|low|moderate|high"] risk of being a harm to others as evidenced by patient's self-report of [select value="not having any|having a"] homicidal ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of patient having a homicidal ideation/plan/intent: [textarea cols="20" rows="1" default= "No action taken."]

2.Harm to self
Suicide Risk Assessment: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, no current plan or intent|current ideation and plan, no current intent|current ideation, plan, and intent"]. Patient is currently assessed to be at [select value="no|low|moderate|high"] risk for self harm as evidenced by patient's self-report of [select value="not having any|having a"] suicidal ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of patient having a suicidal ideation/plan/intent:[textarea cols="20" rows="1" default= "No action taken."]

Self-injurious behavior: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, no current plan or intent|current ideation and plan, no current intent|current ideation, plan, and intent"]. Patient is currently assessed to be at [select value="no|low|moderate|high"] risk for self-injurious harm as evidenced by patient's self-report of [select value="not having any|having a"] self-injurious ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of patient having a suicidal ideation/plan/intent:[textarea cols="20" rows="1" default= "No action taken."]

3. Elopement Risk
[textarea default="Elopement mitigated by inpatient care at medium security psychiatric hospital"]

RISK ASSESSMENT

[text memo="Patient name"] has several static risk factors that raise their baseline risk for harm to self and others and inability to care for self. These include [text memo="SADPERSONS"].

Mitigating factors include [text]. Patient strengths include [text].

Convincingly contracted for safety. Patient is at [select value="Low|Moderate|High"] risk for harm to self-including deliberate self-harm, [select value="Low|Moderate|High"] risk for harm to others including intentional violence, Click or tap here to enter text. risk for vulnerability to harm, and [select value="Low|Moderate|High"] risk for inability to care for self in the context of standard inpatient psychiatric hospital setting.


FORMULATION/RATIONALE FOR DIAGNOSIS
[textarea memo="narrative about diagnosis and supporting elements. Plan."]
Psychiatric Comprehensive Evaluation-PMHNP

History:Very pertinent history, otherwise leave blank

Chief Complaint:In patient's own words

Source of Information and their reliability:


History of Present Illness:
Look at Admission Note

ROS:
Look at Admission Note

Physical Exam:
Look at Admission Note

--Mental Status Examination--

Appearance/Behavior:
-general: ..
-accessibility:.
-grooming: .
-clothing: ,,.
-hygiene: .
-Body habitus: ,.
-facial expression: . Patient is .
-Signs of distress: .
-Eye contact: .


Psychomotor activity:
-abnormal movements: .
-Rate/gait: .
-Coordination: .
-Posture: .


Speech: .
Speech - clarity: .
Speech - quantity: .

Mood/Affect:
-Reported mood:
-Observed mood: .
-Affect: .



Cognition/Memory
-overall functioning: .
-Orientation: .
-Abstraction: .
-Attention & Concentration: .
-Recent Memory:..
-Remote Memory:..

Thought Process: . .

Perceptions: .

Thought content: . .

Insight: . .

Judgment: .
.


CAPACITY OF INFORMED CONSENT
Capacity of consent:


RATIONALE:
They the ability to communicate a choice, and can clearly indicate a preferred treatment option or deny treatment..
They the ability to understand the relevant information, and grasp the fundamental meaning of the information communicated to the patient regarding their medical condition and treatment.
They the ability to appreciate a situation and its consequences, and they acknowledge the medical condition and likely consequence of proposed treatment options and alternatives.
They the ability to reason rationally, and they are able to engage in a rational process of manipulating the relevant information.

Thus, the patient does to have capacity to consent to medical treatment

---ASSESSMENT---
BEHAVIORAL RISK ASSESSMENT
1. Harm to others
Homicidality/bodily injury towards others: . Patient is currently assessed to be at risk of being a harm to others as evidenced by patient's self-report of homicidal ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of patient having a homicidal ideation/plan/intent:

2.Harm to self
Suicide Risk Assessment: . Patient is currently assessed to be at risk for self harm as evidenced by patient's self-report of suicidal ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of patient having a suicidal ideation/plan/intent:

Self-injurious behavior: . Patient is currently assessed to be at risk for self-injurious harm as evidenced by patient's self-report of self-injurious ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of patient having a suicidal ideation/plan/intent:

3. Elopement Risk


RISK ASSESSMENT

Patient name has several static risk factors that raise their baseline risk for harm to self and others and inability to care for self. These include SADPERSONS.

Mitigating factors include . Patient strengths include .

Convincingly contracted for safety. Patient is at risk for harm to self-including deliberate self-harm, risk for harm to others including intentional violence, Click or tap here to enter text. risk for vulnerability to harm, and risk for inability to care for self in the context of standard inpatient psychiatric hospital setting.


FORMULATION/RATIONALE FOR DIAGNOSIS
narrative about diagnosis and supporting elements. Plan.

Result - Copy and paste this output:

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