Clinical Site: [text]

Service Date: [date name="variable_1"]

Semester: Spring 2021

Demographics
• Initials: [text]
• Age: [text]
• Gender: [select name="variable_2" value="Female|Male|Does not identify with a particular gender"]
• Race: [select name="variable_3" value="Caucasian|African-American|Hispanic|Asian"]
• Insurance: [select name="variable_4" value= "Private|Medicaid|Medicare|V.A."]
• Referral: No referral needed
• Type of Exam: Outpatient Psychiatric Evaluation
• Length of Service: [text] minutes

Chief Complaint:[text]

HPI: [text]
Sleep:[text]
Appetite:[text]

Past Psychiatric History:
• [text]

Drug/Alcohol Abuse History:
• [text]

Medical History:
• [text]

Allergies:
• [text]

Social History:
• [text]

Family History (Psychiatric or Substance Abuse):
• [text]

Current Medications: Pre-Admission
• [text]
• [text]
• [text]
• [text]
• [text]
• [text]
• [text]

Constitutional Review of Systems:Vital Signs/Height/Weight
• BP: [text]
• HR: [text]
• RR: [text]
• Height (inches): [text]
• Weight (lbs.): [text]

Musculoskeletal Examination:
• Abnormal/Involuntary Movements: [text]
• Strength: [text]
• Muscle Tone: [text]
• Gait: [text]
• Station: [text]

Mental Status Exam:
• Appearance: [text]
• Speech/Language: [text]
• Attitude/Behavior: [text]
• Mood: [text]
• Affect: [text]
• Orientation: [text]
• Perception/Thought Content: [text]
• Risk Factors: [text]
• Thought Processes: [text]
• Concentration/Attention Span: [text] How Tested/Assessed: Per observation and interview with the patient
• Recent Memory:[text] How Tested/Assessed: [text] out of 3 in 3 minutes
• Remote Memory: [text] How Tested/Assessed: Past events, as relates to history
• Intelligence: [text] How Tested/Assessed: Based on history, vocabulary, content
• Judgement: [text] How Tested/Assessed: Per patient's behavior/History of present illness
• Insight: [text] How Tested/Assessed: Understanding severity of illness/history of present illness

Patient Strengths:
• [text]

Patient Limitations:
• [text]

Admitting Diagnosis:
• [text]
• [text]
• [text]

Initial Plan of Care:
• Group and milieu therapy
• Needs Collateral
• Needs discharge planning
• Meds:
- [text]
- [text]
- [text]
- [text]
- [text]

Estimated Length of Stay: [text]

Initial Discharge Plan: [text]

Prognosis: [text]

Justification for Inpatient Hospitalization:
[checkbox name="variable_1" value="Hallucinations/delusions/agitation/ anxiety/depression resulting in significant loss of functioning|Dangerous to self/others or property with need for controlled environment|Emotional or behavioral conditions and complications requiring 24 hour medical and nursing care|Need for special drug therapy/or other therapeutic program requiring continuous hospitalization|Failure of social or occupational functioning|Inability to meet basic life and health needs|Legally mandated admission|Patient's occupation presents danger to public safety if they continue to use drugs or alcohol|Biomedical conditions and complications requiring 24 hour medical and nursing care|Recovery environment includes detrimental family structure/logical impediments to out-patient treatment|High relapse potential due to inability to control substance use|Needs treatment for acute intoxication or withdrawal|Failure of treatment at a lower level of care"]