Psychiatric Evaluation: CBH
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"]
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