Psychiatry Assessment/Plan list

[comment memo="Assessments- Delirium"]

[checkbox name="DelAss" value="with no history of primary psychotic illness, who presents with multifactorial delirium and situational depression and anxiety in the setting of complex medical problems, recurrent and lengthy hospitalizations.  Currently, the patient is not suicidal/homicidal, combative , or experiencing acute distress due psychiatric symptoms.  There is no indication of need for treatment in an inpatient psychiatric setting.  Primary treatment should focus on identification and treatment of reversible causes and  strategies to support normal circadian rhythms, alertness, cognition, and motor function.
"]


[comment memo="Plan - Meds for Delirium"]

[checkbox name="DelPlanAnti" value="In light of prolonged delirium, hallucinations and significant recent agitation, risks of untreated symptoms and worsening course favor continuation of neuroleptic medication.|option B|option C"]


[comment memo="Plan- Nonpharm Strategies for Delirium"]


[checkbox name="DelNonPharm" value="Important to continue with nonpharmacological interventions for prevention of delirium after discharge, including minimizing CNS active drugs, reinforcement of sleep-wake cycle, mobilization, frequent reorientation, adequate pain management, etc.|option B|option C"]

[comment memo="Plan- Counseling and Education"]

[checkbox name="GenCouns" value="Had 15-minute discussion with patient regarding diagnosis, its historical course with and without treatment, importance of taking prescribed medication daily and potential complications of nontreatment including blank, blank, and blank.  Discussed patient's personal and family risk factors for these conditions.  Also discussed blank and explained possible blank despite not having symptoms or feeling bad.  Patient verbalized understanding and had no questions.  Patient expressed "blank verbatim" and stated blank.  He/She did agree to blank and to follow-up in blank.|option B|option C"]