Psychiatry
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Clinical Site: Covington Behavioral Health

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."]
• Type of Exam: Inpatient Psychiatric Progress Note
• Length of Service: [text] minutes

- INTERVAL HISTORY -

Chief Complaint:[text]

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

Allergies: [text]

Current Medications:
• [text]
• [text]
• [text]
• [text]
• [text]
• [text]
• [text]

Mental Status Exam:
• General Appearance: [text]
• Psychomotor Behavior: [text]
• Speech: [text]
• Attitude: [text]
• Mood: [text]
• Affect: [text]
• Orientation: [text]
• Thought Content/Perception: [text]
• Risk Factors: [text]
• Thought Processes: [text]
• Concentration/Attention: [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
• Insight: [text] How Tested/Assessed: Understanding severity of illness/history of present illness


Diagnosis/Impression:
• [text]
• [text]
• [text]

Plan and Medication Changes/Indications:
• Continue group/milieu/individual therapy
• Continue with discharge planning
• Medication changes:[text]

Lab Studies, other data: [text]

Response to Treatment:
[checkbox name="variable_1" value="Not achieving treatment goals|Has achieved treatment goals, but still in process"]


Estimated Date of Discharge: [text]

Reason for Continued Hospitalization:
[checkbox name="variable_2" value="Severe impairment of level of functioning|Severe depression/anxiety|Inability to protect/care for self|Suicidal ideation|Medication stabilization|Post-acute detox symptoms|Severely impaired disorder - Thoughts perception|Danger to self or others|Discharge may exacerbate illness|Behavior requires 24 hour supervision"]
Clinical Site: Covington Behavioral Health

Service Date:

Semester: Spring 2021

Demographics
• Initials:
• Age:
• Gender:
• Race:
• Insurance:
• Type of Exam: Inpatient Psychiatric Progress Note
• Length of Service: minutes

- INTERVAL HISTORY -

Chief Complaint:

HPI:
Sleep:
Appetite:

Allergies:

Current Medications:








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


Diagnosis/Impression:




Plan and Medication Changes/Indications:
• Continue group/milieu/individual therapy
• Continue with discharge planning
• Medication changes:

Lab Studies, other data:

Response to Treatment:



Estimated Date of Discharge:

Reason for Continued Hospitalization:

Result - Copy and paste this output:

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