Psychiatry Progress Note: Inpatient – Covington Behavioral Health
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"]
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