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Last Modified 1/6/2009
General
Psychiatry Evaluation Medical
Note Template
The general
psychiatry evaluation MedicalTemplate
is suitable for any health care
provider that manages patients with known or suspected psychiatric
disorders such as depression and bipolar disorder. This
MedicalTemplate includes all the required elements for the high
complexity E&M documentation, tailored for the needs of mental
health professionals.
Psychiatry
Evaluation Prototype Date Start time Stop time Patient Name Chief
complaint/Reason for consult Patient DOB Referring MD MRN Substance Use
History ‰Never Smoker ‰Tobacco ____ # Packs X ____ # Yrs ‰ Quit
‰Patient is unwilling to quit ‰Patient willing to consider quitting
‰Patient quit, but resumed smoking ‰Patient willing to quit within 1
month Patient has tried History of Present Illness ‰Patient is
Nonverbal. History obtained from ‰ Family ‰ Medical records ‰Nicotine
replacement ‰Buproprion or nortriptyline ‰Nicotine receptor blockade
Drinks per ‰day ‰week Hazardous drinking NIAAA (National Institute on
Alcoholism and Alcohol Abuse guidelines) ‰Alcohol use Daily, occasional
and ex-smokers are more likely to be hazardous drinkers Men > 14
drinks per week OR > 4 drinks per day Women > 7 drinks per week
OR >3 drinks per day ‰Depressed mood most of the day ‰Diminished
interest in friends, family, usual activities ‰Significant weight loss
or gain ‰Insomnia or hypersomnia ‰Psychomotor retardation or agitation
‰Fatigue ‰Feelings of worthlessness or excessive guilt ‰Decreased
concentration ‰Loss of ability to carry out daily functions ‰Suicidal
ideation ‰No plan ‰With plan ‰Homicidal ideation ‰No plan ‰With plan
Past Psychiatric History ‰Anxiety ‰Bipolar disorder ‰Mania ‰Psychosis
‰Hospitalizations for psychiatric illnesses Last hospitalization Review
of Systems ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰Inflated self esteem, or
grandiosity ‰Pressured speech ‰Flight of ideas ‰More easily
distractible ‰Increase in goal-directed activity ‰Excessive involvement
in pleasurable activities ‰Increased restlessness, or feeling keyed up
‰Hallucinations ‰New or increased substance abuse ‰Patient has the
means to carry out Suicidal Plan ‰Patient has the means to carry out
Homicidal Plan ‰Depression ‰Schizophrenia ‰History of ECT Last
treatment ‰Prior Suicide attempts Last attempt ‰Recreational drug use
‰Inhalational ‰Injectable ‰Ingestible ‰Drug dependence ‰Narcotics
‰Benzodiazepines Allergies ‰ Allergy List reviewed ‰ No drug allergies
‰ No food allergies Medications ‰Medications reviewed ‰Medications
reconciled with Nursing Home or Hospital discharge Information œ46
Changes as follows Constitutional ‰Fatigue ‰malaise ‰fever/chills
‰change in appetite Eyes ‰Vision changes ‰New pain ‰Scotomas ENT/mouth
‰Nose bleeds ‰dental caries ‰dental abscesses ‰jaw pain Resp ‰Dyspnea
‰Cough ‰Phlegm ‰Hemoptysis ‰Wheeze CV ‰Chest pain ‰diaphoresis ‰Ankle
edema ‰PND ‰syncope GI ‰Nausea ‰Weight changes ‰Constipation ‰Diarrhea
‰Abdominal pain GU ‰Change in urinary habits ‰Hematuria ‰Dysuria Musc
‰Myalgias ‰Recent trauma ‰Bony fractures ‰Arthralgias ‰Joint swelling
Skin/breasts ‰Rashes ‰Masses or skin lesions ‰Increased sensitivity to
sun Neuro ‰Seizures ‰Episodic or chronic muscle weakness ‰Headaches
Endo ‰Hair loss ‰Polydipsia Heme/lymph ‰Bleeding gums ‰Unusual bruising
‰swollen lymph nodes Allergy/Immun ‰Sinus probs ‰Recurrent infections
Psych See HPI Surgical History ‰ Malignancy ‰ Neuromuscular weakness ‰
Obstructive Sleep Apnea ‰ Renal Dysfunction ‰ Seizure Disorder ‰
Thrombotic Disease ‰ Thyroid Disease ‰ Tuberculosis Family Medical
History ‰Asthma ‰Seizure Disorder ‰CHF ‰Substance abuse ‰COPD
‰Thrombotic Disorder ‰CAD ‰Thyroid disease ‰Malignancy ‰Thalassemia
‰Anxiety Disorder ‰Bipolar Disorder ‰Major Depressive Disorder
‰Schizophrenia Past Medical ‰ Asthma ‰ Cerebral Artery Disease ‰
Congestive Heart Failure ‰ COPD ‰ Coronary Artery Disease ‰ Diabetes ‰
Hepatic Dysfunction ‰ HIV or AIDS ‰ Hypertension İMB and RR 2006-2008
Revised 20Feb08 e-medtools.com Psychiatry Evaluation Prototype Patient
Assets Patient Name Social History Family of origin Current
Family/Support Nutrition Exercise Abuse History School Work Hobbies
Spiritual History Patient DOB MRN Physical Exam and Mental Status
General Eye ENT Neck Resp CV GI Lymph Musc Skin Neuro Psych ✔ ‰Checked
box indicates findings are within normal limits ‰ Alert Vitals Ht Wt T
P ‰Regular ‰Irregular R ‰ Conjunctivae ‰Pupils ‰Discs ‰Pharynx
‰Dentition ‰ Nasal ‰External ears ‰ Hearing ‰ Exam ‰ Thyroid ‰ Clear to
auscultation ‰ Clear to percussion ‰Effort ‰Normal to palpation ‰
Auscultation ‰ Palpation ‰ Edema ‰Carotids ‰ Aorta ‰Femoral pulses ‰
Pedal pulses ‰Abdomen ‰No hepatosplenomegaly ‰No hernias ‰Rectum ‰
Guaiac ‰Neck ‰Axilla ‰Groin ‰Other ‰Gait ‰Strength ‰Tone ‰ Inspection ‰
Palpation ‰DTR ‰Sensation ‰Coordination Cranial Nerves ‰II ‰III+ ‰V
‰VII ‰VIII ‰IX ‰XI ‰XII ‰Associations ‰Delusions Mental Status BP mmHg
‰Speech ‰Orientation ‰Memory ‰Concentration ‰Affect ‰Language
‰Knowledge ‰Thought ‰Insight Impression Axis I Treatment Plan Axis II
Axis III Axis IV Axis V Signature cc Data Reviewed: ‰ER Notes ‰Chart
‰Nursing Notes ‰ECG İMB and RR 2006-2008 Care Coordinated with: ‰HCPOA
‰ PCP ‰Case Mgmt or SW ‰Pharmacy ‰Nursing Revised 20Feb08
e-medtools.com
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psychiatry evaluation MedicalTemplate functions like
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psychiatry evaluation MedicalTemplates can be printed and
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create a digital health record for your patients.
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psychiatry evaluation MedicalTemplates can
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