INITIAL PSYCHIATRY CONSULTATION SERVICE NOTE

We were asked to see this patient by _ from the _ service to address the question of/
The request for consultation is documented by Dr._ in note dated_

Chief Concern: _

HPI/Symptoms: _

Past Psych Hx:

Inpatient:
Outpatient:
Medication Trials:
Suicide Attempts:
Drug/Etoh:
History of Violence:

Social History:
Housing:
Relationships:
Education:
Financial:
Legal Problems:

Family History: _

Medical History: _

Allergies: _

ROS:
Constitutional: _ Gastrointestinal: _
Cardiovascular: _ Genitourinary: _
Respiratory: _ Ears/Mouth/Nose/Throat: _
Endocrine: _ Heme/Lymph: _
Neurological: _ Integumentary: _
Eyes: _ Allergy/Immunologic: _
Musculoskeletal: _ [_] Unless otherwise indicated, blank items are all negative

Current Medications _

Outpatient Medications _

Mental Status Examination

Appearance:
Behavior/Activity:
Speech:
Thought Form:
Thought Content:
Mood:
Affect:
Suicidal Ideation:
Homicidal Ideation:
Orientation:
Memory:
Judgment/Insight:
Attention/Concentration:
Other:

Vital Signs:_

Lab Findings: _

Assessment/Medical Decision Making (number of possible diagnoses considered) note problems,

management options, dangerousness/risks including risk factors.
Formulation: _
Differential Diagnoses: _
Axis I: (Major Diagnoses) _
Axis II: (Personality Diagnosis) _
Axis III: (Relevant Medical Conditions) _
Axis IV: (Psychosocial Stressors) _
Axis V: (Global Assessment of Function Score) _

Risk Factors
[_] harm to self/others [_] suicidal ideation/plan [_] homicidal ideation [_] grave disability
[_] substance [_] co-morbid medical [_] delirium/cognitive [_] pain
abuse/withdrawal conditions impairment
[_] impulsivity [_] psychosis [_] anxiety [_] other

Treatment Recommendations & Plan (management options considered) _

For Involuntary Patients:

[ ] Case and treatment plan discussed with:
[ ] ER Nursing
[ ] ER MD
[ ] ER Social Work
[ ] Psychiatry Nursing
[ ] Primary Medical Team
[ ] Primary Medical Team Social Work
[ ] Primary Medical Team Nursing

[ ] I have observed and evaluated this patient and have determined that he/she cannot be released from
involuntary treatment to accept treatment on a voluntary basis.

[ ] Patient will be converted to voluntary legal status