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  • Psychiatric Admission Evaluation

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    fernlover3901
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    This psychiatric admission evaluation contains information about a patient including their chief complaint, history of present illness, past psychiatric and medical history, substance abuse history, family history, mental status exam, diagnoses, and treatment plan. The patient, who is seeking admission, reports [CHIEF COMPLAINT] and has a history of [RELEVANT MEDICAL/PSYCHIATRIC HISTORY]. Their mental status exam and diagnoses are documented. The treatment plan is for the patient to attend a partial hospitalization/intensive outpatient program with therapy and medication management.

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    Admission evaluation

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    This psychiatric admission evaluation contains information about a patient including their chief complaint, history of present illness, past psychiatric and medical history, substance abuse history, family history, mental status exam, diagnoses, and treatment plan. The patient, who is seeking admission, reports [CHIEF COMPLAINT] and has a history of [RELEVANT MEDICAL/PSYCHIATRIC HISTORY]. Their mental status exam and diagnoses are documented. The treatment plan is for the patient to attend a partial hospitalization/intensive outpatient program with therapy and medication management.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    104 views5 pages

    Psychiatric Admission Evaluation

    Uploaded by

    fernlover3901
    This psychiatric admission evaluation contains information about a patient including their chief complaint, history of present illness, past psychiatric and medical history, substance abuse history, family history, mental status exam, diagnoses, and treatment plan. The patient, who is seeking admission, reports [CHIEF COMPLAINT] and has a history of [RELEVANT MEDICAL/PSYCHIATRIC HISTORY]. Their mental status exam and diagnoses are documented. The treatment plan is for the patient to attend a partial hospitalization/intensive outpatient program with therapy and medication management.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    of 5

    PSYCHIATRIC ADMISSION EVALUATION

    Patient Name:
    MRN:
    Date of Birth:
    Admission Date:
    Date of Service:

    CLINIC LOCATION: Okaloosa Outpatient Center


    REFFERAL SOURCE:
    ______________________________________________________________________________
    ______________________________________________________________________________
    IDENTIFYING DATA: Patient is an ___________ year old _____________ male/female.
    Include family data.
    CHIEF COMPLAINT: "_________________________________________."
    HISTORY OF PRESENT ILLNESS:
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    CURRENT SCORING TOOLS (PHQ-9, MAST, DAST. ETC.)
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    PAST PSYCHIATRIC HISTORY:
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________

    PAST MEDICATION TRIALS:


    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________

    PAST MEDICAL HISTORY:


    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    PAST PSYCHOSOCIAL HISTORY:
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________

    SUBSTANCE ABUSE HISTORY: (Tobacco/Caffiene/Alcohol/RX/Illegal)


    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    FAMILY HISTORY OF PSYCHIATRIC ILLNESS:
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    LEGAL ISSUES:
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    MENTAL STATUS EXAM: Patient is a color male/female.
    Grooming:_______________
    Hygiene: _________________
    Appearance: _________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    Cognition (A+O x person, place, time)______________________________________________
    Affect:________________________________________________________________________
    Speech:_______________________________________________________________________
    Eye Contact:___________________________________________________________________
    Mood:________________________________________________________________________
    Thought Process:________________________________________________________________
    Suicidal/Homicidal
    Thoughts:_____________________________________________________________________
    ______________________________________________________________________________
    Paranoia/Perceptual
    disturbances:___________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    Insight/Judgement: (note how this was tested):
    ______________________________________________________________________________
    ______________________________________________________________________________
    Recent/Remote Memory (How was it tested):
    ______________________________________________________________________________
    ______________________________________________________________________________
    ADL
    Status:________________________________________________________________________
    ______________________________________________________________________________
    Psychomotor activity/Abnormal
    movements:____________________________________________________________________
    ______________________________________________________________________________
    Sleep:_________________________________________________________________________
    ______________________________________________________________________________
    Energy Levels: _________________________________________________________________
    Appetite/Weight:________________________________________________________________

    STRENGTHS:
    1. Good family and social support.
    2. Access to healthcare.

    WEAKNESSES:
    1. Limited insight.
    2. Poor coping skills.
    DIAGNOSES:
    Psychiatric:
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    Medical:______________________________________________________________________
    ______________________________________________________________________________
    Psychosocial/Context:
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________

    PLAN:
    1. Admit to PHP/IOP_________(track) and begin therapy per protocol ____ days/week
    ______ hours/day. Therapies may include but are not limited to CBT, DBT, Process, and
    Psychoeducational.
    2. Medication:_____________________________________________________________.
    Patient has been educated on this risks and benefits associated with the use of these
    medications and has acknowledged this education.
    3. Labs/Studies/Records:______________________________________________________
    4. Safety Plan: Patient has been educated on the need to report any new or worsening
    symptoms which are medication and/or diagnosis related. Patient has also been educated
    on the following resources: the suicide prevention hotline 1-800-273-talk, 911 for
    emergency services, and to report to the nearest ER for emergency services.
    5. The following changes need to occur in order for the patient to function in a less
    restrictive setting:
    a. Attitude: Maintain a positive attitude toward treatment
    b. Behaviors: (avoid cutting, outbursts, etc.)
    c. Treatment plan goals to be met: (What goals does the patient want to meet?).

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