Patient Name: X Patient DOB: X
Admission Date: X Room: X
Evaluating Provider: X
Psychiatric Evaluation
Identifying The patient is a X-year-old EMPLOYMENT MARITAL
Information:
RACE/ETHNICITY GENDER , without children, living alone, who
presented to the Emergency Room in acute distress. Patient was admitted voluntarily.
Chief Complaint: NARRATIVE
History of Present Pertinent history in record: X
Illness:
During assessment: Patient describes their mood as X and indicated it has gotten
worse in TIME.
Patient self-esteem appears fair, no reported feelings of excessive guilt,
no reported anhedonia, does not report sleep disturbance, does not report change in
appetite, does not report libido disturbances, does not report change in energy,
no reported changes in concentration or memory.
Patient does not report increased activity, agitation, risk-taking behaviors, pressured
speech, or euphoria. Patient does not report excessive fears, worries or panic attacks.
Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s
activity level, attention and concentration were observed to be within normal limits.
Patient does not report symptoms of eating disorder. There is no recent weight
loss or gain. Patient does not report symptoms of a characterological nature.
Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation,
denies violent behavior, denies inappropriate/illegal behaviors.
Past Psychiatric Previous psychiatric diagnoses: none reported.
History: Describes stable course of illness.
Previous medication trials: none reported.
Safety concerns:
History of Violence to Self: none reported
History of Violence to Others: none reported
Mental health treatment history discussed:
History of outpatient treatment: not reported
Previous psychiatric hospitalizations: not reported
Prior substance abuse treatment: not reported
Trauma history: Client does not report history of trauma including abuse, domestic
violence, witnessing disturbing events.
Substance Use: Client denies use or dependence on nicotine/tobacco products.
Client does not report abuse of or dependence on ETOH, and other illicit drugs.
Past Medical History: Medical history: Denies cardiac, respiratory, endocrine and neurological issues,
including history head injury.
Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.
Surgical history no surgical history reported
Medications: No current medications.
Allergies: NKDFA.
Family Psychiatric No reported knowledge of family history of psychiatric issues -
History: No reported knowledge of family history of substance use issues -
Psychosocial History: Occupational History: currently unemployed. Denies military service.
Education history: not reported.
Developmental History: no significant details reported.
Legal History: no reported/known of legal issues, no reported/known conservator or
guardian.
Spiritual/Cultural Considerations: none reported.
Review of Systems: Vital Signs: Stable
Psychiatric. Admits to X as per HPI.
Constitutional: No report of fever or weight loss. Eyes: No report of acute vision
changes or eye pain. ENT: No report of hearing changes or difficulty swallowing.
Cardiac: No report of chest pain, edema or orthopnea. Respiratory: Denies dyspnea,
cough or wheeze. GI: No report of abdominal pain. GU: No report of dysuria or
hematuria. Musculoskeletal: No report of joint pain or swelling. Skin: No report of
rash, lesion, abrasions. Neurologic: No report of seizures, blackout, numbness or
focal weakness. Endocrine: No report of polyuria or polydipsia. Hematologic: No
report of blood clots or easy bleeding. Allergy: No report of hives or allergic
reaction. Reproductive: No report of significant issues.
Laboratory: Lab findings WNL; Tox screen: Negative; Alcohol: Negative, HCG: N/A
Mental Status Patient is cooperative and conversant, appears without acute distress, and fully
Examination: oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity
appears within normal.
Presents with appropriate eye contact, euthymic affect - full ,
even , congruent with reported mood of “x”. Speech: spontaneous ,
normal rate, appropriate volume/tone with
no problems expressing self .
TC: no abnormal content elicited, denies suicidal ideation and denies
homicidal ideation. Process appears linear , coherent ,
goal-directed .
Cognition appears grossly intact with appropriate attention span
& concentration and average fund of knowledge.
Judgment appears fair . Insight appears fair
Strengths/Limitations The patient is able to articulate needs, is motivated for compliance and adherence to
: medication regimen. Patient is willing and able to participate with treatment,
disposition, and discharge planning.
Assessment & Dx: -
Diagnoses: Dx: -
Dx: -
Informed Consent: Patient has the ability/capacity appears to respond to psychiatric
medications and appears to understand the need for medications and
is willing to maintain adherent.
Reviewed potential risks & benefits, Black Box warnings, and alternatives including
declining treatment.
Expected Length of Estimated 3-5 days
Stay:
Impression & Patient is found to be stable and has control of
Recommendations:
behavior. Patient likely poses a minimal risk to self and a minimal risk to
others at this time.
Patient denies abnormal perceptions and does not appear to be responding to
internal stimuli.
1. Safety Risk: Admit to IPLOC for safety and stabilization of symptoms.
2. DX: No changes to current medication, as listed in chart, at this time
3. Health & Wellness: Discussed current tobacco use. NRT not indicated.
4. Follow-up: Patient deferred to designated care team as needed
☒ > 50% time spent
counseling/coordination of ____________________________________________
care. NAME, TITLE
Visit lasted 55 minutes
Date: Time: X
