Dr. Fahed - H&P Consult Note

Chief Complaint

H&P Consult Note

Template

H&P Consult Note Patient Name: [Patient Name] Admission Date: [Admission Date] DOB: [Date of Birth] CHIEF COMPLAINT: “[Patient’s own words]” PRESENT ILLNESS: [Patient Name] is a [Age] [Identified Gender] who lives in [Dwelling Type] with past history of [Psychiatric then Medical Diagnoses] who presents today via [Ambulance/Telepsychiatry/Car] for [Symptoms on Presentation]. [Write a narrative that features: - Chronological progression of symptoms including onset, duration, and trajectory - Note any triggers or precipitating factors - Document specific symptoms with examples - Include frequency and severity of symptoms - Note impact on functioning (work, relationships, ADLs) - Include any current or recent treatment/medications - Document any recent hospitalizations or ED visits - Note any history of self-harm or suicide attempts] Psychiatric Review of Systems Safety: Endorses: [Reported Symptoms] Denies: [Pertinent Negatives] Depression: Endorses: [Reported Symptoms] Denies: [All other symptoms of this diagnosis that were not reported] Mania: Endorses: [Reported Symptoms] Denies: [All other symptoms of this diagnosis that were not reported] Psychosis: Endorses: [Reported Symptoms] Denies: [All other symptoms of this diagnosis that were not reported] Anxiety/Panic: Endorses: [Reported Symptoms] Denies: [All other symptoms of this diagnosis that were not reported] Trauma: Endorses: [Reported Symptoms] Denies: [All other symptoms of this diagnosis that were not reported] OCD: Endorses: [Reported Symptoms] Denies: [All other symptoms of this diagnosis that were not reported] PSYCHIATRIC HISTORY: Previous diagnoses: Per patient: [Patient's Reported Diagnoses] Per chart: [Chart Diagnoses] Safety: Suicide attempts: [Denies/Reports] Self-injurious behaviors: [Denies/Reports] Violent behaviors: [Denies/Reports] Prior outpatient psychiatric care: [Provider] Current outpatient psychiatric care: [Provider] PCP: [Primary Care Provider] IOP: [Denies/Reports] Prior inpatient psychiatric care: Admissions: [Denies/Reports] Treatment trials: Medication: [Denies/Reports] ECT: [Denies/Reports] SUBSTANCE USE HISTORY: Alcohol: [Denies/Reports] Cannabis: [Denies/Reports] Stimulants: [Denies/Reports] Sedatives: [Denies/Reports] Opioids/Opiates: [Denies/Reports] Hallucinogens: [Denies/Reports] Tobacco: [Denies/Reports] Caffeine: [Denies/Reports] Detox/Rehab: [Denies/Reports] Withdrawal: [Denies/Reports] Dual-diagnosis IOP: [Denies/Reports] Substance use last 12 months: [Denies/Reports] PSYCHOSOCIAL HISTORY: Spouse: [Denies/Reports] Children: [Denies/Reports] Occupation: [Denies/Reports] Education: [Denies/Reports] Spirituality: [Denies/Reports] Legal History: [Denies/Reports] FAMILY PSYCHIATRIC HISTORY Psychiatric: [Denies/Reports] Suicide attempts: [Denies/Reports] Self-harm behaviors: [Denies/Reports] Violence history: [Denies/Reports] Outpatient: [Denies/Reports] Inpatient: [Denies/Reports] Medication trials: [Denies/Reports] Substance use: [Denies/Reports] Detox/Rehab: [Denies/Reports] MEDICAL HISTORY: [Document relevant medical history] ALLERGIES: [List allergies] CURRENT MEDICATIONS: [List current medications] OBJECTIVE FINDINGS Labs: [Review the patient's lab results from the last 24 hours. If there are no new labs, state "No new labs." Include any relevant lab results or findings.] Diagnostic: [Review the patient's radiology reports from the last 24 hours. If there are no new radiology findings, state "No new radiology."] Physical Exam: Constitutional: [Describe the patient's general appearance, nutritional status, and any signs of distress.] Head: [Note the condition of the head, including any abnormalities or trauma.] Eyes: [Include details about extraocular movements and any discharge.] Neck: [Describe the range of motion and any abnormalities.] Pulmonary/Chest: [Note any signs of respiratory distress.] Neurological: [Describe any focal deficits and the patient's orientation.] Skin: [Note any abnormalities such as diaphoresis.] Mental Status Examination Version 1: Comprehensive MSE with All Options Appearance: [Select from: Well-groomed, adequately groomed, disheveled, malodorous, unusual dress, appears stated age, appears younger/older than stated age, obese, thin, cachectic, physical disabilities noted, distinguishing features] Behavior and Reliability: [Select from: Cooperative, uncooperative, hostile, guarded, defensive, dramatic, withdrawn, agitated, restless, psychomotor retardation/agitation, catatonic features, reliable historian, poor historian, inconsistent historian] Speech: [Select from: Normal rate/volume/tone, pressured, loud, soft, mumbled, slurred, monotone, stilted, tangential, circumstantial, paucity, mute] Mood: ["Quote patient's subjective report"] Affect: [Select from: Euthymic, depressed, anxious, irritable, angry, euphoric, labile, full range, restricted, blunted, flat, congruent/incongruent with mood, appropriate, inappropriate, labile] Thought Process: [Select from: Logical, goal-directed, circumstantial, tangential, flight of ideas, loose associations, word salad, blocking, perseveration, concrete, abstract] Thought Content: [Select from: No SI/HI/delusions/paranoia, suicidal ideation (passive/active, with/without plan/intent), homicidal ideation (passive/active, with/without plan/intent), delusions (persecutory/grandiose/somatic/reference/control), paranoia, obsessions, phobias, ideas of reference] Insight: [Select from: Good/fair/poor/absent, aware of illness/situation, understands need for treatment] Judgment: [Select from: Good/fair/poor/impaired, able to make reasonable decisions, understands consequences of actions] Memory: [Select from: Recent and remote intact, recent impaired, remote impaired, immediate recall impaired, confabulation present] Attention and Concentration: [Select from: Maintained throughout interview, easily distracted, poor concentration, unable to focus] Language: [Select from: Fluent, no aphasia, word-finding difficulty, paraphasia, neologisms, echolalia] Fund of Knowledge: [Select from: Intact, impaired, current events knowledge, cultural knowledge, educational level appropriate] Version 2: Standard Normal MSE Template Mental Status Examination: [Appearance: Describe grooming, age appearance, and appropriateness of dress.] [Behavior and Reliability: Note cooperation level and reliability as a historian.] [Speech: Comment on rate, volume, and tone.] [Mood: Summarize patient's self-reported mood.] [Affect: Describe range, appropriateness, and congruence with mood.] [Thought Process: Assess logic and goal-directedness.] [Thought Content: Note presence or absence of suicidal/homicidal ideation, delusions, hallucinations, or paranoia.] [Insight: Evaluate awareness of situation.] [Judgment: Assess ability to make reasonable decisions.] [Memory: Evaluate recent and remote memory.] [Attention and Concentration: Assess maintenance throughout the interview.] [Language: Comment on fluency and presence of aphasia or word-finding difficulty.] [Fund of Knowledge: Assess appropriateness for age and education.] INFORMED CONSENT Patient is able to provide informed consent: [yes_or_no] Is the patient safe to remain at current level of care [yes_or_no] Does the patient have a conservator? [yes_or_no] Suicide Risk Assessment: Risk Factors: Psychiatric Disorder(s): Axis I and Axis II: [Past and current disorders] Key Clinical Considerations: [E.g. Intense psychological pain/anguish, agitation, anxiety/panic, physical pain, anhedonia, impulsivity, hopelessness, command hallucinations, worthlessness, intense self‐loathing, excessive guilt, feeling that death would bring relief, executive functioning deficits, relationship difficulties, status of important connections] Suicidal Behavior: [History of prior attempts, self‐injurious behaviors, attempts in hospital, writing/talking/ruminating about death] Family History Psychopathology: [History of suicidality and major mental illness, abuse and neglect] Precipitants/Stressors: [Triggering events, e.g. loss of or threat of loss of relationship, recent deaths, medical illness, public/social humiliation, exposure to trauma, legal or financial difficulties] Access to Firearms/Other Lethal Means: [Current] Protective Factors Internal: [E.g. Ability to cope with stress, religious beliefs, frustration tolerance, a sense of hope] External: [E.g. Responsibility to children/pets, social supports‐specifically positive connections, therapeutic relationships] Suicide Inquiry Ideation: [E.g. Frequency, intensity, duration – recent, worst ever] Plan: [E.g. Timing, location, lethality, availability, preparation] Behavior: [E.g. Past attempts, aborted attempts, rehearsals (tying noose, loading gun), suicide notes, obtaining lethal implements/equipment, stockpiling medication, researching suicide methods on internet] Intent: [E.g. Extent to which patient believes plan is lethal (Note: Young children may believe death is reversible), expects to carry out plan/wishes to die, regrets survival] Collateral: Risk Level: to self: [With the information available to us at this time, the patient is deemed to be at low/moderate/high imminent risk of harm to self, while chronic risk is assessed to be low/elevated.] Comprehensive Suicide Risk Assessment Historical Risk Factors [ ] Past suicide attempts [ ] Violent or serious past attempts [ ] Age (teens or > 45) [ ] Male gender [ ] Past psychiatric hospitalization (especially within 3-6 months post-discharge) [ ] Employment status: Unemployed [ ] Relationship status: Single, widowed, or divorced [ ] Living situation: Living alone [ ] Family history of suicide [ ] History of childhood physical or sexual abuse [ ] Prior non-suicidal self-injury [ ] Education level: High school or less [ ] ED visit within last 6 months Current Clinical Presentation Psychiatric Status [ ] Current psychiatric diagnoses (Axis I and II): _______ [ ] Past psychiatric diagnoses: _______ [ ] Depression [ ] Psychosis [ ] Command hallucinations [ ] Substance use/abuse [ ] Current alcohol misuse [ ] Panic attacks [ ] Chronic physical illness Psychological State [ ] Suicidal ideation (syntonic vs. dystonic) [ ] Frequency: _______ [ ] Intensity: _______ [ ] Duration (recent/worst ever): _______ [ ] Impaired concentration/decision-making [ ] Pervasive hopelessness/pessimism [ ] Constricted thinking (black/white, tunnel vision, catastrophizing) [ ] Irritability/agitation [ ] Impulsivity [ ] Severe anxiety and rumination [ ] Global insomnia [ ] Intense psychological pain/anguish [ ] Anhedonia [ ] Worthlessness/intense self-loathing [ ] Excessive guilt [ ] Feeling death would bring relief [ ] Executive functioning deficits Current Suicidal Planning [ ] Specific plan present: Timing: _______, Location: _______, Lethality: _______ [ ] Access to means (specify): _______ [ ] Preparation/rehearsal behaviors [ ] Suicide notes [ ] Acts of anticipation (wills, giving away possessions) [ ] Intent to act on plan [ ] Expects to carry out plan [ ] Research of suicide methods [ ] Regrets previous survival Precipitating Factors [ ] Recent life crisis [ ] Loss/threat of loss of relationship [ ] Recent deaths [ ] Medical illness [ ] Public/social humiliation [ ] Trauma exposure [ ] Legal difficulties [ ] Financial difficulties [ ] Relationship difficulties Protective Factors Internal [ ] Religious/spiritual prohibition [ ] Fear of social disapproval [ ] Future-oriented thinking [ ] Hopefulness [ ] Ability to cope with stress [ ] Good frustration tolerance External [ ] Good social support system [ ] Stable, supportive marriage [ ] Responsibility for children under 18 [ ] Responsibility to pets [ ] Willingness to accept help/treatment [ ] Good therapeutic alliance [ ] Female gender [ ] Employed [ ] Absence of suicidal ideation/intent [ ] Low symptom severity Collateral Information Source(s): _______ Information obtained: _______ Risk Assessment Current risk to self is assessed to be: [ ] Low [ ] Moderate [ ] Elevated Chronic risk is assessed to be: [ ] Low [ ] Elevated Risk Mitigation The following steps have been taken to address dynamic and clinical risk factors: [[Outline the steps taken to address dynamic and clinical risk factors. Use a numeric list format to detail each step. Include considerations for historical risk factors in the overall risk assessment.] Note: Historical risk factors cannot be mitigated but have been considered in overall risk assessment. Patient's risk factors for harm to others include: demographic factors including [Demographic Factors]; cognitive factors including [Cognitive Factors]; personality traits including [Personality Traits]; criminal history including [Criminal History]; social factors including [Social Factors]; psychiatric history including [Psychiatric History]; situational factors including [Situational Factors]. Protective Factors Patient's protective factors against harm to self/others include [Protective Factors]. Safety Assessment [Provide a detailed narrative on the patient's risk factors for suicide, distinguishing between chronic and modifiable factors. Include information on current treatments addressing modifiable risk factors and any new stressors. Assess the patient's current risk level compared to their baseline and determine the necessity of inpatient admission versus alternative settings. Discuss the effectiveness of previous inpatient psychiatric hospitalizations and evaluate whether the patient's most distressing issues would be impacted by such admissions.] DIAGNOSIS: [List all diagnoses that need to be ruled out. Use a bulleted list format to clearly delineate each diagnosis that is under consideration for exclusion.] IMPRESSION & TREATMENT PLAN: The patient is a [Age] year old [Gender] with past psychiatric history of [Psychiatric History] and past medical history of [Medical History] who presents to the ED via [Mode of Arrival] reporting [Symptoms], for which psychiatry was consulted. On interview, patient reports [Patient's Report]. Past psychiatric history is notable for [Psychiatric History]. Past medical history is notable for [Medical History]. Substance use history is notable for [Substance Use History]. Social history is notable for [Social History]. Family history is notable for [Family History]. Physical exam notable for [Physical Exam Findings]. Mental status exam reveals [MSE Findings]. Vital signs [Vital Signs]. Labs notable for [Lab Findings]. Imaging notable for [Imaging Findings]. Patient's current presentation appears to be consistent with [Diagnosis] driven by [Factors] attributable to [Factors] in the setting of [Context]. Other differentials include [Differential Diagnoses]. [Common phrases: Characterological deficits, help-seeking help-rejecting behavior, cannot rule out secondary gain, affective instability due to prior life circumstances, emotional dysregulation, underdeveloped coping skills, Future-focused, help-seeking, self-preserving behaviors/sentiments, ego-dystonic, participated in safety planning, Least restrictive, Psychiatric condition impairs ability to adequately assess risk] [If discharge from ED to outpatient: Based on the clinical presentation and risk assessment, the patient does not appear to be at acutely elevated risk of harm to self or others due to psychiatric condition, and does not appear to be gravely disabled. The patient's psychiatric needs would be better served in other, less restrictive settings. Thus, PEC and psychiatric admission are not warranted at this time.] [If admission on involuntary: Based on the clinical presentation and risk assessment, the patient appears to be at acutely elevated risk of harm to self due to psychiatric illness. The patient would likely benefit from inpatient psychiatric admission for safety assurance and medication management. Thus, PEC was signed for inpatient psychiatric admission.] RECOMMENDATIONS: [If ED, provide a detailed assessment of the patient's need for psychiatric admission. Include reasons for or against admission, and specify if the patient's needs could be more appropriately addressed in an outpatient or community setting.] Recommend follow up with established [Provider] Referral has been made for [Referral] Continue home medications, including [Medications] Offered [Intervention] which the patient [declined/accepted] [Specify the type of admission, e.g., voluntary or involuntary, and any specific admission codes or criteria used.] [Indicate the current status of the patient, such as boarding in the ED, and any pending actions like awaiting bed availability.] [Outline the frequency and type of observations or checks required while the patient is in the ED and once transferred to the unit.] [Confirm that all recommendations and plans have been communicated to the relevant medical team, specifying the team if necessary.] ** RISK MITIGATION: Although we are unable to mitigate historical risk factors, extensive safety planning was undertaken to mitigate dynamic and clinical risk factors, including: [Include specific strategies, interventions, or actions implemented. ] If outpatient: Plan: Safety Planning [Address any immediate safety concerns, document suicide risk assessment conclusion] [List specific safety measures implemented] [include crisis plan and emergency contacts] [document lethal means counseling if done] [note family/support system involvement] Diagnosis [List primary psychiatric diagnosis with code] [Include relevant secondary diagnoses] [Document rule-out diagnoses to consider] [Note if any diagnoses are provisional] [Include relevant medical diagnoses] Medication Plan [List new medications prescribed, including the rationale for each medication] [Specify the starting dose and provide a detailed titration schedule for each new medication] [Identify the target symptoms that each medication aims to address] [Discuss potential side effects for each medication, ensuring the patient is informed] [Detail the continuation of current medications, including any adjustments if necessary] [List medications to be discontinued or tapered, including the rationale for these changes] [Note any pharmacy preferences, such as specific pharmacies to use or avoid] [Outline required monitoring, including necessary labs and vital signs to be checked] Therapy/Counseling [Type of therapy recommended] [frequency of sessions] [specific therapeutic goals] [referrals to specific providers/programs] [group therapy recommendations] [family therapy if indicated] Substance Use Treatment (if applicable) [Level of care recommended] [specific program referrals] [medication-assisted treatment options] [recovery support recommendations] [drug screening protocol] Additional Referrals [Specialist consultations needed] [psychological testing if indicated] [support group recommendations] [case management needs] [social work services] Medical Monitoring [Baseline labs/tests ordered] [follow-up labs needed] [medical clearance requirements] [primary care coordination] [vital sign monitoring needs.] Lifestyle Modifications [Sleep hygiene recommendations] [exercise recommendations] [dietary modifications [stress management strategies] [substance use restrictions] Follow-up Planning [Next appointment timing] [frequency of follow-up] [criteria for earlier return] [between-visit communication plan] [coordination with other providers] [Format Instructions: List each intervention with clear rationale, include specific timeframes for follow-up, note who is responsible for each action item, document patient agreement/concerns, include contingency plans, specify any barriers to implementation, note education provided to patient/family.] [For urgent issues: Bold any time-sensitive items, list specific steps for addressing urgent concerns, include timeframes for completion, document responsible parties, note verification/follow-up plans.] [For missing elements: Note "to be addressed at follow-up" rather than omitting, document what information is needed to complete plan, include interim recommendations.] [Conclusion: Summarize key interventions, list critical follow-up items, document patient's understanding and agreement, note any remaining concerns to address.] Parts of this note were dictated utilizing voice recognition software. Occasional wrong-word or sound-alike errors may have occurred.