Psychiatry Medical Consult

Chief Complaint

Psychiatry Consultation Report

Template

Dear Dr. [Referring Physician's Last Name], Thank you for your referral request regarding [Patient's Full Name], a patient who is currently under your care on [Unit Name/Number], [Department Name], [Facility Name]. Identification: [Patient's Full Name] is a [Patient's Age]-year-old [marital status] [gender]. [Provide details about the patient's living situation, including any pets or companions, and the date of admission.] Reason for consultation: [Provide a narrative summary of the patient's admission, including the date of admission, reason for admission, and any significant findings or diagnoses. Include details about any incidents leading to the admission, such as falls or injuries, and any concerns raised, such as elder abuse.] [Include details of any consultations or referrals made during the admission, specifying the departments involved and the purpose of the consultation. Mention any diagnoses or conditions identified during these consultations, such as pseudoseizures or functional neurological disorders.] Informants: [Describe the sources of information used for the consultation, such as team rounds, interviews with the patient, and chart reviews.] Relevant medical/psychiatric history: [Provide a narrative detailing the circumstances of the patient's hospital admission, including any incidents leading to the admission and living arrangements prior to admission. Include any relevant social or environmental factors impacting the patient's health.] Past Medical History: [For each diagnosis, provide the following details in a bulleted list format, maintaining the original order of diagnoses. Each bullet should include the diagnosis and associated details as specified.: Diagnosis name Date of diagnosis (if available) Relevant details or notes associated with the diagnosis, such as test results, treatment plans, or follow-up actions. Any associated symptoms or conditions linked to the diagnosis. Organize the section in a bulleted list format, maintaining the original order of diagnoses. Each bullet should include the diagnosis and associated details as specified.] [For each medication, provide the following details in a bullet list format: Medication name and strength Dosage instructions including the amount and frequency Duration of the prescription Any discrepancies in administration noted by the patient Quantity provided and refill information] ... [Provide a detailed narrative of the patient's mental health history, including any previous psychiatric assessments, diagnoses, and treatments. Include specific details such as childhood mental health issues, cognitive assessments, and any noted intellectual disabilities. Mention any family psychiatric history, Include any relevant family history of psychiatric conditions or events.. Note any substance use history and current medications or lack thereof prior to the encounter. Provide a statement regarding the presence or absence of facility-administered medications prior to the encounter. Use a narrative paragraph style to maintain consistency with the input content.] Current Outpatient Medications on File Prior to Encounter [For each medication, provide the following details in a bullet list format: Medication name and strength, Dosage instructions including the amount and frequency, Duration of the prescription, Any discrepancies in administration noted by the patient, Quantity provided and refill information] Allergies: [List the patient's allergies, including the allergen and the reaction.] For example: • [Allergen 1]: [Reaction] • [Allergen 2]: [Reaction] **CLINICAL INFORMATION:** [Provide a detailed narrative of the patient's clinical background, including age, gender, dominant hand, and relevant medical history. Mention any recent admissions, symptoms, or episodes relevant to the EEG.] **MEDICATIONS:** [List all current medications, including name, dosage, route, frequency, and any special instructions or notes about the medication.] **INVESTIGATIONS:** [Summarize any relevant investigations, including EEG, imaging studies and their findings. Created a bulleted list of the results.] History of presenting illness [Provide a narrative detailing the patient's admission date and any significant personal circumstances, such as pets or living arrangements, that may impact their emotional state. Include any distress related to potential changes in living situations or care arrangements.] [Describe the patient's mental health struggles, including specific phobias, depression, anxiety, and any recent changes in mood, energy, appetite, or concentration. Highlight any stressors related to their current living situation, such as roommates or homelessness, and any additional concerns about personal belongings or pets.] [Outline the circumstances leading to the patient's current presentation, emphasizing any traumatic experiences or physical limitations. Include details about any challenges faced during emergency medical services (EMS) intervention.] [Summarize the patient's current hospital experience, noting any difficulties with room arrangements, feelings of loneliness or isolation, and lack of external support. Address any feelings of guilt or thoughts of death, ensuring to note any passive death wishes or denial of suicidal intent.] Relevant personal history [Provide a detailed narrative of the patient's personal history, including birthplace, family background, and any significant events or experiences. Include details about any history of abuse, family dynamics, education, and significant life changes or moves. Mention any marriages, children, and current family concerns. Note any financial or social vulnerabilities and significant past experiences that have impacted the patient's life. Use a narrative paragraph style to maintain the flow of the personal history.] Mental status examination [Interview Setting: Describe the setting and manner in which the patient was interviewed, including any notable observations about their appearance and demeanor.] [Appearance: Provide a detailed description of the patient's physical appearance, including age, build, and any distinctive features.] [Perception: Note any hallucinations or perceptual disturbances reported or observed.] [Thought Process: Describe the patient's thought process, including coherence, linearity, and any noted disturbances.] [Hearing: Mention any hearing difficulties observed or reported by the patient.] [Eye Contact and Rapport: Comment on the patient's ability to maintain eye contact and establish rapport during the interview.] [Psychomotor Activity: Note any psychomotor activity or lack thereof.] [Mood and Affect: Describe the patient's mood as self-reported and observed, including any discrepancies between the two.] [Thought Content: Detail any specific thoughts or feelings expressed by the patient, such as feelings of helplessness or discouragement.] [Suicidal Ideation: Note any denial or admission of suicidal thoughts or feelings of hopelessness.] [Insight and Judgment: Assess the patient's level of insight and judgment based on their responses and behavior during the interview.] Impression and recommendations [For each problem, provide numbered list of diagnosis, add any relevant history, and any associated factors or conditions if applicable. Use a numeric list format to maintain clarity and organization. Ensure each problem is clearly delineated and described in a concise manner.] [Provide a narrative paragraph detailing the patient's background, including personal history, trauma history, current living situation, and any recent events leading to the current hospital admission. Include information about the patient's mental health struggles, any recent medical findings, and the impact of these issues on the patient's current mental and emotional state. Discuss any noted concerns about abuse and the patient's response to these stressors, including any documented symptoms such as pseudoseizures.] After meeting with the patient, we discussed the following: [discuss the suggested interventions in a numeric list format:] [Outline the discussion about ongoing counseling, including the type of counseling and the patient's response to continuing with this support.] [Detail any medication changes, including the reasons for the change, the specific medications involved, dosages, and the patient's response to these suggestions.] [Conclude with the patient's overall response to the interventions and any follow-up plans, including which team will monitor the patient and how to contact them for acute issues.]