Psychiatric Evaluation Late May 2022

PSYCHIATRIC EVALUATION
Patient Name
Patient ID Number
Patient Unit:
DATE OF EVALUATION

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time

Hour Minutes

AM/PM Option
CPT CODE
Check if Telehealth
CHIEF COMPLAINT (Quoted, "In the patient's own words."):
HISTORY OF PRESENT ILLNESS (To include onset of illness and circumstances leading to admission.)

0/0950
PAST PSYCHIATRIC HISTORY
Past diagnoses: Past hospitalizations: Previous and current Psychiatrist: Past Therapy: Previous Medication Trials: Previous Suicide attempts: History of cutting or self-injurious behavior: History of Trauma:
DRUG / ALCOHOL ABUSE HISTORY: (To include drugs of choice, patterns of use, treatment history.)
Meth/Stimulants: Opiates: Alcohol: Nicotine/Cigarettes: Other: History of Rehab placement: History of DUI/Legal problems due to substances:
MEDICAL HISTORY (To include chronic/acute illness, current medical treatment, past surgical procedures, recent hospitalization)
ALLERGIES:
SOCIAL HISTORY: (To include educational level, vocational/occupational/employment history/status, interpersonal relations ships and supports.)
Marital Status: Employment Status: SSI/Disability: Living Situation: Children: Education Level: Current Legal Problems: Military History:
FAMILY HISTORY (To include any psychiatric or substance history within the family.)
CURRENT MEDICATIONS
CONSTITUTIONAL REVIEW:
Enter Height
Enter Weight
Enter RR
MUSCULOSKELETAL EXAMINATION (Check Items):
Abnormal/Involuntary
Strength:
Weakness:
Muscle Tone:
Gait:
MENTAL STATUS EXAMINATION (Check Items):
Station:
General Appearance:

Other
Speech / Language

Other
Attitude / Behavior:

Other
Mood

Other
Affect

Other
Orientation
Perception/ Thought Content:

Other
Hallucinations: (Pick here)
Delusions (describe)
Obsessions (describe)
Phobias (describe)
Risk Factors
Suicidal:
Describe:
Homicidal:
Describe:
Thought Processes:

Other
Concentration/ Attention Span:
WNL
How Tested/Assessed
Recent Memory:
WNL
How Tested/Assessed
Remote Memory:
WNL
How Tested/Assessed
Intelligence:
WNL
How Tested/Assessed
Judgment:
WNL
How Tested/Assessed
Insight:
WNL
How Tested/Assessed
PATIENT STRENGTHS (Check 2 or more and then give patient-specific detail, explanation, description.):
Steady employment, financial stability:
Housing stability:
Able to vocalize needs:
Values and traditions:
Motivation, readiness for change:
Setting and pursuing goals, hopes, dreams, aspirations:
Resources – social, interpersonal, monetary:
Vocational interests, hobbies and/or talents:
Interpersonal relationships and supports available – family, relatives, friends:
Cultural/spiritual/religious and community involvement:
Managing surrounding demands and opportunities:
Exercising self-direction:
Awareness of substance use issues:
Knowledge of medications:
Other (Please add any item not on the above list and elaborate checked areas.)
PATIENT LIMITATIONS (Check 1 or more)

Other
ADMITTING DIAGNOSIS
INITIAL PLAN OF CARE and Medication Consent (as applicable) Patient was provided with detailed information about 1) Proposed medications and dosage range and frequency. 2) The purpose of the treatment. 3) Common short and long term side effects of the proposed medication, including contraindications and clinically significant interactions with other medications:

0/725
ESTIMATED LENGTH OF STAY (Number of days anticipated)
INITIAL DISCHARGE PLAN

Other
Referred to therapist (specify)
PROGNOSIS
JUSTIFICATION FOR HOSPITALIZATION (Select from Inpatient or Partial Hospitalization)
Inpatient Hospitalization - Check below:

Other
Partial Hospitalization - Check below:

Other
Provider Name:
PLEASE CLICK BELOW ONCE YOU SELECT A PROVIDER NAME
Completed by Scribe?
Scribe Name:
Scribe Use Only:
Scribe Email
example@example.com
Scribe Signature (Sign your Full Name and Credentials):
Provider Signature (Sign your Full Name and Credentials):
I certify that the above note is ready for printing
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Time
  
  Hour Minutes
  
  AM/PM Option
- Provider Email
  example@example.com
- Ready for printing?
- Patient Name 2
- Patient ID Number
- Patient Name 3
- Patient ID Number
- Patient Name 4
- Patient ID Number
- Patient Name 5
- Patient ID Number
- Patient Name 6
- Patient ID Number
- Scribe Attestation
- Scribe Attestation Template
  I, ____________________________, am scribing for, and in the presence of, ______________________________.
- Provider for Scribe Attestation:
- Provider Attestation for Scribe
- Provider Attestation for Scribe Template
  I personally performed the services described in this documentation, as scribed in my presence, and it is both accurate and complete.
- Should be Empty:

PSYCHIATRIC EVALUATION

MUSCULOSKELETAL EXAMINATION (Check Items):

MENTAL STATUS EXAMINATION (Check Items):

Risk Factors

Concentration/ Attention Span:

Recent Memory:

Remote Memory:

Intelligence:

Judgment:

Insight:

JUSTIFICATION FOR HOSPITALIZATION (Select from Inpatient or Partial Hospitalization)