Structured Progress Note
Precision Psychiatric Services
Patient's Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Evaluation
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Other
Referred From:
Sick Call
Nursing/Medical
Mental Health
Security
Post Suicide Watch Release Follow Up
Other
Reason for Referral/Subjective Finding
Current Status:
Medication Adherent?
Yes
No
N/A
Suicidal Ideations Noted?
Yes
No
Refused to answer
Homicidal Ideations Noted?
Yes
No
Refused to answer
Mental Status Exam
Appearance:
Appropriate
Meticulous
Unclean
Disheveled
Other
Speech:
Appropriate
Expressive
Loud
Slowed
Pressured
Slurred
Other
Mood:
Appropriate
Depressed
Euphoric
Anxious
Angry
Irritable
Other
Affect:
Appropriate
Tearful
Blunted
Flat
Labile
Hostile
Other
Thought Process:
Coherent
Circumstantial
Tangential
Loose Associations
Poverty of Thought
Flight of Ideas
Other
Thought Content:
Appropriate
Auditory Halucinations
Visual Hallucinations
Obsessive
Delusional
Suicidal Ideations
Homicidal Ideations
Other
Orientation:
Person
Place
Time
Situation
Intelligence:
above average
average
below average
well below average
Memory:
Intact
Immediate impaired
Recent impaired
Remote impaired
Insight:
Good
Fair
Poor
Judgement:
Good
Fair
Poor
Behavior:
Appropriate
Belligerent
Agitated
Impulsive
Withdrawn
Other
Diagnosis and Assessment and Intervention Provided:
PLAN:
Continue MH Visits
MH to f/u PRN or through sick call
Placed on Special Needs
Recommend Participation in available programming
Consult with Psychiatrist
Consult with Correctional Staff
Consult with Psychologist
Other
Referred to
Medical
Psychiatric Provider
Discharge planner
Other
Should be seen by psychiatry within ( ) days:
Education
Follow up in:
2 weeks
3 weeks
30 days
45 days
60 days
Other
Signature
Clinician Name
Submit
Should be Empty: