Choose 2 psychiatric patients and complete below with each patient

Subjective:

 

Chief Complaint:

History of Presenting Illness (HPI):

Past Psychiatric History:

Past Medical History:

Social/Developmental History:

Allergies:

 

Objective:

 

Mental/Functional:

Mental Status Examination:

Appearance:

Orientation:

Speech/Language:

Mood:

Affect:

Thought Content:

Insight:

Judgement:

Suicidality & Homicidality:

 

Assessment:

 

DSM-V Diagnoses:

Risk Assessment:

Vital Signs:

Height/Weight/BMI:

 

Plan and Recommendation:

 

Supportive psychoeducation:

Safety Plan:

Medications:

Follow-up:

 

SAMPLE

SUBJECTIVE

Chief Complaint: “ I feel depressed and sad.”

History of Presenting Illness: Ashley and her mother presented for initial evaluation. She reported struggling with depression since September of 2018. She described her depression as sadness, irritability, lack of motivation and interest. She feels overwhelmed and easily agitated. She also feels anxious and panic attacks sometimes. She reported lack of appetite some times. Mother reported Ashley cries for no reason. She would tell mother that she cries for no reason. Mother got concerned about this. She then took her to the Doctor who referred her to the hospital. Ashley did well at school with report card of A’s, B’s, C’s. She also reported difficulties with attention and focus. She gets distracted easily. She struggles with completing class and home. Mother reported since she started 8th grade, Ashley has been struggling.Choose 2 psychiatric patients and complete below with each patient

 

Past Psychiatric History: No hospitalization. She is not in therapy. She is has not been on medications. No drugs or alcohol use.

Medical History: No past medical history has been documented for this patient.

Psychiatric Family History: No family history of mental illness.

Social /Developmental History: Ashley lives with her parents and her siblings. Mother described her pregnancy as normal. She weighed about 6 pounds 6 ounces. Her developmental milestones were normal. No abuse or neglect. Ashley is going into the 8th grade in regular education.Choose 2 psychiatric patients and complete below with each patient

Allergies: No known allergies

 

OBJECTIVE

Mental/Functional:

Normal

Mental Status Exam:

Appearance: Attire was casual; adequate hygiene and grooming

Orientation: Oriented to person, place, time, event/situation

Speech/Language: Clear; spontaneous, normal rate; normal prosody

Mood: “I feel sad and depressed”

Affect: congruent

Thought Content: No obsessions/compulsions; no evidence of perceptual disturbances

Insight: Good

Judgment: GoodChoose 2 psychiatric patients and complete below with each patient

Suicidality and Homicidality: Denies

 

 

ASSESSMENT

 

DSM-5 Diagnoses:

1) ADHD, predominantly combined type

2) Generalized anxiety disorder

3) MDD, RE, moderate

 

Risk Assessment: The patient denies SI/HI and/or behaviors, intent, and/or plan. Current protective and risk factors were reviewed, and the patient is not currently at clinically significant risk for suicide/homicide. The patient acknowledged understanding of emergency resources such as going to the ER or dialing 911 if experiencing suicidal/homicidal ideation.

 

Vitals:

Ht: 5’0”

Wt: 132lbs oz

BMI: 25.78

 

PLAN AND RECOMMENDATION:

1) Supportive psychoeducation completed

2) Safety plan discussed

3) Medications:

– No prescription today. Consider medications after completing the forms.

Complete Conner’s Scale provided for teachers and parents.

Complete baseline EKG

Overall treatment plan was discussed with the patient. Patient voiced understanding.

Continue to require outpatient treatment and medications.

Risks, benefits, side effects, and alternative treatments regarding prescribed medications were discussed with the patient/family. Patient expressed understanding and provided informed consent to be on aforementioned medications.

Rechecks with PCP for further evaluation and treatment of medical problems. Patient voiced understanding.

Patient was advised to immediately return to clinic, call 911, or go to the nearest ER for worsening symptoms, side effects, thoughts of harming others, or any concerns. Patient verbalized understanding.

Referrals: Psychotherapy encouraged

Next Follow-up: 4 weeks or sooner if needed.