Psychiatrist Template

Inpatient Intake Note

A professional Psychiatrist template for healthcare professionals.

About this template

The Inpatient Intake Note template is a comprehensive documentation tool designed for obstetricians and gynaecologists to capture detailed patient information upon hospital admission. This template facilitates the recording of a patient's medical history, current symptoms, and treatment plans, ensuring a thorough assessment of conditions such as ectopic pregnancy. It includes sections for psychiatric history, substance use, social and family history, and more, making it an essential resource for managing complex inpatient cases. This template is optimized for use with Heidi, enhancing efficiency and accuracy in clinical documentation.

Preview template

Summary: - The patient, a 32-year-old female, was admitted for severe abdominal pain and heavy bleeding. She is currently receiving inpatient care for suspected ectopic pregnancy. Progress includes stabilization of vital signs and pain management. - Key strengths include a supportive family and a positive attitude towards recovery. Challenges involve managing anxiety related to the diagnosis. Treatment goals focus on resolving the ectopic pregnancy and ensuring future reproductive health. Chief Complaint: - Severe abdominal pain and heavy vaginal bleeding. History of Present Illness (HPI): - The patient experienced sudden onset of severe abdominal pain and heavy bleeding two days ago. Symptoms have progressively worsened, leading to her admission. She reports no recent life events or stressors but has a history of irregular menstrual cycles. Prior to admission, she attempted to manage symptoms with over-the-counter pain relief without success. Psychiatric History: - No previous psychiatric diagnoses or treatments. No history of self-harm or suicidality. Medications: - Current Medications: Ibuprofen 400mg for pain relief. - Possessed Medications: None brought to the facility. - Medication Access: No challenges reported. - Inpatient Medications: - PRN: Paracetamol 500mg as needed for pain. - STAT: Methotrexate administered for ectopic pregnancy management. - Medication Refusal: None reported. Substance Use: - Denies use of alcohol, tobacco, or recreational drugs. Pain History: - Reports chronic dysmenorrhea but no other chronic pain conditions. Drug Screen Result: - Negative for all substances. Social History: - Lives with her partner and has a strong family support system. Works as a teacher and is actively involved in community activities. Family History: - Mother has a history of endometriosis. No known family history of substance use disorders. Legal History (Guardianship, Conservatorship, Representation, etc.): - No legal issues or guardianship concerns. Trauma/Abuse History: - No history of physical, emotional, or sexual abuse reported. Sleep: - Reports difficulty sleeping due to pain but generally has good sleep quality. Functioning Status: - Able to perform activities of daily living independently. Social functioning is intact. Disposition: - Patient is anxious but motivated to follow the treatment plan and achieve discharge goals. Aggression: - No instances of aggression or hostility observed. Review of Systems (ROS): - Anxiety: Reports increased anxiety related to current health condition. - Depression: Denies symptoms of depression. Mental Status Exam: - Appears well-groomed, cooperative, with a mood congruent to the situation. Thought process is logical, with good insight and judgment. Tests and Scores: - PHQ-9 score of 3, indicating minimal depression. Allergies: - No known drug allergies. Review of Systems (General ROS): - Reports occasional headaches but no other systemic complaints. Physical Exam: - Abdominal tenderness noted on examination. No other significant findings. Vital Signs: - Blood pressure: 120/80 mmHg, Heart rate: 78 bpm, Respiratory rate: 16 breaths/min, Temperature: 36.8°C, O2 saturation: 98% on room air. Level of Observation and Precautions: - Regular observation with no specific precautions required. Physical Safety Risks: - No physical safety risks identified. Safety Assessment: - No suicidality or self-harm risk. Protective factors include strong family support. Assessment: - Suspected ectopic pregnancy with associated pain and bleeding. Anxiety related to health condition. DSM-5-TR Codes: - None applicable. Plan: - Continue methotrexate therapy and monitor hCG levels. Provide supportive care and pain management. Schedule follow-up ultrasound to assess treatment efficacy. - Treatment Changes: None at this time. Follow-Up Email: - Summary of visit outcomes and recommendations will be sent to the patient’s email. Contact information provided for any questions. Billing Codes: - ICD-10: O00.1 (Ectopic pregnancy), CPT: 99221 (Initial hospital care). To-Dos: - Schedule follow-up ultrasound. Arrange consultation with a fertility specialist post-discharge.

Summary: - [Provide a brief summary of the patient’s presentation, current inpatient treatment, and progress] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [List key strengths, challenges, and treatment goals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Chief Complaint: - [State the patient’s primary reason for admission or presenting issue(s)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) History of Present Illness (HPI): (write this in a narrative paragraph format, use full sentences) - [Describe the onset, duration, and progression of symptoms leading to inpatient admission] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Include any triggers, recent life events, or stressors contributing to symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Document any prior attempts at treatment or symptom management] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Psychiatric History: - [Include previous diagnoses, treatments, hospitalizations, and response to care] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Document history of self-harm, suicidality, or other psychiatric events] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Medications: - Current Medications: [List all prescribed medications, including doses and purposes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Possessed Medications: [List medications brought by the patient to the facility, if applicable] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Medication Access: [Document challenges accessing medications prior to admission] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Inpatient Medications: - PRN: [Include as-needed medications prescribed and administered] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - STAT: [Document any emergency/urgent medications given] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Medication Refusal: [Note any instances where the patient refused prescribed medications and reasons if known] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Substance Use: - [Document the patient’s alcohol, tobacco, and recreational drug use, including frequency and duration] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Cravings/Withdrawal: [Include any reported cravings or withdrawal symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Pain History: - [Include any chronic or acute pain history reported by the patient] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Drug Screen Result: - [List results of any drug screens performed upon admission] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Social History: - [Describe living situation, relationships, support system, and relevant social factors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Family History: - [Document family history of psychiatric, medical, or substance use disorders] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Legal History (Guardianship, Conservatorship, Representation, etc.): - [Include details on legal guardianship, conservatorship, or representation, if applicable] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Document any history of legal issues or involvement with the criminal justice system] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Trauma/Abuse History: - [Describe any history of physical, emotional, or sexual abuse, as reported by the patient] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Document protective factors or ongoing trauma concerns] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Sleep: - [Include details of sleep quality, duration, and disturbances] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Functioning Status: - [Describe patient’s ability to perform activities of daily living (ADLs) and social functioning] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Disposition: - [Document the patient’s emotional state, insight, and motivation regarding their treatment plan and discharge goals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Aggression: - [Include any instances of aggression or hostility, if observed or reported] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Review of Systems (ROS): - ADHD: [Document symptoms consistent with ADHD] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Anti-Sociality: [Include behavioral concerns or traits associated with antisocial tendencies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Anxiety: [Document symptoms such as restlessness, worry, or panic attacks] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Autism: [Include observations or patient history consistent with autism spectrum disorder] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Depression: [Document symptoms such as low mood, hopelessness, or anhedonia] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Eating Disorder: [Include disordered eating behaviors, if observed or reported] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Mania: [Document symptoms such as elevated mood, impulsivity, or reduced need for sleep] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - OCD: [Include obsessive thoughts or compulsive behaviors, if present] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Personality Disorder: [Document traits consistent with personality disorders] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Psychosis: [Include hallucinations, delusions, or other symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Trauma: [Document symptoms of post-traumatic stress or avoidance behaviors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Mental Status Exam: - [Include observations of appearance, behavior, mood, thought process, insight, and judgment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Tests and Scores: - [Include results of validated rating scales or diagnostic tests (e.g., PHQ-9, GAD-7)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Allergies: - [Document any known allergies or adverse medication reactions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Review of Systems (General ROS): - [List other relevant systems or complaints as reported by the patient] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Physical Exam: - [Include findings from the patient’s physical examination, if conducted] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Vital Signs: - [Document vital signs including blood pressure, heart rate, respiratory rate, temperature, and O2 saturation] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Level of Observation and Precautions: - [List observation level (e.g., 1:1, Q15min checks) and any precautions such as suicide or elopement risk] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Physical Safety Risks: - [Document any physical risks such as falls or injuries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Safety Assessment: - [Include assessment of suicidality, self-harm, or danger to others] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Document protective factors and safety planning] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Assessment: - [Summarize findings, diagnoses, and progress in treatment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) DSM-5-TR Codes: - [List all relevant DSM-5-TR diagnostic codes with descriptions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Plan: - [Include treatment plan components such as medications, therapy, and lifestyle changes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Treatment Changes: [Document any updates or adjustments to treatment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Follow-Up Email: - [Summarize visit outcomes, recommendations, and provide contact information for questions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Billing Codes: - [List appropriate ICD-10 and CPT codes for the visit and services provided] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) To-Dos: - [List tasks for the care team, such as referrals, follow-ups, or medication adjustments] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Include follow-up actions for the patient, such as completing assessments or attending therapy sessions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or recommendations - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, just leave the relevant placeholder or section blank. Use as many bullet points as needed to capture all relevant information from the transcript.)

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