PSYCHIATRY ADMISSION NOTE
Patient Info:
CC:
HPI:
Past psychiatric history:
Patient denies past history of psychiatric illness or treatment.
Current psychiatric medications:
Patient is currently not taking any psychiatric medications
Substance use/abuse:
Patient denies any alcohol, smoking, or other drug use.
Suicide:
Patient dienes any past suicidal ideation or attempted suicide.
Violence:
Patient denies having any thoughts of violence towards others or any past acts of violence.
Trauma/abuse:
Patient denies any past history of traumatic events or abuse.
Past medical history:
Patient denies a past history of medical conditions or any notable past medical history.
Non-psychiatric medications:
Patient denies taking any medications or supplements at this time.
Allergies:
Patient denies any allergies.
Family history:
Patient denies any family history of mental illness or other diseases.
Social history:
- Residence:
- Level of education:
- Employment:
- Financial stability:
- Supporters:
- Children:
Mental status exam:
- General appearance: clean and well appearing.
- Behavior: cooperative and pleasant.
- Psychomotor: patient sits in place without any tics.
- Level of consciousness: alert and awake.
- Speech: relaxed, appropriate volume and pace.
- Attention: patient can complete serial 7s (100, 93, 86, 79, 77, 70, 63….)
- Language: patient can repeat back the sentence “The quick brown fox jumped over the lazy dogs”
- Memory: patient can repeat back the words: face, velvet, church, daisy, red. Was able to remember all 5 words after 5 minutes.
- Orientation: patient knows their full name, where they are, and the date.
- Mood: relaxed
- Affect: even
- Thought process: linear and cohesive
- Thought content: no hallucinations, delusions, or paranoia
- Insight/judgement: patient demonstrates good insight/judgment. When asked what they would do if they found a postmarked letter on the street, replied that they would simply mail it.
Strengths/weaknesses/risks:
Assessment and plan:
Mr. Stepwards
HARVARD MEDICAL SCHOOL MS3