This note is designed to serve as an initial writeup for a patient who is being admitted to the psych department (such as a triage from the emergency department). It is important to try and characterize the nature of the patient’s possible psychiatric condition thoroughly, so this is one of the more extensive notes that would be written on a patient.
KEY COMPONENTS OF THE NOTE
Title: “Psychiatric Admissions Note”
Patient name, sex, and age: these are key identifying pieces of information. The gender can be included as well if it is relevant to the clinical context of the patient.
Chief complaint (CC): similar to many other notes, this is the reason the patient is coming to the hospital/being admitted.
History of present illness (HPI): similar to many other notes, this section will help give the progression of the currently illness that has led to the patient’s admission. For psychiatry in specific there are a few important pieces of information that can be included (when appropriate). These are:
- Suicidal ideation: is the patient at risk for trying to commit suicide?
- Harm to others: does the patient pose a danger to others around them?
- Paranoia: does the patient believe people are out to get them?
- Hallucinations: does the patient see or hear things that others do not? If the patient hears voices do they every command the patient to do things?
- Thought broadcasting: doe the patient believe that others know what they are thinking?
- Thought withdrawal: does the patient believe others can take thoughts out of their minds?
- Focused ROS: exploring the patient’s sleep, eating, and level of interest in activities can help contextualize things.
Past psychiatric history: because this is a note written within the psychiatric specialty, it is important to provide psychiatric history separate from a regular “Past medical history” section. This will ensure important information is not lost within the depths of the note. Make sure to include the following important components in this section:
- Past diagnosis: what psychiatric conditions has the patient been formally diagnosed with?
- Treatments: what treatments has the patient received for psychiatric conditions?
- Hospitalizations: has the patient been hospitalized before for any psychiatric conditions?
- Past psych medications: what medications has the patient received in the past for psychiatric conditions? Timeframe and dose can be useful to discover if possible.
Current psychiatric medications: while there may be some overlap with this section and the above one, it is important to have a separate section that clearly highlights what psychiatric medications the patient is currently taking. Finding out the dose and how long the patient has been on the medication can be useful if possible.
Substance use/abuse: it is important to discover this element of the patients history. Make sure to ask/document the following components:
- What substances:is the patient drinking alcohol, smoking cigarettes, smoking marijuana, smoking crack cocaine, snorting cocaine, injecting heroin, snorting heroine, dropping acid, eating mushrooms, etc? It is important about asking about IV drug usage (clear risk factor)!
- Amount/frequency of usage: this will help contextualize the nature of the drug use (i.e. how many drinks a day)
- First usage: when did the patient start using the substance in question?
- Longest period of sobriety: what helped the patient remain sober? What compromised their sobriety?
- Withdrawal symptoms: has the patient ever felt symptoms of withdrawal when they have stopped using the substance in question?
- Detoxes: has the patient been admitted for substance use/abuse and for detox? How many times?
Suicide: a very important aspect to characterize about the patient. Some things to clarify are:
- Suicidal ideation: has the patient ever contemplated suicide?
- Planning of suicide: has the patient every made a plan of how they will commit suicide? What was the plan?
- Attempted suicide: has the patient ever tried to commit suicide? How did they attempt it? What happened?
- Current attitude to suicide: does the patient want to commit suicide now?
Violence: characterizing the nonviolent/violent nature of the patient in question is an important safety measure. It is important to clarify the following:
- Thoughts of violence to others: has the patient every thought about harming others around them?
- Planned acts of violence: has the patient every thought about how they would harm others?
- Past acts of violence: has the patient ever harmed others around them? What acts did they engage in?
- Legal aspects: has the patient ever been tried/prosecuted for acts of violence? Have they served jail time?
Trauma/abuse: it is important to explore if the patient has a past history of any type of abuse or if they have experienced any significant traumatic events in their lifetime.
Past medical history (PMH): this is similar to a PMH that would show up in other notes. That being said, for psychiatry specifically it would be useful to include a history of things like head trauma or seizures at the top of the list. After these types of entries are prioritized, other medical conditions should be listed.
Non psychiatric medications: here we can include medications for other non-psychiatric conditions.
Allergies: same as for many other medical notes.
Family history: for this section, typical family history entries (such as a history of cancer etc) should be included. That being said, for psychiatry specifically, any past family history of psychiatric conditions should be noted first!
Social history: this section is comparable to many other notes. Important aspects to touch on are:
- Residence: where does the patient live? Who do they live with?
- Level of education: has the patent completed high school, college, an advanced degree?
- Employment: what does the patent do for a living?
- Financial stability: is the patient able to afford a home, food, medicine, medical care? Are they insured?
- Supporters: who looks after the patient? Does the patient have family in the area? Are they married? Do they have a significant other?
- Children: does the patient have any children?
Mental status exam: using the neurological mental status exam as a reference, this section can be used to characterize your findings. Important sections include:
- General appearance: is the patient dirty or clean? Disheveled? How are they dressed?
- Behavior: is the patient agitated or angry? Cooperative? Pleasant?
- Psychomotor: does the patient have a restless leg? Any types of repetitive actions or motions?
- Level of consciousness: is the patient awake? Arousable?
- Speech: is it pressured, latent, slurred, loud, soft? How is their vocabulary?
- Attention: can the patient complete the serial 7s? Spell WORLD forward and backward?
- Language: can the patient repeat back a sentence or two?
- Memory: can the patient repeat back 3-5 words? Can they remember the words after 5 min?
- Orientation: does the patient know their name, where they are, and the date?
- Mood: are they angry, anxious, apathetic, euphoric, irritable?
- Affect: depressed, flat, grandiose?
- Thought process: are they a linear thinker, tangential, flight of ideas? Loose associations? Paranoid?
- Thought content: do they have hallucinations and/or delusions?
- Insight/judgement: is there ability to reason compromised?
Strengths/weaknesses/risks: this portion of the note is designed to evaluate the comprehensive status of the patient. What established risk factors do they have for certain types of psychiatric behaviors? What positive elements do they have in their life that serves a protective function? What elements of their life compromise their mental health?
Assessment and plan: similar to other notes, at the end of the admission note you should included your assessment of the patient (i.e. what is going on?) and also what you think the appropriate treatment of the patient will be.
A blank template (with some normal baseline results) can be found here to save you time in creating your own psychiatric admissions note!
Page Updated: 05.01.2016