Date and Location:

Identifying Patient Data (name, gender, age, race, marital status, number of children, type of
residence, occupation):
Chief Complaint:





History of Present Illness (Skim! 4 Ps: factors predisp to, precip,
perpet and prot ag curr epis, why seek trtmt today, how have
wrk/rel been affect, rel btwn phys/psyc sx):













Psychiatric ROS (past suicide att/self-harm/trauma or viol,
plan/means if yes, epis of mania/psychos, veg sx- qual of sleep,
appet, psychomotor agit/retard, concentr):








Past Psychiatric History (incl info about prev epis/inpt adm,
prev outpt care (psychiatric and counsel), first contact,
diagnoses, past legal prob):








Past Medical History (only psych-rel, or those req cont care,
head trauma, seizures, preg status, past hospit, incl if at CPMC):




Allergies:
Current Psychiatrist:
Current Therapist/Counselor:
Case Manager:
PCP:
Current Medications (include suppl and OTC, doses, if psych
meds says whether psych or PCP prescr them):
Substance Use History (Pert pos for pres, incl
drugs, smk, alc, caffeine, nicotine, memb of
AA/NA?):








Family Psychiatric History (1
st
degr rel only):






Developmental History (NOT for rounds, achv
devel milest on time, friends in school, perf
academ):






Social History (childr, marital status, who pt lives
with, dist/level of contact with friends/relat, hous,
edu, work, milit hx, relig, amt of exercise, hx of
trauma/abuse):







Mental Status Exam:
Appearance (gend, age, type of clothg, hyg,
posture, grooming, phys abnorm, jewelry
and cosmetic use, tats, lev of consc -, alert,
drowsy, leth, stup, pupil size, bruises,
needle marks, eros of teeth, cuts),
Behavior (Mannerisms, tics, eye cont, activ
level, psychomotor retard/activ, akathisia,
automatisms- purposeful vs disorg,
catatonia, choreoath mov, compuls,
dystonias, extrapyram sx, tard dyskin,
tremors, Attitude: Coop, seduct, flatt,
charm, eager to please, entitled, controll,
uncoop, hostile, guarded, critical, antag,
childish):





Date and Location:
Identifying Patient Data (name, gender, age, race, marital status, number of children, type of
residence, occupation):

Speech (rate- press/slowed, reg,
rhythm/prosody, articulation (stutter),
accent/dialect, modulation (loud or soft),
long or short latency) and Language:






Mood (how pt says he/she feels):






Affect (Quality- range of feelings descr as
flat/none, blunt/shallow, constr/lim,
full/avg, intense/more than nrml, Motil-
how quick emot change, descr as slug,
suppl, lab, Appr/not appr):







Thought Process (loos of assoc, flight of id,
neol, word salad, clang assoc, thought
block, tang, circum):







Thought Content (pov of thought vs
overab, del- biz vs nonbiz, grand, paran,
ref, thought broadc, relig, som, suic/homic
thoughts- plan, means):









Perceptions (halluc- descr sens mod,
whether ring/hum/voices,
hypnagog/pomp):



Presence of Suicidality/Homicidality):




Judgement (descr as excel, good, fair or
poor, ask hyp q: what to do if smell smk in
crwd movie theater) and Insight (underst
of sit- full, partial/ limited or none):











Sensorium and Cognitive Functions
(Consc- alert, drowsy, leth, stupor, coma,
Orient- to pers, plac, time, calc- can
add/subtr, Mem- immediate: repeat digits
or words, recent: events w/in past few
days or hours, remote: long-term, Fund of
Knwldg- who is presid, Attn/Conc- serial
7s, spell world bckwrds, Reading/Writing-
make sure pt is liter first, Abstr Conc:
expln sim btwn obj, mng of prov):








Laboratory and Imaging Results (pert pos and neg
only:



Diagnostic Impressions/Assessment (NOT for
rounds):










Plan (NOT for rounds):