Copyright © 2014 J.

Zuniga, MD

Reviewed February 2016

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Washed hands General appearance Behavior
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confidential.
Greetings & Introduction .Informed the patient regarding status and asked how he/she would like to be addressed – called)
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Onset (made comments on the C/C & ensured confidentiality)
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confidential.
Maintained an appropriate distance /nearby doors to secure exit and staff safety

Duration (established timelines) within 7 days

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confidential.
Settings/Triggers related to chief complaint
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lose trust or not discuss personal matters which may have bearing on
Frequency (first time vs. previous Hx) and follow up
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allowed to make their own medical decisions.
Commented on the talk (pressured speech)
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Energy level (reflected-verbalized)
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Mood Concentration/distractibility
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Ideas (racing thoughts /changing topics /excessive writing

Perceptions Delusions
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Hallucinations(visual/auditory) mind playing tricks/hearing voices paranoid/blocking-stealing-inserting thoughts/implanted microchip

HARMS & SAFETY Suicide “if yes” (contract) Homicide

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Indiscretions Financial Trouble with the law Driving Hyper-sexually/ unprotected sex
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Sleep (hours) Appetite (#meals) Judgment Access to weapons
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Causes + Hypomania Bipolar Head injuries Hyperthyroidism
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DDx Substances Schizophrenia Brain Ca Seizures
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Hyperthyroidism
Past Medical History Medications Allergies Hospitalization for mental illness (follow up)
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Family History Mood disorder Suicide
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Social History Ocupation ADLs Support System/Plans
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Closing remarks (admission +provided an opportunity for the patient to ask questions .Offered to call family member

How would you rate the doctor’s communication skills and professionalism? Organized

Poor Fair Very Good Excellent Was the station completed on time? YES NO

Final standing

Fail Borderline Pass Good Excellent

Disclaimer: This checklist is not intended to be a substitute for professional medical counseling, diagnosis or treatment. It is recommended to consult a variety of references to stay current. This material contains
information that may be subject to updates without further notice