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Psych - H&P Template

This document contains a template for a psychiatric history and physical examination. It includes sections for the chief complaint, history of present illness, review of systems, psychiatric history, past medical history, family history, social history, review of systems, physical examination, psychiatric examination, medications, labs, imaging, assessment, suicide assessment, and plan of care. The template provides guidance on what to include in each section, such as ensuring a thorough medical review of systems, asking about family psychiatric history, and including discharge planning resources.

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3K views3 pages

Psych - H&P Template

This document contains a template for a psychiatric history and physical examination. It includes sections for the chief complaint, history of present illness, review of systems, psychiatric history, past medical history, family history, social history, review of systems, physical examination, psychiatric examination, medications, labs, imaging, assessment, suicide assessment, and plan of care. The template provides guidance on what to include in each section, such as ensuring a thorough medical review of systems, asking about family psychiatric history, and including discharge planning resources.

Uploaded by

jhhjjh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PSYCH: H&P TEMPLATE

CC: This can use a direct quote from the patient.

HPI:

ROS: Please be sure to capitalize and put a + sign in front of what is positive, this way it will stand out and make this
section of your note easier for people to interpret! Also, yes this is psych but be sure to ask a good medical ROS and list
any pertinent positives in this section.

Depressed:
SIGECAPS

Manic:
DIGFAST

Anxious:
PTSD?
Flashbacks?
Avoidance?
Hypervigilance?

All patients:
SI: intent? plan?
HI: intent? plan?
AVH: describe

PPH:
Psych Dx:
Current psych meds: Do not just list medication names, list dosing and timing too!!!
Past psych meds (if no longer taking, why?):
Past hospitalizations:
Past suicide attempts (when/how many?):
Outpt Tx (clinic/provider/contact #):

PMH:

PSH:

FH: Be SURE to ask about fam psych hx!!!

SH:
Lives with:
Occupation:
Current stressors:
Current legal problems:
T/E/D (current and past, including any abuse/dependence hx, and any tx/rehab for such):
T:
E:
D:
Developmental Hx:
Hx of abuse?

ALLG: NKDA

OTHER MEDS (outpt):


PHYSICAL EXAM: ***Please do a good general physical exam even though you’re on psych!!! Important!!!
VS:
GEN: NAD, A&Ox3
HEENT: NC/AT, no scleral icterus, PERRL, EOMI, mmm, no lymphadenopathy
CV: rrr, no m/r/g, no carotid bruits, no JVD
RESP: CTAB, no wheezes/rhonchi/crackles 
ABD: soft, NT/ND, +BS, no HSM
EXT: WWP, no c/c/e
NEURO: CN 2-12 grossly intact, no focal deficits appreciated, MAEW, sensation to light touch grossly intact,
2+ patellar tendon reflexes BL

PSYCH EXAM:
Appearance:
Dress/grooming
Cooperativeness
Eye contact
Psychomotor agitation/retardation
Attitude
Bizarre mannerism/gestures/facial expressions

Mood:
Dysphoric, euthymic, euphoric, hostile
Affect (observed emotional state):
Expansive, labile, normal, constricted, flat
Appropriateness

Sensorium:
Level of consciousness: Alert/drowsy/stuporous
Orientation: Person, place, date, situation (A+O x 4)
Concentration:
1) Spell “world” backwards
2) Serial 7’s or 3’s
3) Months of year backwards
Memory:
1) Immediate: Instant recall of 3 objects/digit span
2) Short term: Recall of 3 objects in 5 minutes
3) Long term: Ask about pts past hx
Abstract thinking (Similarities/Proverbs):

Intelligence:
General fund of knowledge:
1) Current/past president
2) Historical events (9/11)

Thought:
1) Speech: speed, volume, clarity
2) Thought type: Circumstantial, tangential, linear, flight of ideas, “word salad”
3) Thought Content:
Hallucinations (AH/VH)
Delusions (persecution, grandiose, erotomanic, somatic)
Suicidal/homicidal ideation (SI/HI)
Derealization/depersonalization

Insight (pts understanding of his/her illness):


Judgement (solutions to hypothetical situations):
Impulse control (based on observation):
MEDS (inpt): ***IMPORTANT TO PUT ANY PSYCH MEDS THEY RECEIVED IN THE ER!!!

LABS: Please remember to TREND your labs, one day’s lab values isn’t very helpful (unless these are the admit labs).

IMAGING: It’s okay to just put the “impression” here, but please be sure to read the whole report! Sometimes important
findings that you would want to include in your note are not mentioned in the impression. Be aware of this!

ASSESSMENT:

AXIS I: principal psych d/o


AXIS II: any personality d/o
AXIS III: any medical/neuro d/o
AXIS IV: current/recent psychosocial stressors
AXIS V: GAF (global assessment of function)

Suicide Assessment:

PLAN: ***May do a problem list for the plan, with psych issues first (obviously). Be SURE to include a good
DISPO section. These pts often need a lot of SW help!!! Include all pertinent phone numbers for pt’s friends/fam!

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