1.
IDENTIFYING INFORMATION:
The patient is a _______year old Caucausian/African American Fe/male who was referred to
this facility from _________________ where s/he has reside since______________________.
The patient brought to the facility via ambulance/family member. The patient's primary
contact are ____________________, telephone number ________________. The patient is a
Full code/ DNR.
2. Code Status:
REASON FOR ADMISSION/CHIEF COMPLAINT:
______________________________________________
3. HISTORY OF PRESENT ILLNESS: The patient reports that his/her symptoms started
about___________________________________
Triggers:
SI/HI
SA
where he was admitted for increasing aggressive towards family/staff/destruction of
property/ agitation/ psychosis.
During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.
Patient self-esteem appears fair, no reported feelings of excessive guilt,
no reported anhedonia, does not report sleep disturbance, does not report change in appetite,
does not report libido disturbances, does not report change in energy,
no reported changes in concentration or memory.
Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or
euphoria. Patient does not report excessive fears, worries or panic attacks.
Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity
level, attention and concentration were observed to be within normal limits. Patient does not
report symptoms of eating disorder. There is no recent weight loss or gain. Patient does
not report symptoms of a characterological nature.
Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent
behavior, denies inappropriate/illegal behaviors.
PAST PSYCHIATRIC HISTORY:
Previous psychiatric diagnoses: none reported.
Describes stable course of illness.
Previous medication trials: none reported.
Safety concerns:
History of Violence to Self: none reported
History of Violence to Others: none reported
Mental health treatment history discussed:
History of outpatient treatment: not reported
Previous psychiatric hospitalizations: not reported
Prior substance abuse treatment: not reported
Trauma history: Client does not report history of trauma including abuse,
domestic violence, witnessing disturbing events.
Substance Use: Client denies use or dependence on nicotine/tobacco products.
Client does not report abuse of or dependence on ETOH, and other illicit drugs.
MEDICAL HISTORY:Denies cardiac, respiratory, endocrine and neurological issues, including
history head injury, seizures
Patient: denies history of chronic infection, including MRSA, TB, HIV, Hep C.
Surgical history no surgical history reported
ALLERGIES:
FAMILY PSYCHIATRIC HISTORY:
No reported knowledge of family history of psychiatric issues -
No reported knowledge of family history of substance use issues
SOCIAL AND PERSONAL HISTORY:
Occupational History: currently unemployed. Denies military service.
Education history: not reported.
Developmental History: no significant details reported.
Legal History: no reported/known of legal issues, no reported/known conservator
or guardian.
Spiritual/Cultural Considerations: none reported.
REVIEW OF SYSTEM:
Vital Signs: Stable
Psychiatric. Admits to X as per HPI.
Constitutional: No report of fever or weight loss. Eyes: No report of acute vision
changes or eye pain. ENT: No report of hearing changes or difficulty swallowing.
Cardiac: No report of chest pain, edema or orthopnea. Respiratory: Denies dyspnea,
cough or wheeze. GI: No report of abdominal pain. GU: No report of dysuria or
hematuria. Musculoskeletal: No report of joint pain or swelling. Skin: No report of
rash, lesion, abrasions. Neurologic: No report of seizures, blackout, numbness or focal
weakness. Endocrine: No report of polyuria or polydipsia. Hematologic: No report of
blood clots or easy bleeding. Allergy: No report of hives or allergic reaction.
Reproductive: No report of significant issues.
MENTAL STATUS EXAM:
Patient is cooperative and conversant, appears without acute distress, and fully oriented x
4. Patient is dressed appropriately for age and season. Psychomotor activity appears
within normal.
Presents with appropriate eye contact, euthymic affect - full, even, congruent with
reported mood of “x”. Speech: spontaneous, normal rate, appropriate volume/tone with
no problems expressing self.
TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation.
Process appears linear, coherent, goal-directed.
Cognition appears grossly intact with appropriate attention span & concentration and
average fund of knowledge.
Judgment appears fair . Insight appears fair
ESTIMATED LENGTH OF STAY: 1-2 Weeks
ASSETS:
The patient is able to articulate needs, is motivated for compliance and adherence to medication
regimen. Patient is willing and able to participate with treatment, disposition, and discharge
planning.
Patient lives in a skill nursing facility where ___ receives structure and supervison, and
medications can be monitored . Supportive family member.
LIABLITIES: Progressive cognitive decline
DIAGNOSTIC IMPRESSION:
Axis I
1.
2.
3.
Axis II: None
Axis III:
1.
2.
3.
4.
Axis IV:
Axis V:
PLAN:
RELEASE: Patient is found to be stable and has control of behavior.
Patient was seen today sitting in DR eating, lying in bed. She is dressed appropriately. She is
alert and awake. Oriented x 1-2. Speech is clear, garbled, mumbled, slurred, loud, slowed,
pressured. S/he denies SI/HI/AH/VH. Patient denies anxiety or depression. Patient mood is
good, bad, euphoric, anxious, angry, irritable. Affect is blunted, constricted, tearful, labile,
hostile, flat. Thought form is coherent, circumstantial, tangential, loose association, poverty of
thought, flight of idea. Thought content is compulsive obsessive, thought insertion, broadcasting,
delusional, hallucination, suicidal, homicidal. Memory appears to be intact, impaired. Insight is
good, fair or poor. Judgment is good, fair or poor. His behavior is belligerent, agitated,
withdrawn, cooperative, uncooperative. Patient appetite and sleep are "good". Patient is taking
medication with no side effects. No behavior issues was reported from night shift. No changes
have been made to medication. We will continue to monitor patient's mood, behavior and
medication compliance.
Patient was seen lying in bed. She is dressed appropriately. Patient is alert and awake.
Oriented x 2-3. Speech is clear. Patient is cooperative. Reports mood as "good". Denies
SI/HI/AH/VH. Denies anxiety or depression. Appetite and sleep are "good". Reports taking
medication with no side effects. No behavior issues reported from overnight. No changes
made to medication. Will continue to monitor mood, behavior and medication compliance.
Cheryl Graham, FNP 1/1/20
Patient was seen lying in bed. He is dressed appropriately. Patient is alert and awake.
Oriented x 2-3. Speech is clear. Patient is cooperative. Patient is unable to articulate whether
he endorses SI/HI/ or has AH/VH. Unable to assess for anxiety or depression as patient does
not answer to questions. Appetite and sleep are good per staff. Staff reports that patient is
taking medication with no side effects. No behavior issues reported from overnight. No
changes made to medication. Will continue to monitor mood, behavior and medication
compliance.
