Proper Format for Inpatient Psych Notes?

Discussion in 'Psychiatry' started by prominence, Jul 1, 2005.

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  1. prominence

    prominence Senior Member 10+ Year Member

    Dec 19, 2001
    after a psych patient is admitted to an inpatient floor, what are u supposed to include in the daily note (especially after writing a very thorough admission note)? is there any recommended format?

    any suggestions for the best way to write a note when requested to do a psychiatry consult?

    i would appreciate any advice from any new PGY-2's (i.e. Anasazi23) or other senior psychiatry residents. thank you in advance.
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  3. doctor4ever

    doctor4ever 10+ Year Member

    Jul 21, 2002
    This is what I give the medical students and I follow the same outline.

    Day #

    S: 42 y/o single, white male admitted for [Axis I Diagnosis]. Include a quote from the patient of his/her symptoms, change in mood, med s/e. Overnight events from nursing notes (e.g. refusing meds, restless, sleep)

    O: Vital Signs

    Mental Status Exam

    Current Meds (Med Day #, PRNs given since previous day)

    Labs: New labs (e.g. drug levels, CBC, UDS, TSH)

    A: Axis I Clinical Disorders
    Axis II Personality disorders, Mental retardation
    Axis III General Medical Conditions
    Axis IV Stressors
    Axis V GAF

    Overall Condition: Improved, Worse, or Same

    P: Any changes in meds
    Next step if there is no improvement
    Anticipated discharge date
  4. prominence

    prominence Senior Member 10+ Year Member

    Dec 19, 2001

    thanks for the reply! question: do u include a complete daily mental status exam, or just a mini-mental exam to examine the sensorium and cognition?

    also, what's ur format for a psychiatry consultation?
  5. Anasazi23

    Anasazi23 Your Digital Ruler Moderator Emeritus 10+ Year Member

    Hi prominence,

    Depending on the institution, daily psych progress notes aren't even required. Some places do notes the first few days, then every other day thereafter, or some such iteration. Either way, you've got a choice, but most institutions usually have their own preferred way.

    You can do a traditional medical SOAP note tailored for psychiatry:

    S: Patient seen this am at bedside. Reports less akithesia, better sleep, but still with decreased PO intake. Admits to crying bouts and occasional continued passive suicidal thoughts.

    O: Either a brief or truncated mental status exam. Report on their appearance, speech, thought content, suicidal/homicidal ideation, paranoid ideas or lack thereof, hallucinations, and general comparison compared to previous days. Other relevant medical info goes here. Blood sugars, +cogwheeling, etc.

    [Enter relevant labs and vitals here: Li = .62, WBC trend, BUN/CR,RPR status results, TFTs, etc.]

    A/P: Is often combined...
    Mr. Johnson is a 47 year old white male with a history of DM II, admitted on 6/29/05 with paranoid thoughts, suicidal ideation, and auditory hallucinations.
    1. Lithium increased to 300 Qam, 600HS
    F/U repeat Li levels.
    Continue Geodon 120mg Qd
    2. DM II: Continue Avandia 2mg BID
    3. Acute renal insufficiency: continue IVF, encourage PO intake, f/u repeat BUN/CR.
    4. Disposition planning: Social Work reports bed hold at patient's group home.

    etc, etc.

    Our hospital came up with the "STOP" note, which is similar to the SOAP, but is a little different, and works well also.

    S = subjective
    T = treatment
    O = Outcome
    P = Plan

    Subjective is basically the same as in the SOAP note. The "treatment" is a list of medications and other medical interventions, including therapies. Outcome is then the patient's change in psychiatric status based on your above treatments. i.e. Improved sleep, improvement in cogwheeling, less frequent auditory hallucinations, etc. Plan is basically the same.

    From my experience, write in the note what's important and what other physicians need to read...don't be a slave to protocol at the expense of good information because it doesn't "seem to fit in anywhere." If you saw the patient doing something strange, or suspect malingering because of a specific behavior you witnessed, mention it. (Be careful with accusations or assertions of malingering).

    Good luck. Keep the questions coming. We're here to help.
  6. prominence

    prominence Senior Member 10+ Year Member

    Dec 19, 2001
    thanks for all the replies.

    any suggestions on how to write a note when requested to do a psychiatry consultation?
  7. Anasazi23

    Anasazi23 Your Digital Ruler Moderator Emeritus 10+ Year Member

    Psychiatry consults, as you'll see, are written largely like any other medical consult. The job of the consultant is to review the case thoroughly, summarize their understading thus far, offer diagnostic possibilites, and most importantly, give medical adivce to the physician requesting the consult.

    Many psychiatry residents write "wishy-washy" consults, often without commiting to diagnoses or treatment options. Unless the case is substantially difficult or other unusual circumstances, make a diagnosis (if appropriate), and give solid treatment options. Check with your hospital to see if the consulting psychiatry resident will write the orders suggested from the consult. Our hospital, for example, wants all major orders to come from the primary medical team. In this sense, the consultant is just that, a consultant giving an opinion and advice.

    The consult generally consists of the following:

    1. Short HPI, rehashing the case events thus far.
    "Mrs. X is a 32 year old single female who was admitted to the general medical floor for severe electrolyte imbalance secondary to what the patient describes as intractible vomiting. Psychiatry was consulted to evaluate the possibility of self-induced vomiting, and to recommend treatment options if warranted."

    Then, go into your details of the psychiatric interview, using quotes for the patient's own words when appropriate.

    2. Past medical history

    3. Past surgical history

    4. Family history

    5. Social history, including substance use, living situation, alcohol use, IVDA, other drug use, detoxes, OTC meds, etc.

    6. List medications, dosages.

    7. List most recent labs, if appropriate, imaging results, and lab trends. Add vitals above this.

    8. Mental status results

    9. "Diagnostic Impression:"
    Use the DSM-IV 5 axis system here, being sure to include all relevant medical issues on III.

    10. Impression: Restate the initial question, then summarize briefly your thoughts and list, very clearly, your treatment suggestions, including medications, dosages, psychiatric followup and other plans. If the case warrants followup by the psych c/l team, indicate that psychiatry will follow the case, or that they can reconsult psychiatry if needed.

    Keep in mind that most residents, interns, and attendings will only read the Diagnosis, impressions, and recommendations section of your consult. Make it good and make it clear. Don't be afraid to give basic science reasons for decisions you make. This is often appreciated, and gives the resident presenting the case on rounds an understanding as to why they should follow your suggestions. If you're not sure what to suggest, ask your resident or attending.

    Good luck! :luck:

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