Behavioral Medicine Consultation Note (Inpatient/Outpatient)

Date/Time of Consultation: [Date and time]

Patient Location: [Unit, room/bed if inpatient]

Consulting Clinician: [Name, credentials, role]

Requesting Clinician/Service: [Name and service]

Consult Modality: [in-person / telehealth / telephone / chart review only] (If not in-person, note limitations such as "no direct patient interview performed.")

Interpreter: [Language and interpreter type] (Omit line if not applicable.)

Consult Question

[Exact consult question(s) from the primary team] (Quote or closely paraphrase the request. If vague, restate as 1–3 concrete, answerable questions and note clarification was provided. Prioritize safety, then capacity, then symptom management, then disposition.)

Clinical Summary

[One-sentence synthesis: patient age, key medical context, primary psychiatric/behavioral issue, and why the consult is needed now]

Bottom Line

Primary Impression(s): [Plain-language impression(s)] (Define psychiatric terms briefly if needed.)

Immediate Safety Needs: [Safety status and immediate needs, or "None identified"]

Recommendations:

1. [Actionable recommendation with clear owner and timing]
2. [Actionable recommendation with clear owner and timing]
3. [Actionable recommendation with clear owner and timing]
4. [Additional recommendations as needed, 3–8 total]

(For medication recommendations, specify drug, dose, route, frequency, indication, and key monitoring parameters. If no changes recommended, state explicitly with what to monitor.)

Sources of Information

[Patient interview, chart review, nursing staff, family/caregiver collateral, outpatient clinicians, EMS, external records] (List sources consulted. Include reliability statement when history is limited, e.g., "History limited by somnolence" or "Patient intoxicated at time of interview." State plan to obtain collateral if needed.)

History of Present Illness

[Narrative description of why the consult is occurring now, including triggering events and timeline] (Attribute behavioral observations to specific sources and times. Note precipitants: medication changes, ICU course, sleep disruption, pain, infection, metabolic issues, intoxication/withdrawal risk. Use brief quotes for pivotal statements informing risk or capacity.)

Psychiatric Symptom Review

[Relevant symptom domains pertinent to the consult question: mood, anxiety/panic, mania/hypomania, psychosis, cognition, sleep/appetite, substance use/withdrawal, safety] (Include only domains directly relevant to the consult question; omit non-contributory domains. If safety screening not performed, explicitly state why and when reassessment will occur.)

Pertinent Background

(Include only subsections relevant to clinical reasoning. Omit irrelevant subsections entirely rather than populating with "Unknown." When relevant but unobtainable, document "Unable to obtain due to..." and plan to obtain collateral.)

Past Psychiatric History

[Prior diagnoses and similar episodes; psychiatric hospitalizations; prior suicide attempts/self-harm with method, lethality, timing; history of violence; prior medication trials with responses and adverse effects]

Substance Use

[Substances used, patterns, last use; withdrawal risk and prior withdrawal history; treatment history; current MOUD if applicable]

Relevant Medical History

[Neurologic disease, organ failure, endocrine/metabolic disorders, chronic pain, sensory impairment, or other conditions affecting mental status]

Current Medications

[Home psychiatric medications and adherence; current medications affecting cognition/behavior (opioids, benzodiazepines, anticholinergics, steroids, dopaminergics)]

Allergies

[Agent and reaction] (Differentiate intolerance vs true allergy when possible.)

Social History

[Living situation, supports/caregivers, baseline functioning; access to lethal means when safety is a concern]

Family History

[Serious mental illness, suicide, or substance use disorders in first-degree relatives] (Include only if it informs risk or treatment.)

Objective Data

Vital Signs: [Relevant vitals and trends] (Include when agitation, delirium, or medical instability is a concern.)

Laboratory/Imaging/EKG: [Pertinent results; highlight abnormalities driving formulation]

Nursing/Behavioral Observations: [Agitation episodes, sleep/wake patterns, restraint use, elopement attempts, 1:1 observation, PRN administrations and responses]

Mental Status Examination

Exam Date/Time: [When examined] (If no exam performed, document why and note limitations.)

Appearance: [Brief objective description]

Behavior/Cooperation: [Engagement, eye contact, cooperation, agitation]

Psychomotor Activity: [Normal / increased / decreased; abnormal movements]

Speech: [Rate, volume, fluency, articulation]

Mood (patient-reported): [Patient's description]

Affect (observed): [Quality, range, reactivity, congruence]

Thought Process: [Coherent/goal-directed/linear vs disorganized/tangential]

Thought Content: [Suicidal or homicidal ideation, delusions, obsessions]

Perception: [Hallucinations or illusions if present]

Cognition: [Orientation, attention, memory; bedside testing if performed; note fluctuations if delirium suspected]

Insight: [Assessment-based description]

Judgment: [Assessment-based description]

Risk Assessment

(Include when any of the following apply: suicidal ideation, self-harm, ambiguous statements, severe depression, psychosis, intoxication/withdrawal, delirium with impulsivity, threats/aggression, or when safety evaluation is specifically requested. If risk cannot be fully assessed, document interim safety measures and plan for reassessment.)

Suicide/Self-Harm Risk

[Current ideation, plan, intent, access to means, preparatory behaviors; relevant past attempts; risk and protective factors; structured tool and result if used; disposition-linked actions: observation level, environmental precautions, safety planning, lethal means counseling]

Violence/Aggression Risk

[Homicidal ideation with target, plan, intent; weapon access; past violence; current agitation drivers; staff safety guidance if needed]

Capacity Assessment

(Include only when relevant: refusal of essential treatment, leaving AMA when unsafe, consent for high-risk procedures, code status decisions, or when capacity evaluation is specifically requested.)

Decision Being Assessed: [Specific decision] (Capacity is decision-specific, not global.)

Information Provided to Patient: [What was explained and by whom]

Functional Abilities Assessment:

• Communicating a choice: [Document with supporting evidence]
• Understanding relevant information: [Document with supporting evidence]
• Appreciation of situation and consequences: [Document with supporting evidence]
• Reasoning: [Document with supporting evidence]

Conclusion: [Patient has / lacks] capacity for [specific decision] at this time.

Reversible Contributors: [Delirium, intoxication, metabolic or medication effects; reassessment plan if applicable]

If Lacks Capacity: [Surrogate decision-maker, legal/ethical pathway per policy, interim safety steps]

Assessment

[Concise synthesis linking medical context, mental status, behavioral observations, and objective data to diagnosis or syndromic impression] (Use problem-oriented format when multiple issues are present. Label uncertainty appropriately: "likely," "possible," "cannot rule out." Include differential diagnosis when clinically important, contributing/maintaining factors, and expected trajectory.)

1. [Problem 1]: [Synthesis, likely diagnosis, key contributors, expected trajectory]
2. [Problem 2]: [As above, if applicable]

Recommendations

(Answer each consult question directly. Use numbered recommendations with clear actions, timing, and responsibility. Include categories below as applicable.)

Safety/Milieu: [Observation level and duration; environmental modifications; de-escalation approach; criteria to escalate/de-escalate]

Non-Pharmacologic: [Sleep optimization, orientation strategies, mobilization, sensory aids, pain management coordination, behavioral interventions]

Pharmacologic: [Start/stop/adjust medications with dose, route, frequency, indication; monitoring parameters; PRN strategy with indication and max daily dose] (Note interactions, organ function adjustments, QTc/EKG needs, EPS/sedation/fall risk.)

Diagnostic: [Additional labs, toxicology, imaging, cognitive testing, specialty consultations; plan to obtain collateral]

Capacity-Related: [Surrogate pathway, ethics/legal steps if lacking capacity; reassessment timeline] (Include only if capacity assessment performed.)

Disposition: [Criteria for psychiatric admission vs medical management with follow-up] (Explicitly state if psychiatric admission is not indicated when this is a key question.)

Communication and Follow-up

Discussed With: [Names and roles of clinicians; date/time]

Patient/Family Communication: [What was discussed and with whom]

Coordination: [Other services involved: social work, addiction medicine, neurology, outpatient psychiatry]

Follow-up Plan: [Behavioral Medicine will continue to follow daily / Sign-off today; re-consult if (specific triggers)] (If signing off, restate active issues, what is stabilized, and how to reach the service.)