Consultation-Liaison Psychiatry Consult Note

Date/Time of Encounter: [Date and time]

Patient Location: [Unit and room]

Requesting Service/Team: [Service or team name]

Contact Person: [Name, role, and contact method]

Consult Priority: [routine / urgent / emergent] (Include only if specified.)

Sources of Information

• Patient interview: [interviewed / unable to interview] (If unable, state reason and what was attempted.)
• Chart review: [Sources reviewed: prior psychiatric notes, MAR, vital trends, nursing notes, recent labs/imaging, consult notes] (List only sources actually reviewed.)
• Collateral contacts: [Family, nursing, primary team, outpatient providers, EMS, other] (Include names/roles and substance of contact. If attempts made but unavailable, document attempts.)
• Interpreter: [Language and modality] (Include only if used.)
• Reliability and limitations: [Specific limitations affecting data reliability and their causes] (Do not use N/A; state specific limitations or absence thereof.)

Reason for Consultation

[Consult question reformulated into actionable clinical tasks] (1–3 sentences. Examples: diagnostic clarification, capacity for specific decision, safety assessment, treatment recommendations, behavioral management plan.)

Brief Clinical Context

[Age, admission diagnosis, hospital day, key medical comorbidities, neuropsychiatric risk factors, and current clinical status impacting evaluation] (1–3 sentences. Avoid duplicating full chart.)

History of Present Illness

[Focused narrative anchored to consult question: time course and precipitants; target symptoms tied to consult question; relevant hospital course; medication contributors and timing; substance exposure or withdrawal timeline if relevant; delirium features if applicable; patient perspective with clarifying direct quote if relevant]

Collateral: [Information attributed to specific sources with discrepancies noted] (If history unobtainable, document attempts, cause, and objective data substitutes.)

Psychiatric Review of Symptoms

(Include when diagnostic uncertainty exists. Omit if delirium prevents meaningful assessment or if consult question is narrow and mental state is well characterized elsewhere; document reason for omission.)

• Mood/depression: [Symptoms]
• Anxiety/panic: [Symptoms]
• Mania/hypomania: [Symptoms]
• Psychosis: [Hallucinations, delusions, disorganization]
• Trauma-related: [Symptoms] (Include only if relevant.)
• Cognitive: [Memory, attention, executive concerns]

Safety and Risk Assessment

• Suicide and self-harm:
  • Ideation: [none / passive / active]
  • Intent and plan: [Details if present]
  • Preparatory behaviors: [Details]
  • Prior attempts: [Number, methods, most lethal, timing]
  • Recent self-injury: [Details]
  • Access to lethal means: [Firearms, medications, other]
• Violence risk:
  • Ideation and intent: [Details]
  • Identified target: [If applicable]
  • Access to weapons: [Details]
  • Recent aggression and triggers: [Behavioral incidents and context]
• Other acute risks: [Elopement, inability to adhere to medical care, severe impulsivity, intoxication/withdrawal concerns]
• Protective factors: [Supports, reasons for living, therapeutic alliance, coping skills]
• Current mitigation: [Observation level, sitter, ligature precautions, visitor restrictions, environmental changes]
• Risk level: [low / moderate / high] Rationale: [Clinical reasoning and factors that would change risk level]

Psychiatric and Substance Use History

• Prior diagnoses: [Document as "history of" unless currently confirmed]
• Psychiatric hospitalizations: [Number and most recent]
• Suicide attempts and self-injury history: [Details]
• Violence history: [Details]
• Medication trials: [Effective, ineffective, adverse reactions]
• Current outpatient treatment: [Providers, frequency, adherence]
• Baseline cognition and function: [If known]
• Substance use: [Alcohol, opioids, sedatives, stimulants, cannabis, other; last use, quantity, route; withdrawal history; current tox/EtOH results; prior treatment]

(If history unobtainable, state why.)

Medical History and Allergies

• Relevant medical comorbidities: [Conditions impacting psychiatric care: seizure disorder, hepatic/renal impairment, dementia, OSA, parkinsonism, cardiac conduction disease]
• Allergies and adverse reactions: [Differentiate true allergy from intolerance]

Medication Review

• Home psychotropics: [Medications with doses and adherence]
• Current inpatient psychotropics: [Scheduled and PRN with relevant start/stop dates]
• High-risk non-psychiatric medications: [Steroids, anticholinergics, opioids, benzodiazepines, dopaminergics]
• Recent medication changes: [Changes temporally linked to symptoms]
• Safety considerations: [QTc, sedation, respiratory risk, interactions] (Include only if relevant.)

Mental Status Exam

• Appearance, behavior, arousal, psychomotor: [Findings] (If unable to assess, state why.)
• Speech: [Rate, volume, fluency]
• Mood: [Patient's words]
• Affect: [Range, reactivity, congruence]
• Thought process: [Coherence, organization, goal-directedness]
• Thought content: [SI/HI, delusions, obsessions, preoccupations]
• Perception: [Hallucinations, illusions]
• Cognition: [Orientation; attention testing if delirium evaluation; memory/abstraction if relevant]
• Insight and judgment: [Assessment]

Objective Data Reviewed

• Vital signs: [Relevant trends with dates/times]
• Key labs: [CBC, CMP, glucose, ammonia, TSH, B12/folate, UA, tox screen with dates]
• Imaging and neurodiagnostics: [CT/MRI brain, EEG with dates and findings]
• EKG: [QTc value with timestamp; relevant conduction findings]
• Lines, tubes, restraints, sedation: [Current devices and sedative exposure]
• Screening tools: [Scores with timestamps: delirium screens, withdrawal scales, cognitive tests]

(If no data reviewed, state explicitly.)

Assessment and Formulation

[Biopsychosocial formulation integrating medical contributors and hospital context]

Differential diagnosis: [Ranked list with brief rationale, prominently including medical and medication causes when relevant]

Working diagnoses: [Problem list]

Delirium assessment: [Fit with criteria, likely contributors, suspected vs confirmed] (Include only when delirium is being evaluated.)

Capacity assessment: [Specific decision evaluated; information disclosed to patient; assessment of understanding, appreciation, reasoning, and ability to express choice; barriers identified; conclusion as has capacity or lacks capacity for specific decision at this time; next steps if lacking] (Include only when capacity is the consult question.)

Recommendations and Plan

(Organize by problem in order of urgency. Include only applicable sections.)

• Safety precautions: [Observation level, environmental measures, restrictions with rationale]
• Delirium management: [Nonpharmacologic interventions, workup recommendations, contributors to address] (Include only if delirium suspected.)
• Agitation management: [De-escalation strategies, PRN algorithm with indications and sequencing, monitoring parameters]
• Psychiatric treatment: [Medication recommendations: drug, dose, route, frequency, indication, stop/hold parameters, monitoring requirements, rationale; nonpharmacologic interventions]
• Substance use management: [Withdrawal protocol, medications, monitoring, counseling/referral] (Include only if applicable.)
• Sleep optimization: [Nonpharmacologic measures; medications if indicated]
• Behavioral and environmental interventions: [Triggers, communication approach, staff consistency, reorientation, sensory aids, mobilization, family involvement]
• Disposition: [Psychiatric admission vs outpatient vs no psychiatric barrier to discharge; transition criteria]

Role clarity: [What psychiatry will manage vs what primary team should implement]

Follow-up plan: [daily / one-time with re-consult PRN / other] (Include triggers for re-evaluation.)

Communication

• Method and timing: [Verbal discussion / paging / secure messaging with timestamp]
• Recipient: [Name and role]
• Key content communicated: [Safety precautions, urgent medication changes, capacity conclusions, critical recommendations]
• Patient communication: [What was explained and patient response]

(If unable to reach team, document attempts and escalation.)

Legal and Regulatory Considerations

(Include only when relevant: capacity conclusions with surrogate identification, restraint/seclusion with least restrictive rationale, involuntary hold processes, firearms counseling, safety planning documentation.)

[Relevant legal and regulatory documentation]