Consultation-Liaison Psychiatry Consult Note (Pediatric Inpatient)

Date/Time of Service: [Date and time]

Patient Name: [Full name]

MRN: [Medical record number]

Age: [Age in years; include months if under 5 years]

Location/Unit: [Unit and bed location]

Requesting Service: [Service name]

Requesting Clinician: [Name and role]

Reason for Consult: [Brief reason in requesting service's words]

Admission Diagnosis: [Primary medical diagnosis or diagnoses]

Hospital Day: [Number]

Interpreter Used: [Language, modality, and interpreter ID / not required]

History Obtained From: [Patient / parent or guardian (name, relationship) / bedside nurse / primary team / chart review / outpatient clinician] (List all sources used today)

Guardian/Decision-Maker: [Name, legal relationship, authority scope] (Include only if relevant to today's consult)

Consult Question

• Verbatim consult request: [Exact wording from order or requesting clinician]
• Clarified psychiatric question: [Specific operationalized question being addressed today]
• Consultation type: [Diagnostic clarification / safety assessment / agitation management / capacity or assent evaluation for (specific decision) / medication recommendations]
• Clarification obtained: [Contact name and agreed-upon question] (Include only if original request was vague)

Sources of Information

• Informants interviewed: [Names, roles, and relationship to patient]
• Chart review: [Key records reviewed with dates]
• Outpatient provider contact: [Name, role, date and time of contact] (Include if obtained)
• Reliability statement: [Comment on consistency and reliability of sources]
• Collateral pending: [Attempts made and status] (Include if collateral not yet obtained)

Chief Complaint

[Presenting concern in patient's own words, or attributed to source: "Per (source): (concern)"]

History of Present Illness

Brief admission summary and psychiatry involvement: [3–5 sentence overview of admission reason, key medical events, current status, and why psychiatry is consulted]

Medical course and timeline: [Admission reason; ICU course and procedures; sedation and analgesia exposure; infections or metabolic derangements; pain; sleep; delirium risk factors]

Psychiatric symptom timeline: [Onset; fluctuation pattern; relation to procedures or medications; sleep disruption; diurnal variation; course since admission]

Target symptoms relevant to consult: [For delirium: fluctuation, inattention, altered awareness, disorientation, perceptual disturbances, sleep-wake disruption] [For mood/anxiety: mood state, anhedonia, irritability, worry, somatic symptoms compared to baseline] [For agitation: antecedents, triggers, escalation pattern, effective and ineffective strategies] [For capacity: specific decision pending and urgency]

Baseline functioning: [Home cognitive and behavioral baseline; school functioning; neurodevelopmental diagnoses; IEP/504 services]

Patient and family understanding: [Understanding of illness; key stressors; alignment or conflict with medical team goals; preferences and values] (Use direct quotes sparingly, only when clinically essential)

Safety and Risk Assessment

• Suicidal ideation and behaviors: [Presence or absence; frequency; plan; intent; preparatory behaviors; past attempts with brief method, lethality, and dates] (If unable to assess, state reason)
• Self-harm (NSSI): [Methods, frequency, medical severity, functions and triggers]
• Violence and aggression risk: [Threats; assaultive behaviors; agitation severity; delirium-driven behaviors]
• Elopement risk: [Risk factors; recent attempts; environmental vulnerabilities]
• Abuse or neglect concerns: [Concerns identified; mandated reporting status; actions taken] (Include only if applicable)
• Protective factors: [Caregiver supervision and engagement; reasons for living; coping skills; treatment alliance; supports]

Risk summary: Acute suicide risk: [low / moderate / high]. Self-harm risk: [low / moderate / high]. Violence/aggression risk: [low / moderate / high]. Elopement risk: [low / moderate / high].

Mitigation plan: [Observation level; 1:1 sitter; environmental restrictions; visitor restrictions; de-escalation plan; means restriction; duration and review time]

Past Psychiatric History

• Diagnoses: [Past and current working diagnoses relevant to management]
• Prior hospitalizations and ED visits: [Dates, indications, outcomes]
• Past suicide attempts and NSSI: [Methods, medical severity, dates]
• Aggression or legal history: [Brief summary] (Include only if relevant to safety)
• Treatment history: [Therapy modalities; PHP/IOP; outpatient prescribers]
• Medication trials: [Agents, dose ranges, duration, response, adverse effects including activation, EPS, QTc, paradoxical reactions]
• Trauma history: [Relevant highlights only]
• Unable to obtain: [Reason] (Include if history unavailable)

Medical History

• Conditions relevant to psychiatric management: [Cardiac disease; epilepsy and seizure risk; hepatic and renal impairment; endocrine disorders; respiratory status; pain]
• Neurologic baseline: [Cognitive and motor baseline; prior TBI; developmental considerations]
• Current delirium risk factors: [Infections; metabolic disturbances; polypharmacy; immobilization; sensory impairment; sleep deprivation]

Background History

• Developmental history: [Milestones; language; learning disorders; IEP/504; autism, ADHD, or intellectual disability; services received]
• Family psychiatric history: [Psychiatric diagnoses, suicide history, substance use in first-degree relatives]
• Social context: [Living situation; custody and legal decision-maker; school status; peer supports; key stressors; child welfare or legal involvement; substance use]

(This section may be abbreviated if well-documented and not pertinent to today's consult)

Medications and Allergies

• Current inpatient medications (psychiatry-relevant): [Sedatives; analgesics; anticholinergics; steroids; antiemetics; QT-prolonging agents; serotonergic agents]
• Home psychotropics: [Agent, dose, schedule, last taken; adherence pattern]
• Patient weight: [Weight in kg]
• Renal and hepatic function: [Summary if relevant to prescribing]
• EKG/QTc: [Date and QTc in ms] (Include if considering QT-active agents or if available)
• Allergies and adverse reactions: [Agent and reaction type: true allergy / intolerance / behavioral activation]

Objective Data Reviewed

• Vital sign trends: [Pertinent trends with dates and times]
• Pertinent labs: [Electrolytes; glucose; LFTs; renal function; ammonia; TSH; toxicology with dates]
• EKG, imaging, or EEG: [Findings with dates] (Include if relevant)
• Delirium screening scores: [Tool name, scores, dates] (Include if unit uses validated tool)

Mental Status Examination

• Appearance and behavior: [Grooming; attire; activity level; abnormal movements]
• Cooperation and eye contact: [Cooperative / guarded / irritable; eye contact quality]
• Speech: [Rate; volume; articulation; spontaneity]
• Mood: [Patient-stated mood or observed affective tone]
• Affect: [Range; intensity; stability; congruence]
• Thought process: [Linear / goal-directed / circumstantial / tangential / disorganized]
• Thought content: [SI/HI; obsessions; delusions; themes; state if denies or unable to report]
• Perceptual disturbances: [Hallucinations or illusions; responses to internal stimuli]
• Cognition: [Level of arousal; orientation; attention with age-appropriate testing; memory]
• Insight: [Age-appropriate understanding of condition]
• Judgment: [Safety and decision-making in current context]
• Reliability: [Good / fair / poor with brief rationale]

Delirium-focused observations: [Fluctuation; arousal level; inattention testing results; disorientation; perceptual disturbances; sleep-wake pattern; tool scores] (Include if delirium is the consult question)

(If patient is not interviewable, document observational MSE: arousal level, spontaneous behaviors, speech output, response to stimuli, and pertinent nursing observations)

Assessment

[2–4 sentence integrative summary linking medical illness, medications, developmental context, and psychosocial factors to current presentation]

Differential diagnosis: [Delirium or acute encephalopathy / primary psychiatric disorder / medication or substance effect / other] (Prioritize and justify briefly)

Working diagnoses: [Primary and secondary psychiatric diagnoses using DSM terminology; medical diagnoses impacting mental status]

Biopsychosocial formulation: [Biological: medical etiologies, medications, sleep, pain] [Psychological: coping, trauma reactions, illness meaning] [Social: family stressors and supports, school disruption, resources]

Capacity or assent evaluation: [Decision: specific decision evaluated] [Understanding: findings] [Appreciation: findings] [Reasoning: findings] [Communication of choice: findings] (Include only if capacity consult; capacity is decision-specific)

Plan

(Organize by problem in order of clinical priority)

[Problem 1: Name]

• Nonpharmacologic interventions: [Environmental modifications; reorientation; family presence; coping strategies; de-escalation plan; sleep hygiene]
• Medication recommendations: [Agent] [weight-based dose in mg/kg] [route] [frequency]; max [dose per day]. [Indication and rationale; alternatives considered]
• Monitoring: [Vitals; EPS; sedation; QTc with repeat EKG timing; labs as indicated]
• Follow-up: [Re-evaluation timing; escalation thresholds; PRN parameters]

[Problem 2: Name]

• [Use same structure as above]

Delirium and acute encephalopathy: (Include if relevant)

• Etiology workup: [Targeted labs, imaging, or EEG suggestions within psychiatry scope]
• Nonpharmacologic bundle: [Reorientation cues; day-night normalization; minimize overnight disruptions; early mobilization; optimize pain control; ensure sensory aids; caregiver presence; minimize tethers]
• Medication review: [Reduce or avoid deliriogenic agents; simplify regimen; adjust anticholinergics, benzodiazepines, or steroids]
• Pharmacologic for severe distress: [Antipsychotic agent, dose in mg/kg, route, frequency, PRN limits, monitoring] (Reserve for refractory symptoms impacting safety)

Agitation and behavioral dysregulation: (Include if relevant)

• Likely drivers: [Delirium / withdrawal / anxiety or trauma / psychosis / pain / environmental factors]
• Stepwise approach: [Environmental modification] → [Verbal de-escalation and sensory tools] → [PRN medication: agent, dose in mg/kg, route, frequency, max per 24 hours]
• What helps and what to avoid: [Specific strategies]

Suicide and self-harm risk: (Include if relevant)

• Observation level: [Level and duration with rationale]
• Safety planning: [Triggers identified; coping strategies; caregiver roles; means restriction counseling]
• Disposition considerations: [Psychiatric admission criteria; medical stability prerequisites; barriers]

Anxiety, depression, or adjustment: (Include if relevant)

• Supportive interventions: [Psychoeducation; coping strategies; family coaching]
• Medication if indicated: [Agent, dose, titration plan, expected onset, side effects, monitoring]

Capacity or assent recommendation: (Include if relevant)

• Decision evaluated: [Specific decision and urgency]
• Recommendation: [Proceed with guardian consent / defer until delirium improves / ethics consult / additional education needed]

Ownership and follow-up:

• Psychiatry team will: [Re-evaluate by date and time; obtain collateral from specific contacts; coordinate with outpatient providers]
• Primary team to: [Implement specific orders and precautions; monitoring; arrange family meeting]
• Page psychiatry urgently for: [Escalating agitation unresponsive to plan; new suicidal statements or behaviors; acute mental status change; medication adverse event]

Communication and Disposition

• Recommendations communicated to: [Names and roles] via [in-person / phone / page / EHR message] on [date and time]
• Psychiatric admission considerations: [Medical stability prerequisites; bed availability; barriers; contingency plan] (Include if applicable)
• Care coordination needs: [Family meeting; social work; school liaison; outpatient follow-up planning; handoff items]