Crisis Psychiatry Evaluation Note (ED/Urgent)

Date/Time: [Evaluation timestamp and location (ED / PES / urgent care)]

Evaluator: [Clinician name and role]

Referral Source/Consult Question: [Who requested evaluation and primary consult question]

Reason for Urgent Evaluation: [Brief crisis description (e.g., SI with plan, agitation requiring medication, new psychosis)]

Legal/Administrative Status: [voluntary / involuntary hold / detention / seclusion / restraints / 1:1 observation / other] (Omit if not applicable.)

Interpreter: [Language and modality] (Omit if not applicable.)

Chief Concern / Reason for Evaluation

[Patient-stated chief concern in quotation marks when available]

[Reason psychiatry was consulted if different from patient concern; immediate safety concerns (SI/HI/agitation/elopement risk); medical stability issues affecting evaluation (intoxication, delirium concern, head injury); core decision needed today (discharge vs admit, voluntary vs involuntary, medical vs psychiatric bed)]

Sources / Collateral / Reliability

• Primary historian: [Patient vs other; participation level and limitations such as intoxication or sedation]
• Collateral obtained: [Names/roles/relationships; method (phone/in-person); key corroborating or discrepant information] (If not obtained, state attempts made, patient consent/refusal, and barriers. If refusal overridden due to imminent risk, document rationale per policy.)
• Records reviewed: [Recent ED notes, inpatient/outpatient psychiatry, prior discharges, crisis line documentation, PDMP; salient findings]
• Reliability assessment: [e.g., guarded, inconsistent timeline, collateral corroborates; specify reasons]

HPI (Crisis-Focused)

[Baseline mental health and functioning—typical mood, psychosis, substance use, sleep, supports, adherence]

[Precipitants and triggers—interpersonal conflict, loss, trauma reminder, housing/legal stress, substance use, medication nonadherence, medical illness, insomnia]

[Escalation and current symptoms—onset, severity, and change from baseline for depression, hopelessness, anxiety, insomnia, mania symptoms, psychosis (hallucinations/delusions with quotes for command content when clinically necessary), behavioral agitation (objective descriptions such as pacing/shouting/throwing objects), intoxication or withdrawal symptoms]

[Treatment context—current providers, recent medication changes, adherence, recent discharges, missed appointments]

[ED arrival and course to evaluation—mode of arrival, restraints/sedation used, response to de-escalation or medications]

[Patient goals and preferences today—help-seeking vs ambivalent vs refusing; desired disposition]

(If patient cannot participate due to agitation, intubation, or somnolence: document that history is limited, summarize observed behaviors and collateral-based history, and note plan/timing for re-evaluation.)

Past Psychiatric History

• Prior diagnoses: [Documented vs patient-reported]
• Prior inpatient/residential treatments: [Most recent first with dates if known]
• Suicide attempt history: [Method, lethality, medical severity, date of last attempt; aborted/interrupted attempts]
• Non-suicidal self-injury: [History and methods]
• Violence history: [Assaults, weapons use, restraining orders, incarceration related to violence]
• Prior psychiatric medications: [Effective agents, adverse reactions, allergies]
• Trauma history: [Include only if relevant to current crisis]

Substance Use

• Substances: [Type; last use timing; typical pattern; recent binge or escalation]
• Withdrawal risk: [Alcohol/benzodiazepine focus; prior withdrawal seizures or DTs]
• Relationship to current symptoms: [Connection to SI, psychosis, or agitation]
• Objective data: [UDS, BAL, other labs] (Include only if used in clinical reasoning.)

Medical History & Medications

• Key comorbidities: [Conditions affecting mental status or disposition—TBI, seizures, chronic pain, pregnancy, dementia, endocrine disease]
• Current medications: [Psychiatric and high-yield non-psychiatric (e.g., steroids); adherence issues]
• Allergies: [Medication and reaction type]

Social / Environment / Supports

• Living situation: [Alone vs with others; housing stability; shelter status]
• Supports: [Who can participate in safety planning; ability and willingness to supervise]
• Employment/school: [Current status; recent losses or stressors]
• Legal status: [Include only if impacting risk or disposition]
• Follow-up access: [Transportation and phone availability]
• For minors: [Guardian/custody status, supervision capacity, school context] (Include only if applicable.)

Targeted Medical Symptom Screen

[Pertinent positives and negatives—head trauma, seizure, fever, chest pain, shortness of breath, confusion, sleep deprivation, pain; for psychosis/mania presentations include delirium red flags (fluctuation, inattention, new focal neurologic symptoms)]

(Omit this section if no medical concerns impact the differential or if already addressed elsewhere.)

Objective (Pertinent)

• Vital signs: [Pertinent values]
• Physical/neurologic exam: [Pertinent findings]
• Behavioral observations: [Agitation episodes, elopement attempts, security involvement; objective descriptions]
• Labs/imaging: [Results reviewed and used in decision-making]
• ED interventions: [Medications given with dose/route/time and observed response]

(If no objective data were reviewed at time of evaluation, state explicitly.)

Mental Status Examination

• Appearance: [Grooming, clothing, signs of intoxication or withdrawal]
• Behavior/psychomotor: [Cooperation, agitation, retardation, abnormal movements]
• Speech: [Rate, volume, pressure, latency]
• Mood: [Patient's words]
• Affect: [Range, intensity, congruence, stability]
• Thought process: [Linear / circumstantial / tangential / disorganized / flight of ideas]
• Thought content: [SI (current/passive/active), HI, delusions, guilt, hopelessness, obsessions/intrusive thoughts (clarify ego-dystonic vs ego-syntonic)]
• Perception: [AH/VH, command hallucinations, response to internal stimuli]
• Cognition: [Orientation, attention/concentration, memory grossly]
• Insight: [Level of awareness of illness]
• Judgment: [Assessment of decision-making capacity]
• Impulse control: [Observed or reported]

(Note reliability/validity concerns such as intoxication. Specify any elements unable to assess with reason.)

Suicide Risk Assessment & Formulation

Screening/assessment tools: [Tool name, time administered, result] (Do not imply tool score alone determines disposition.)

Suicide Inquiry

• Ideation: [Passive vs active; frequency; intensity; duration; worst point]
• Intent: [Degree of intent; ambivalence; reasons to die vs reasons to live]
• Plan: [Specificity; timing; location; lethality; feasibility]
• Preparatory behaviors: [Acquiring means, note-writing, rehearsal, giving away belongings]
• Past suicidal behavior: [Attempts with method/lethality/rescue; aborted or interrupted attempts]
• Non-suicidal self-injury: [Current and historical]
• Substance use: [Proximate to ideation or behavior]
• Contributing factors: [Psychosis/mania, command hallucinations, severe insomnia, impulsivity, recent losses/trauma/humiliation]

Lethal Means Access & Counseling

• Firearms: [Home/vehicle/relative's home; loaded/unlocked; who controls access; immediacy of access]
• Medications: [Stockpiles; opioids/benzodiazepines; access to others' medications]
• Other means: [Ligatures, heights, sharp objects as relevant]
• Means counseling performed: [What was counseled; specific action plan—who will do what, where items stored, by when]

Risk and Protective Factors

• Static risk factors: [Prior attempts, chronic illness, long-standing SUD, trauma history]
• Dynamic risk factors: [Current intoxication, acute insomnia, escalating conflict, new firearm access, medication nonadherence, worsening psychosis]
• Protective factors: [Behaviorally anchored—e.g., "agrees to call sister and stay with her tonight"]

Risk Level & Justification

Acute risk: [Level with justification tied to dynamic factors]

Chronic/baseline risk: [Level with justification]

[How risk level informs disposition and safety measures today]

(If unable to complete assessment: document elements attempted, why completion was not possible, interim safety actions taken, and plan/timing for reassessment.)

Violence Risk / Homicidality

(Include this section only when relevant to presentation.)

• HI or threats: [Target, intent, plan, access to weapons, proximity]
• Recent violent acts: [Objective descriptions and timing]
• Contributing factors: [Intoxication, withdrawal, delirium, impulsivity, command hallucinations]
• Protective factors: [Supervision, separation from target, engagement with care]
• Duty-to-warn/protect actions: [Recipients and rationale per local policy] (Avoid unnecessary PHI.)

Capacity / Consent / Refusal

(Include when decisions hinge on capacity assessment.)

• Capacity assessed for: [Hospitalization / medications / interview / collateral contact / safety planning / transfer]
• Basis for incapacity: [Delirium, severe intoxication, psychosis impairing reality testing] (If applicable.)
• Authority used: [Surrogate or emergency authority per institutional policy]

Assessment

[Clinical synthesis—primary working diagnoses and key differentials (primary psychiatric vs substance-induced vs medical/delirium); supporting data from symptom pattern, time course, toxicology, prior history, MSE findings; primary safety concerns (suicide, violence, grave disability) with dynamic factors driving risk]

Plan

• Safety/observation: [Observation level, ligature/elopement precautions with rationale]
• Agitation management: [Non-pharmacologic de-escalation attempted; PRN medications (drug/dose/route/time/response); if restraint/seclusion used, summarize clinical necessity, alternatives attempted, and response]
• Suicide-specific interventions: [Safety plan completion; lethal means counseling with concrete plan; crisis resources provided]
• Medications: [Start/continue/hold with rationale; precautions (QTc, withdrawal prophylaxis)]
• Medical issues: [Evaluation/management steps relevant to mental status or disposition]
• Referrals/consults: [Psychiatry, addiction medicine, social work, medical services; reason and urgency]
• Communication: [Who notified (ED attending, nursing, family, accepting facility) and agreed-upon plan]
• Pending: [Labs/imaging awaited; re-evaluation timing; collateral calls planned]

Disposition & Level of Care Rationale

Disposition: [Discharge home with self-care / discharge to supervised setting / crisis stabilization or observation unit / voluntary psychiatric admission / involuntary psychiatric admission or hold initiated / medical admission with psychiatry follow-up / transfer to outside psychiatric facility / other]

Rationale: [Why this level of care is appropriate today—tie to acute risk formulation, dynamic factors, safety planning ability, capacity and willingness, lethal means access and mitigation, supervision/supports, outpatient follow-up feasibility. If admitting/holding, document why less restrictive options are insufficient. If discharging, document why higher levels are not required.]

If Discharging

• Safety plan: [Completed and provided / refusal documented]
• Lethal means plan: [Who will do what; storage/removal location; by when]
• Follow-up: [Appointment arranged or referral made; warm handoff actions]
• Crisis resources: [988, local crisis line, ED return instructions]
• Return precautions: [Behaviorally specific warning signs]
• Supervision: [Who will monitor; environment confirmed safe (names/roles)]

If Admitting or Transferring

• Admission type: [Voluntary / involuntary or hold] and legal status
• Medical stability: [Considerations affecting placement]
• Precautions: [Required on receiving unit]
• Handoff: [Receiving team/facility; acceptance confirmation]

ED Course / Interval Reassessment

[Time-stamped addenda for post-sobriety reassessment, post-medication reassessment, new collateral obtained, or changes in disposition. Document time, what changed, and impact on assessment/plan.]

(Global instructions: Omit sections not clinically relevant or assessed. Use explicit "unable to assess" statements with reason and reassessment plan for critical domains. Do not auto-populate "denies" unless directly assessed. Do not infer denial of SI, HI, firearm access, or safe supervision—document explicitly or state assessment was limited. Label acceptable inferences as such. For involuntary holds, document clinical facts supporting criteria and reference local policy rather than asserting legal conclusions. Use objective, non-stigmatizing language; include verbatim quotes only when clinically necessary.)