Emergency Department Psychiatry Evaluation (Pediatric)

Date/Time: [Evaluation date and time]

Location: [ED room / consult room / telepsychiatry]

Evaluator: [Name, credentials, role]

Reason for Consult: [Requesting party and specific clinical question]

Patient: [Full name], [DOB], [Age], [MRN]

Legal Guardian/Decision-Maker: [Name(s), relationship, and who is present]

Arrival: [Arrived with: family / EMS / police / school]; [Legal status: voluntary / involuntary hold]

Chief Complaint

[Primary reason for presentation] (Use patient's or guardian's words when illuminating; use quotation marks for key statements.)

Sources and Reliability

• Patient interview: [alone / with caregiver present]; [Interpreter: yes / no]; [Limits of confidentiality explained: yes / no] (For adolescents, document offer of time alone.)
• Parent/Guardian interview: [Name, relationship, and key information provided]
• Collateral sources: [EMS / police / school / outpatient providers / prior records and summary of information obtained]
• Missing collateral: [Who was contacted, method, and outcome] (Include only if key collateral was not obtained.)
• Overall reliability: [good / fair / poor] — [Brief rationale]

ED Course

(Include only if relevant psychiatric safety interventions or behavioral events occurred. Omit if uneventful.)

• Observation level: [standard / 1:1 / elopement / violence precautions]
• Behavioral events: [agitation / elopement attempt / aggression / self-injury and brief summary]
• Restraints/seclusion: [none / physical / chemical / seclusion] — [Indication, duration, response]
• PRN medications: [Agent, dose, route, time, response]
• Medical clearance issues: [Pertinent findings affecting psychiatric differential or disposition]

History of Present Illness

[Precipitating events and stressors leading to ED presentation today]; [Crisis behaviors observed or reported]; [Onset, duration, course, and escalation] (2–4 paragraphs, narrative format.)

[Patient's stated intent and meaning] (Use direct quotes for high-stakes statements.) [Caregiver's interpretation if different]; [Developmental appropriateness of understanding regarding death and permanence]

[Functional impact: school, sleep, appetite, social withdrawal]; [Interventions attempted before arrival and response]; [School context: IEP/504 status, disciplinary actions, school safety assessments if relevant]

[Substance use or intoxication/withdrawal context if relevant]; [Recent losses, trauma, or precipitating events temporally linked to crisis]

Suicide and Safety Assessment

• Screening tool: [Tool name and result] (Include only if performed.)
• Current suicidal ideation: [present / absent]; [frequency, intensity, triggers, controllability]
• Plan: [specific / vague / none]; [method and feasibility]; [preparatory behaviors]
• Intent: [desire to die / desire to escape / ambivalent / denies]; [deterrents]
• Access to means: [firearms / medications / sharps / ligatures] — [Availability at home, relatives' homes, school]
• Recent suicidal behaviors: [Description, dates, medical consequences]
• History of suicide attempts: [Number, methods, lethality, most recent date and circumstances]
• Non-suicidal self-injury: [Method, frequency, function] (Include only if present.)
• Protective factors: [Reasons for living, supportive relationships, future orientation, treatment engagement]
• Contagion exposure: [Peer attempts/deaths, social media, community cluster] (Include only if relevant.)

Violence and Threat Assessment

(Include only when clinically relevant.)

• Homicidal ideation: [present / absent]; [target, plan, intent, weapon access]
• Aggression history: [Fights, property destruction, cruelty, prior restraints, expulsions]
• Threat credibility: [Factors supporting or reducing credibility]
• Current protective controls: [Supervision and environmental safety measures in place]

Abuse/Neglect Concerns

(Include only if indicated by disclosure or concerning findings. Document factually.)

• Disclosure/observation: [What was disclosed or observed, by whom, when]
• Actions taken: [Mandatory report filed / social work notified / case number]

Background

Psychiatric History: [Prior diagnoses]; [ED visits and hospitalizations]; [Prior suicide attempts and self-harm]; [Current outpatient treatment]; [Medication trials with response]; [What has helped in past crises]

Medical and Developmental: [Major medical conditions]; [Neurodevelopmental diagnoses]; [Communication needs and sensory considerations]; [Developmental factors affecting capacity or reliability]

Substance Use: [Screening tool and result if used]; [Substances by category, pattern, recency]; [High-risk exposures]; [History obtained privately: yes / no] (For patients age 12 and older.)

Family and Social: [Living situation and custody]; [Primary caregivers and supervision capacity]; [School functioning and stressors]; [Peer relationships and relevant online activity]; [Legal involvement]; [Access to lethal means across environments]

Mental Status Examination

• Appearance/behavior: [Grooming, dress, cooperation, eye contact]
• Psychomotor: [normal / agitated / retarded / other]
• Speech: [Rate, volume, tone]
• Mood: [Patient-stated mood]
• Affect: [Range, intensity, congruence, stability]
• Thought process: [logical / tangential / disorganized / other]
• Thought content: [SI/HI status, delusions, preoccupations]
• Perception: [Hallucinations present / absent]; [Command hallucinations: yes / no]
• Cognition: [Orientation, attention, memory]
• Insight/Judgment/Impulse control: [Brief assessment relevant to risk]
• Engagement/reliability: [Level of participation] (If exam limited, state reason and what was observed.)

Pertinent Studies

• [Vital signs if relevant]
• [Labs and toxicology with interpretation]
• [Imaging or other studies pertinent to psychiatric differential]

Assessment

Working diagnoses: [Primary psychiatric diagnoses] (Specify provisional when uncertain.)

Differential diagnosis: [Brief differential including consideration of intoxication, withdrawal, delirium, or medical etiologies] (Include only when relevant.)

Biopsychosocial formulation: [Predisposing, precipitating, perpetuating, and protective factors]; [What drove today's ED visit]

Risk Formulation

• Acute suicide risk: [low / moderate / high] — [Rationale integrating ideation, plan, intent, means access, intoxication, psychosis, agitation, recent attempt, supports]
• Chronic suicide risk: [low / moderate / high] — [Rationale including attempt history, psychiatric history, trauma, chronic stressors]
• Risk drivers: [Acute and dynamic factors elevating risk]
• Protective factors: [Factors mitigating risk]
• Violence risk: [low / moderate / high] — [Rationale] (Include only if applicable.)

Disposition and Plan

Disposition: [Discharge home / Discharge to alternative caregiver / Psychiatric admission (voluntary) / Psychiatric admission (involuntary) / Medical admission with psychiatry follow-up / Transfer / Continued ED observation] — [Explicit rationale linked to risk formulation, supervision feasibility, mental status, and intoxication status; address why this level of care versus alternatives]

If discharging:

• Adult assuming care: [Name, relationship]
• Supervision plan: [Who monitors, when, sleeping arrangements, school plan]
• Lethal means safety: [What will be secured or removed, by whom, timeline]
• Follow-up plan: [Setting and timing; referrals placed]
• Collaborative safety plan: [Warning signs]; [Coping strategies]; [Social supports]; [Crisis resources including 988]; [Reasons for living] (If unable to complete, document why and what alternative counseling occurred. Do not use no-harm contracts.)
• ED return precautions: [Provided and summarized: yes / no]

If admitting or transferring:

• Legal status: [voluntary / involuntary; hold type]
• Recommended precautions: [suicide / violence / elopement / observation level]
• Unit recommendation: [Adolescent inpatient / pediatric medical with sitter / other]
• Medication recommendations: [Agents and doses if applicable]

Communication

• [ED attending notified and agrees with plan: yes / no]
• [Caregiver notified and understanding confirmed: yes / no]
• [Outpatient clinician notified: name, method, time] (If applicable.)
• [Mandatory reports filed: agency, time, reference number] (If applicable.)