Inpatient Behavioral Health Consultation Note (Older Adult)

Patient: [Name, age, MRN]

Location: [Unit/bed, admitting service]

Date/Time of Consult: [Date and time]

Date/Time Seen: [Date and time]

Consult Type: [Initial / Follow-up]

Requesting Service/Clinician: [Service and clinician name]

Sources of Information: [patient / chart / nursing / family / facility / outpatient providers / EMS / other] (Select all that apply; name specific individuals when possible.)

Reliability: [Reliability assessment] (Note limitations: delirium, aphasia, hearing/vision impairment, language barrier with interpreter ID, sedation, or acute medical instability.)

Reason for Consultation

[Consult question framed as a specific, answerable clinical task] (If original request was vague, document the clarified question agreed upon with requesting team.)

Hospital Course and Presenting Concern

[Narrative of current hospitalization including reason for admission, major medical events, and current medical status affecting cognition/behavior] (Include infection, hypoxia, pain, withdrawal risk, metabolic disturbance. State current precautions: [sitter / observation level / restraints / none].)

[Specific behavioral or cognitive issue prompting consult] (Describe what happened, when, severity, frequency, and impact on care or safety.)

History of Present Illness

[Symptom onset, duration, and fluctuation pattern] (Emphasize day-night variation and triggers. Include sleep-wake disruption, affective symptoms, and psychotic symptoms if present with content, distress, and behavioral impact. Note substance use and withdrawal risk. Screen for reversible contributors: pain, constipation, urinary retention, dehydration, hypoxia, overstimulation.)

Baseline status: [Prior cognitive function, functional abilities (ADLs/IADLs), living situation, mobility/falls, sensory function, and typical personality] (Include prior delirium episodes. If unknown, state: "Baseline cognition/function unknown—collateral pending from [source].")

(Use brief direct quotes only for high-stakes statements: self-harm intent, refusal rationale, or paranoid content driving nonadherence.)

Collateral Information

• [Source 1: relationship/contact] — [Key facts obtained]
• [Source 2: relationship/contact] — [Key facts obtained]
• [Summary of relevant prior documentation: psychiatry/neurology/geriatrics notes, cognitive testing, neuroimaging]

(Document attempts if collateral is pending.)

Relevant History

(Include only sections pertinent to the consult question.)

Psychiatric History: [Prior diagnoses, hospitalizations, delirium/mania/psychosis episodes, suicide attempts or aggression, prior medication trials with notable adverse effects (EPS, QTc, paradoxical reactions)]

Substance Use: [Alcohol, benzodiazepines, opioids, other substances: quantity/frequency, last use, withdrawal complications]

Medical History: [Neurocognitive disorders, stroke/TBI, Parkinsonism/Lewy body features, seizure disorder, cardiac conduction disease, renal/hepatic impairment, falls]

Social and Functional: [Living situation, supports, caregiver burden, healthcare proxy/decision-maker, baseline mobility/assistive devices, sensory aids availability in hospital, firearms access if relevant]

Current Medications

• Home psychotropics: [List with doses/frequencies; note recent changes]
• Inpatient psychotropics: [List with doses/frequencies; note PRNs given with effect]
• Non-psychiatric medications affecting cognition/behavior: [Anticholinergics, opioids, steroids, sedatives, dopamine agonists]
• Allergies/ADRs: [Allergies and notable adverse drug reactions]

Medication Safety Statement: [Polypharmacy assessment, anticholinergic burden, sedation/fall risk, QTc considerations, renal/hepatic dosing adjustments]

Objective Findings

Vitals/Observations: [Pertinent trends: fever, hypoxia, tachycardia, hypotension; arousal level, cooperation, sitter/restraints status] (Include pain scores if relevant.)

Pertinent Exam: [Neurologic and motor findings relevant to differential or medication effects: gait, rigidity, tremor, akathisia, cogwheeling, focal deficits, signs of withdrawal/intoxication]

Labs/Studies:

• [CBC, CMP, glucose, UA/urine culture, lactate] (State "Not available" or "Not obtained" if applicable.)
• [B12, TSH, RPR/HIV] (Include only if obtained.)
• [Toxicology levels/screens] (Include only if relevant.)
• [EKG with QTc: value/date] (Required if antipsychotics considered.)
• [Neuroimaging/EEG results] (Include only if obtained.)

Mental Status Examination

• Appearance/Behavior: [Description; note sensory aids present/absent]
• Cooperation: [cooperative / guarded / irritable / minimally responsive]
• Psychomotor: [retardation / agitation / within normal limits]
• Speech: [Rate, volume, articulation; aphasia/dysarthria if present]
• Mood: "[Patient's words]"
• Affect: [Range, reactivity, congruence]
• Thought Process: [linear / tangential / disorganized / perseverative]
• Thought Content: [Delusions, paranoia, obsessions; SI/HI; refusal rationale if relevant]
• Perceptions: [Hallucinations/illusions; insight into experiences]
• Cognition: [Orientation, attention, short-term memory, language] (Always comment on attention and fluctuation. Note if exam limited by sensory/language barriers.)
• Insight: [intact / partial / limited]
• Judgment: [intact / impaired in medical decision-making / impaired in safety]

(If not assessable, state: "Unable to assess due to [reason].")

Cognitive and Delirium Assessment

Assessment approach: [Bedside attention testing or formal screening tool used]

• Delirium Features: [acute onset / fluctuating course / inattention / disorganized thinking / altered arousal] (Identify likely contributing factors.)
• Dementia Considerations: [Baseline decline trajectory, collateral confirmation, functional impact]
• Depression vs Cognitive Disorder: [Comment on pseudodementia features vs neurocognitive disorder vs delirium if relevant]

Assessment

[Integrated clinical formulation summarizing medical context, baseline status, current findings, key drivers, and diagnostic reasoning]

Problem List

• [Problem 1]: [Most likely diagnosis with supporting evidence, relevant differentials, acuity/severity, and reversible vs chronic factors] (Label as provisional when key data are missing.)
• [Problem 2]: [Diagnosis or clinical impression with reasoning]

Risk Assessment

• Suicide Risk: [SI/intent/plan/behaviors; passive death wishes; protective factors] (If unable to assess, state reason and base on observation/collateral.)
• Violence/Aggression Risk: [Homicidal ideation, aggression risk on unit, recent behaviors]
• Self-Neglect/Refusal of Essential Care: [Description]
• Elopement/Wandering Risk: [Description]
• Means Access: [Firearms/medications/others for discharge planning]

Overall Risk Level: [low / moderate / high] — [Brief rationale]

Mitigation Plan: [Observation level, environmental controls, de-escalation approach, means safety counseling]

Capacity Evaluation

(Include only when capacity is at issue or explicitly requested.)

• Decision at Issue: [Specific decision being evaluated]
• Information Provided: [What was explained to the patient]
• Decisional Abilities:
  • (1) Communicates a choice: [present / absent]
  • (2) Understanding: [Teach-back findings]
  • (3) Appreciation: [Applies information to self; acknowledges consequences]
  • (4) Reasoning: [Compares options logically]
• Modifying Factors: [Communication barriers, delirium fluctuation, hearing/language barriers, undue influence, pain]
• Conclusion: [Capacity present / absent] for this decision at this time; [reassessment indicated?]
• Next Steps: [Surrogate/healthcare proxy identification, ethics or legal involvement if needed]

Recommendations

(Write for non-psychiatric providers. This section should stand alone.)

Behavioral Strategies

• Communication: [One speaker at a time, simple choices, calm tone, validate then redirect, consistent messaging]
• Environment: [Orientation cues, optimize lighting, minimize nighttime disruptions, reduce overstimulation, ensure sensory aids available]
• Care Tasks: [Cluster care, explain before touching, offer breaks, schedule procedures at patient's best time of day]
• Behavior Response Plan: [Target behaviors, triggers and hypothesized function, prevention strategies, stepwise de-escalation, escalation criteria and contacts]

(If no active behavioral issues, provide brief delirium prevention bundle.)

Medication Recommendations

• Start: [Medication, dose/route/frequency, indication, max daily dose, monitoring] (Document nonpharmacologic attempts; include risk-benefit reasoning for antipsychotics in dementia and deprescribing plan.)
• Stop: [Medications to discontinue with rationale]
• Hold: [Medications to hold with criteria to restart]
• PRN protocol: [Indication, nonpharmacologic steps first, agent/dose/route/frequency, max daily dose, when to notify team]
• Monitoring: [QTc/EKG timing, orthostatic vitals, fall precautions, EPS, sedation level]

(If no medication changes recommended, state explicitly with rationale.)

Workup Recommendations

• [Additional labs, imaging, or evaluations to pursue]

Disposition Planning

• Psychiatric clearance: [cleared / not cleared / conditional]
• Disposition needs: [home with supports / SNF / memory care] (Criteria to meet before discharge.)
• Caregiver readiness: [Education needs and plans]
• Outpatient follow-up: [Geriatrics, neurology, geriatric psychiatry; timeline and referrals]
• Discharge medication plan: [Medication list, taper schedules, deprescribing plan]
• Safety plan: [Means counseling, wandering risk mitigation, supervision needs]
• Decision-maker status: [Surrogate/proxy/guardianship; APS referral if applicable]
• Pending items: [Information needed and from whom]

Communication

[Who received recommendations (name/role), method (in-person/phone/page), and time; whether patient/family were informed]

Follow-Up Plan

[Follow-up plan] (State: "Will follow daily until [milestone]" or "One-time consultation; re-consult if [criteria]." List items to follow: medication response, collateral calls, reassessment timing.)

Follow-Up Note Structure

(Use this condensed format when Consult Type is Follow-up.)

• Interval Events: [Overnight behaviors, staff observations, restraints/sitter updates]
• Medication Changes: [Doses, PRNs given with effect, adverse effects]
• Updated MSE/Cognition: [Key changes; attention and fluctuation status]
• Updated Risk: [Changes only; state if unchanged]
• Updated Assessment: [Brief synthesis of current status]
• Recommendations: [Prioritized updates; Start/Stop/Hold and behavioral strategies]
• Disposition Updates: [Barriers, criteria, pending items]
• Communication: [Who, how, when]
• Follow-Up Plan: [Next review timing]