Inpatient Pediatric Psychology Consultation-Liaison Note

Date/Time of Encounter: [YYYY-MM-DD HH:MM]

Consulting Service: [Service name]

Requesting Clinician: [Name, credentials]

Consult Priority: [routine / urgent / emergent]

Informants Present: [patient / caregiver(s) (relationship) / bedside nurse / interpreter (language, modality) / other]

Sources Reviewed: [chart / nursing notes / prior psychology or psychiatry notes / outside records / other]

Reason for Consult

[Primary consult question(s)] (State the explicit question from the requesting team in 1–3 lines. Lead directly with the question; do not bury it in background.)

Clinical Context & Focused History

[Anchor sentence: patient age, gender if relevant, reason for admission, and reason for consult]

• [Medical context relevant to the consult] (Salient diagnoses, key procedures, sedation/pain status affecting assessment, discharge barriers related to behavioral health.)
• [Behavioral health concern during hospitalization] (Onset and course relative to admission; triggers and maintaining factors; patterns observed.)
• [What has helped vs. not helped on the unit]
• [Impact on care] (Effects on adherence, procedures, sleep, eating, mobility, staff–family dynamics, safety.)
• [Relevant prior psychiatric/behavioral and neurodevelopmental history] (Include only if pertinent.)
• [Family/caregiver context at bedside] (Roles, availability, coping capacity, cultural or language considerations.)
• [Trauma exposure relevant to triggers/avoidance] (Include only if clinically relevant; keep minimal.)
• [Collateral information status] (If key collateral unavailable, note attempts made and plan to obtain.)

(Omit domains that do not apply. Separate what was reported from what was observed.)

Behavioral Observations & Mental Status

• Appearance/Behavior: [appearance, distress level, engagement, cooperation, psychomotor activity]
• Speech/Language: [rate, volume, clarity, developmental appropriateness]
• Mood: [patient-reported mood, brief quote if salient]
• Affect: [observed range, intensity, stability, congruence with stated mood]
• Thought Process/Content: [organization, goal-directedness, worries, preoccupations]
• Cognition: [alertness, orientation, attention, delirium concerns if applicable]
• Insight/Judgment: [developmentally anchored insight into illness/hospitalization]
• Behavioral Functioning on Unit: [sleep, appetite, cooperation with care, agitation episodes]

(Include brief quotes for key patient statements. If a domain was not assessed, state: "Not assessed—[reason].")

Risk & Safety Assessment

[Global safety statement] (Required. Use: "No acute safety concerns identified based on assessment on [YYYY-MM-DD]" OR "Safety assessment limited due to [reason]; plan to reassess [when].")

• Suicide/Self-Harm: [ideation, plan, intent, past attempts, access to means, risk factors, protective factors] (Include when assessed or indicated.)
• Violence Toward Others: [threats, intent, targets, history] (Include if relevant.)
• Non-suicidal Inpatient Safety Risks: [elopement risk, severe dysregulation, refusal of essential care, device interference] (Include if relevant.)
• Abuse/Neglect Concerns: [concern summary, actions taken, mandated reporting if applicable] (Include if relevant.)

Risk Stratification: [low / moderate / high] — [brief rationale]

Immediate Safety Actions: [observation level, precautions, sitter, psychiatry consult, safety planning] (Document actions taken or recommended with responsible party.)

Assessment & Formulation

(List 1–5 active psychosocial/behavioral problems relevant to hospitalization in priority order. Use symptom-focused impressions when appropriate.)

[Problem 1]: [Working impression or diagnosis]

• Predisposing: [developmental, psychological, medical, or family factors]
• Precipitating: [hospitalization-related triggers, recent events, procedures, pain]
• Perpetuating: [avoidance, reinforcement patterns, sleep disruption, communication mismatches]
• Protective/Strengths: [skills, supports, motivations, effective strategies]

(Add additional problems as needed. Brief formulation is sufficient for lower-priority problems.)

Interventions Delivered

• [Intervention type] for [target problem]: [What was done], [patient/family response], [plan for reinforcement by staff/caregivers].
• [Psychoeducation]: [Content provided], [recipient], [understanding demonstrated].
• [Skill training]: [Technique practiced], [patient response/effectiveness], [cueing plan for staff].
• [Caregiver coaching]: [Strategies provided], [caregiver response], [follow-through plan].
• [Team coordination]: [Child life, environmental modifications, procedure timing], [roles clarified].

(Omit this section if no interventions were delivered.)

Recommendations

(Numbered, actionable items for the primary team. Specify what, who, when, escalation triggers, and brief rationale. Include only applicable categories.)

• 1) Safety: [observation level / precautions / escalation plan] — [who initiates], [criteria].
• 2) Communication: [approach and brief scripts for procedures/limit-setting], [who uses].
• 3) Procedural Support: [timing, choices, positioning, distraction, child life involvement].
• 4) Behavioral Management: [preventive strategies, reinforcement, de-escalation steps], [consistency plan].
• 5) Service Coordination: [child life / social work / psychiatry / pain team], [specific requests].
• 6) Discharge Planning: [outpatient referral type], [warm handoff status], [safety/coping plan provided].

Follow-Up & Disposition

• Inpatient Psychology Follow-Up: [frequency / PRN with criteria]
• Post-Discharge Plan: [referrals placed or recommended], [appointment status], [materials provided to family]
• Outstanding Collateral: [information needed], [who will obtain], [expected date]
• Communication: [discussion with primary team (name, date/time)], [nursing handoff], [outpatient provider contact], [unanswered attempts]