Inpatient Psychiatry Admission H&P

Date/Time of Evaluation: [Date and time]

Location/Unit: [Inpatient unit/bed]

Clinician Name and Role: [Name, credentials, role]

Attending of Record: [Name, credentials]

Patient Name, Age, Legal Sex, Gender Identity/Pronouns: [Name]; [Age]; [Legal sex]; [Gender identity/pronouns if known]

Legal Status: [voluntary / involuntary - specify hold type and jurisdiction] (Note guardianship/conservatorship if applicable)

Admission Source: [ED / outside hospital / medical unit / other]

Sources of Information: [Sources used, e.g., patient, collateral contacts with name and relationship, records, PDMP]

Reliability of History: [good / fair / limited] — [Brief reason if fair or limited, e.g., intoxication, psychosis, cognitive impairment]

Chief Complaint

"[Patient's own words]" (If patient cannot provide, document reason and identify collateral source instead.)

[One-sentence clinical summary framing the presentation]

Reason for Admission

• [Specific risk or impairment requiring inpatient care, e.g., danger to self, danger to others, grave disability, severe psychosis/mania, inability to ensure safety in less restrictive setting]
• [Behavioral facts supporting criteria] (For involuntary admissions, document concrete behaviors/events rather than conclusory statements.)

History of Present Illness

[Chronological narrative of current episode beginning with the chief complaint] (Include onset, duration, progression, precipitating events, psychosocial stressors, functional decline in sleep/appetite/self-care/work/relationships, current treatment engagement and adherence, recent medication changes and response, substance use temporally related to symptoms, and events immediately leading to admission. Integrate immediate safety elements: suicidal ideation/behavior with plan/intent/preparation, homicidal ideation, self-harm, aggression/violence, access to lethal means, elopement risk, intoxication/withdrawal concerns.)

[Collateral and record review summary with explicit source attribution] (Note when information is corroborated or contradicted by external sources.)

Past Psychiatric History

• Prior Diagnoses: [Patient-reported and documented diagnoses]
• Outpatient Care: [Providers, clinic, last visit, adherence]
• Prior Psychiatric Hospitalizations: [When, where, reason, outcomes]
• Suicide Attempts: [Number, most recent date, method, lethality, intent]
• Non-Suicidal Self-Injury: [History and patterns]
• Violence/Aggression: [History, targets, consequences]
• Medication Trials: [Names, doses, response, adverse effects, reason stopped]
• Somatic Treatments: [ECT/TMS/ketamine if applicable—dates, response, adverse effects]

(If history unavailable, document "Unknown" with reason and plan to obtain.)

Substance Use History

• Tobacco/Nicotine: [Route, quantity/frequency/duration, last use, prior quit attempts]
• Alcohol: [Quantity/frequency/duration, last use, history of withdrawal/seizures/DTs, prior treatment]
• Cannabis: [Route, quantity/frequency/duration, last use]
• Opioids: [Type/route, quantity/frequency/duration, last use, overdose history, prior MOUD]
• Stimulants: [Type/route, quantity/frequency/duration, last use]
• Benzodiazepines/Sedatives: [Agent, quantity/frequency/duration, last use, withdrawal/seizure history]
• Other Substances: [Specify substance, route, pattern, last use]

(Document each substance used; if none or unknown, state explicitly.)

Medical History

Past Medical History: [Major chronic diseases, seizures/head injury, relevant infectious disease]

Surgical History: [Relevant surgeries]

Allergies: [Medication and reaction type] (Distinguish allergy vs intolerance.)

Current Medications: [Scheduled, PRN, OTC/supplements with adherence and last taken; note recent psychotropic changes]

Family History

• [Psychiatric disorders in first-degree relatives]
• [Suicide attempts or completed suicides]
• [Substance use disorders]
• [Relevant neurologic disease]

(Document "Unknown" if not available.)

Social History

• Living Situation/Housing: [Current housing and stability]
• Key Supports: [Family, friends, community resources]
• Education/Employment/Disability: [Current status]
• Relationship Status/Dependents: [Details]
• Legal Involvement: [Current charges, probation, pending court dates]
• Trauma History: [Document if assessed; do not force disclosure]
• Safety Concerns: [Domestic violence, exploitation, if applicable]
• Access to Firearms/Lethal Means: [Details and willingness to restrict]
• Baseline Functioning: [ADLs, self-care, work/community functioning]

Strengths and Protective Factors: [Descriptive strengths] (Document descriptively, e.g., "identifies children as reason for living," "engaged in outpatient care," "supportive sibling available," "stable housing," "future-oriented goals.")

Physical Examination

Vital Signs: [Values] (obtained at [time])

General Exam: [Appearance, hydration/nutrition, skin findings relevant to self-harm or injection drug use, neurologic screen as indicated] (If exam not performed or incomplete, document reason and plan to reassess.)

Diagnostic Data

• Labs: [CBC, CMP, TSH, toxicology, BAL, pregnancy test as indicated — values and dates]
• EKG: [Date, QTc, other relevant findings]
• Imaging: [Study, date, key findings if performed]
• Medication Levels: [Agent, date, value, reference range if applicable]

(Provide brief interpretation only when clinically necessary.)

Mental Status Examination

Appearance: [Dress, hygiene, apparent age]

Behavior: [Cooperation, eye contact, attitude toward examiner]

Psychomotor: [Agitation, retardation, abnormal movements]

Speech: [Rate, volume, prosody, latency]

Mood: "[Patient's word]"

Affect: [Range, congruence, intensity, stability]

Thought Process: [Linear / tangential / circumstantial / disorganized]

Thought Content: [SI/HI, delusions, obsessions, paranoia] (Quote examples of abnormalities.)

Perceptions: [Hallucinations by type/content, responding to internal stimuli]

Cognition: [Alertness, orientation, attention, memory]

Insight and Judgment: [Assessment with brief behavioral justification]

Risk Assessment

Suicide Risk:

• Ideation: [Passive / active; frequency, intensity]
• Plan: [Method specificity, preparation, rehearsal]
• Intent: [Desire to die vs ambivalence, reasons for living]
• Past Attempts/Self-Harm: [Details with dates, methods, lethality]
• Access to Means: [Firearms, medications, other; steps taken or recommended]
• Acute Risk Factors: [Intoxication, agitation, insomnia, command hallucinations, recent loss]
• Protective Factors: [Internal and external factors]

Violence Risk:

• Ideation/Plan/Intent/Target: [Details]
• Access to Weapons: [Details]
• History of Violence: [Context, frequency, consequences]
• Duty-to-Protect Actions: [Actions taken, if applicable]

Other Inpatient Risks:

• Elopement: [Risk level and factors]
• Falls: [Risk level and factors]
• Vulnerability: [Risk level and factors]
• Withdrawal: [Risk and monitoring protocol, e.g., CIWA/COWS]
• Medical Instability: [Concerns and monitoring needs]

Safety Measures:

• Observation Level: [standard / q15min / line-of-sight / 1:1] — [Rationale]
• Precautions: [suicide / assault / elopement / falls / seizure]
• Lethal Means Counseling: [Completed / planned; specifics]
• Safety Plan Elements: [Warning signs, coping strategies, supports, emergency contacts]

Overall Suicide Risk: [low / moderate / high] [acute / chronic] — [Brief rationale]; Mitigation: [Specific measures ordered]

(If assessment is limited, document reason and plan/timing to reassess.)

Assessment

Working Diagnoses: [Provisional DSM-consistent psychiatric diagnoses, substance-related diagnoses, relevant medical diagnoses affecting presentation]

Differential Diagnosis: [Substance-induced vs primary disorder, medical/neurologic mimics, trauma-related vs psychotic vs personality contributions] (Include when diagnostic uncertainty exists.)

Formulation: [Brief biopsychosocial summary linking predisposing, precipitating, perpetuating, and protective factors to treatment targets]

Medical Necessity: [Why inpatient level of care is required and why less restrictive alternatives are insufficient]

Plan

• Safety: [Observation level, environmental precautions, behavioral interventions, PRN medications for agitation with indications, de-escalation approach]
• [Primary Psychiatric Diagnosis]: [Treatment goals; medication plan with start/continue/hold and rationale, doses, target symptoms, monitoring; therapy/milieu interventions]
• Substance Use: [Withdrawal protocol and monitoring, medication-assisted treatment considerations, counseling, referral planning]
• Medical: [Relevant consults, continuation of chronic medications, monitoring plans]
• Workup: [Additional labs/EKG/imaging with rationale and timeline]
• Coordination: [Collateral contacts planned, ROIs needed, questions to clarify]
• Disposition Planning: [Expected discharge destination, barriers, discharge criteria, follow-up needs]

(For safety-critical items—suicide risk, legal status, dangerousness—always include section and document limitations with plan to reassess. For non-critical items not obtained, omit or note "Not obtained due to [reason]; will reassess.")