Inpatient Psychiatry Admission H&P (Child/Adolescent)

Patient: [Full legal name], MRN: [Medical record number], DOB: [Date of birth], Age: [Age in years and months]

Date/Time of Admission: [Date and time]

Date/Time of Evaluation: [Date and time]

Location/Unit: [Hospital and unit/bed]

Evaluator: [Evaluator name, credentials]

Sources of Information: [List sources and roles; note reliability concerns if any] (Include patient, parent/guardian, ED staff, school, outpatient clinicians, EMS. Note interpreter use if applicable.)

Legal Status: [voluntary / involuntary]; [Guardian/custody status]; [Consent authority] (Include any active holds, court orders, or hearing dates.)

Chief Complaint

[One sentence capturing the core crisis precipitating admission, in patient's own words if possible; attribute source if using guardian or ED wording]

History of Present Illness

[Chronological narrative of events leading to admission] (Include onset, duration, progression, precipitating stressors over hours to weeks. Describe current target symptoms, impact at home and school, interventions already attempted, and explicit justification for inpatient level of care. Integrate collateral information with attribution; if accounts conflict, document both and state how they were weighed.)

• Current Target Symptoms: [Mood; anxiety; psychosis; sleep; appetite; agitation; dissociation; other relevant symptoms and severity]
• Functional Impairment: [Home routines; school attendance/performance; peer/family relationships; ADLs]
• Interventions Tried: [Outpatient medication/therapy changes; crisis or ED care; safety plan steps; response to interventions]
• Rationale for Inpatient Care: [Specific safety, medical, supervision, or stabilization needs not manageable at lower level of care]

Safety-Relevant Details:

• Suicidal Ideation/Behavior: [Ideation; plan; intent; means; recent escalation; preparatory behaviors] (Include patient and collateral reports with attribution.)
• Self-Injury (NSSI): [Methods; frequency; function; most recent episode; medical treatment if any]
• Homicidal Ideation/Aggression: [Threats; targets; severity; injuries; property destruction; legal consequences]
• Psychotic Symptoms: [Hallucinations including command content; delusions; disorganization] (Note links to safety risk.)
• Elopement/Runaway Risk: [History; recent attempts; triggers; supervision needs]
• Intoxication/Withdrawal Risk: [Recent use; observed intoxication; withdrawal risk]
• Access to Lethal Means: [Firearms; medications; ligatures; sharps; family steps to secure means; counseling provided]

(When information is missing, document "Unknown," "Unable to obtain" with reason, or "Deferred" with plan to obtain.)

Psychiatric Review of Systems

• Depression: [Symptoms not already detailed in HPI]
• Anxiety: [Generalized; panic; separation; social; school avoidance]
• OCD: [Obsessions; compulsions; avoidance]
• Trauma-Related: [Intrusions; avoidance; hyperarousal; dissociation]
• Psychosis: [Hallucinations; delusions; paranoia]
• Mania/Hypomania: [Elevated/irritable mood; decreased sleep need; grandiosity; risky behavior]
• Eating/Feeding: [Restriction; binge; purge; ARFID concerns; body image]
• Attention/Executive Function: [Inattention; hyperactivity; impulsivity; organization]
• Autism Spectrum Concerns: [Social communication; repetitive behaviors; sensory issues]
• Other: [Tics; enuresis/encopresis; other relevant domains]

(If a domain was not assessed due to acuity, state "Deferred" rather than omitting.)

Past Psychiatric History

• Prior Diagnoses: [List with dates/ages if known]
• Hospitalizations/Residential: [Dates; reasons; treatments; outcomes]
• ED/Crisis Evaluations: [Dates; reasons; dispositions]
• Suicide Attempts: [Methods; lethality; medical treatment; triggers; dates]
• Self-Injury: [Methods; frequency; function; last occurrence]
• Violence/Aggression: [Targets; injuries; legal outcomes; restraints]
• Outpatient Care: [Therapist; psychiatrist; school counseling; frequency; engagement]
• Medication Trials: [Medication; max dose; duration; response; adverse effects; reason discontinued]
• Psychological/Neuropsych Testing: [Dates; key findings; diagnoses; recommendations]

Medical History

• Medical Conditions: [Neurologic; cardiac; endocrine; GI; other relevant conditions]
• Surgical History: [Relevant procedures and dates]
• Reproductive: [Menstrual history; pregnancy possibility; contraception] (Include only if clinically relevant.)
• Primary Care/Specialists: [Names; last follow-up]

Allergies

[Allergies with reaction type and severity] (If none, state "No known drug allergies.")

Current Medications

• Home Psychiatric Medications: [Name; dose; route; frequency; last dose taken; adherence; recent changes and reasons]
• Home Medical/OTC/Supplements: [Name; dose; frequency; last dose]
• Recent PRNs: [Medication; indication; response] (Include ED-administered medications.)

Family Psychiatric History

• [Psychiatric conditions in first-degree relatives]
• [Substance use disorders in family]
• [Family history of suicide attempts or completions]
• [Other heritable conditions relevant to care]

(If unknown, document why: adopted, estranged, no guardian available.)

Social and Developmental History

• Living Situation: [Household members; primary caregivers; custody arrangement; family supports]
• Developmental: [Pregnancy/birth history; milestones; early interventions] (Include if relevant.)
• Education: [Grade; school; attendance; academic performance; IEP/504; discipline; bullying concerns]
• Peers/Activities: [Friendships; extracurriculars; social media stressors]
• Legal/Child Welfare: [CPS involvement; probation; foster care; court dates]
• Strengths/Protective Factors: [Interests; goals; reasons for living; supportive relationships; cultural/spiritual resources]

Trauma and Adversity History

• [Abuse: physical; sexual; emotional]
• [Neglect]
• [Exposure to domestic or community violence]
• [Significant losses or separations]
• [Bullying or harassment]
• [Current safety from any identified perpetrator]

(If mandated reporting is indicated, document the disclosure in non-graphic terms, that a report was or will be made, and immediate safety steps taken.)

Substance Use History

• Tobacco/Nicotine: [Pattern; last use; dependence; withdrawal risk] (Include vaping.)
• Alcohol: [Pattern; last use; consequences; withdrawal risk]
• Cannabis: [Pattern; last use; effects on mood/anxiety/psychosis]
• Other Substances: [Type; pattern; last use; consequences; withdrawal risk]
• Urine Drug Screen: [Results; clinical interpretation] (Note if pending.)
• Relationship to Presenting Crisis: [How substance use contributed or not]

Review of Systems

• Cardiac: [Syncope; palpitations; chest pain]
• Neurological: [Seizures; headaches; tics; tremor]
• Sleep: [Duration; latency; awakenings; nightmares]
• Appetite/Weight: [Changes; restrictive behaviors]
• Pain: [Location; severity; impact]

(Focus on symptoms affecting medication safety or medical clearance.)

Objective

Vitals: T [Temperature], HR [Heart rate], BP [Blood pressure], RR [Respiratory rate], SpO2 [Oxygen saturation], Ht [Height], Wt [Weight], BMI [BMI and percentile]

Physical Exam: [Focused exam findings] (If full physical performed by another service, note where documented and that it was reviewed.)

Labs and Studies: [Pertinent results: CBC; CMP; TSH; urine drug screen; pregnancy test; EKG with QTc; other] (Distinguish results reviewed from studies pending.)

Mental Status Examination

• Appearance: [Grooming; dress; hygiene; notable features]
• Behavior/Psychomotor: [Calm; agitated; restless; tics; mannerisms]
• Attitude/Cooperation: [Engaged; guarded; oppositional]
• Eye Contact: [Good; fair; limited]
• Speech: [Rate; volume; articulation; prosody]
• Mood: "[Patient's words]"
• Affect: [Quality; range; intensity; congruence]
• Thought Process: [Linear; logical; circumstantial; tangential; disorganized]
• Thought Content: [Suicidal ideation; homicidal ideation; obsessions; delusions; guilt/worthlessness]
• Perceptions: [Hallucinations; illusions; derealization; presence or absence of command hallucinations]
• Cognition: [Orientation; attention; memory; fund of knowledge]
• Estimated Intellectual Functioning: [Above average / average / below average]
• Insight: [Good / fair / limited / absent]
• Judgment: [Good / fair / poor]
• Impulse Control: [Good / fair / poor / variable]

Risk Assessment

Suicide and Self-Harm Risk:

• [Current ideation, plan, intent, and preparatory behaviors]
• [Past attempts (most lethal and most recent) and NSSI behaviors]
• [Access to means and family's ability to restrict]
• [Protective factors]
• Risk Level: [low / moderate / high] — [Brief rationale]

Violence Risk:

• [Homicidal ideation; specific threats; identified targets]
• [History of aggression and triggers]
• [Current psychosis, intoxication, or impulsivity contributing]
• Risk Level: [low / moderate / high] — [Brief rationale]

Other Safety Risks:

• [Elopement risk]
• [Severe self-neglect or inability to care for self]
• [Abuse/neglect concerns requiring mandated reporting; status of report]

Mitigation Plan:

• [Observation level with rationale]
• [Precautions: suicide / self-harm / aggression / elopement]
• [Environmental precautions; means restriction counseling provided to family]
• [De-escalation approach]
• [PRN medication plan with indications and maximum daily doses]

Assessment

[Diagnostic formulation synthesizing presenting problems, developmental context, family/school/system factors, and strengths. State primary working diagnosis and key differentials. Note areas of diagnostic uncertainty and what data will help resolve them.]

Diagnoses:

• [Primary diagnosis] [provisional / confirmed]
• [Additional diagnoses]
• [Rule-outs/Differentials]

Plan

(Organize by problem with goal, intervention, and monitoring. Order by decreasing severity and risk.)

Safety and Milieu

• [Observation level and rationale]
• [Precautions: suicide / self-harm / aggression / elopement]
• [Legal status actions and next steps]
• [Guardian notification and consent plan]

Medications

• [Medication: indication linked to target symptoms; starting dose; titration plan; monitoring; side effect counseling; guardian consent obtained; patient assent discussed]
• [PRNs: name; indication; dosing; maximum per 24 hours]

Medical

• [Labs ordered and monitoring plan]
• [Medical consults requested]
• [Sleep, nutrition, and pain management]

Therapeutic Interventions

• [Individual therapy focus]
• [Group programming goals]
• [Family therapy goals and timing of family meeting]

Systems Coordination

• [Collateral contacts planned: outpatient providers; school; community supports]
• [Educational services while inpatient]

Disposition Planning

• [Anticipated discharge level of care: outpatient / IOP / PHP / residential]
• [Barriers to discharge]
• [Preliminary discharge criteria]

Treatment Goals

• Short-term (24–72 hours): [Specific, measurable goals: group participation; sleep; safety adherence on unit]
• Discharge: [Resolution of acute risk; completed safety plan; family means restriction confirmed; aftercare scheduled]