Inpatient Psychiatry Admission Note

Inpatient Psychiatry Admission Note

Date/Time of Encounter: [Date and time]

Patient Name: [Full name]

DOB: [Date of birth]

Attending of Record: [Attending name and credentials]

Legal Status: [voluntary / involuntary] (If involuntary, specify hold type and legal basis; include guardian/conservator status; if unknown, state "unknown at time of note; will verify with [source].")

Information Sources: [Sources consulted] (List sources such as patient, collateral, prior records, pharmacy database, outside hospital paperwork; note reliability limitations if applicable.)

Chief Complaint

[Chief complaint in patient's own words] (Use quotation marks when using patient's exact words; limit to one line.)

Reason for Admission

[Precipitating factors and acute concerns prompting admission] (Attribute each item to its source—patient report, collateral, or ED documentation. Include precipitating events, symptoms, functional decline, safety concerns, self-care inability, medication nonadherence, or treatment failure. Format as 2–5 bullet points or a short paragraph.)

History of Present Illness

[Introductory synopsis] (Begin with a 1–2 sentence overview: "This is a [age] [gender] with [relevant history] presenting for [primary reason]...")

[Chronological narrative of current episode] (Include onset, duration, and progression; current psychiatric symptoms; safety-relevant events such as suicidal/homicidal ideation, self-harm, command hallucinations, agitation, impulsivity, or intoxication; functional impact on sleep, appetite, ADLs, work/school; recent treatment and medication adherence with last doses, perceived benefit/side effects, and barriers; and observed patient strengths. Use subheadings within HPI only when needed for clarity. If information is unavailable, state what is missing, why, and how gaps will be addressed.)

Past Psychiatric History

• Prior diagnoses: [Diagnoses] (Distinguish patient-reported vs documented.)
• Prior hospitalizations/IOP/PHP: [Dates, indications, outcomes]
• Suicide attempts/aborted attempts/NSSI: [Methods, severity/lethality, dates if known]
• Violence toward others: [Incidents and legal consequences]
• Medication trials: [Names, response, adverse effects, adherence barriers] (Do not infer doses.)
• Psychotherapy and somatic treatments: [Type, duration, helpfulness; ECT/TMS/ketamine if applicable]

Substance Use History

(Time-anchored to past 12 months. For each relevant substance, document type, amount, frequency, route, last use, and consequences. If unable to obtain, document reason and plan to complete.)

• Alcohol: [Pattern, quantity, frequency; blackouts; withdrawal/DTs/seizures history; last use]
• Opioids: [Type, route; tolerance/withdrawal; overdose history; naloxone access; last use]
• Stimulants: [Type; intoxication-related symptoms; last use]
• Cannabis: [Pattern; last use]
• Nicotine: [Form, amount; last use]
• Other substances: [Type, pattern, last use]
• Prior SUD treatment and current interest: [Detox/rehab/MAT history; readiness to engage]

Trauma History

[Trauma exposure and relevant symptoms] (Document whether trauma exposure is endorsed. If endorsed, note current trauma-related symptoms relevant to inpatient care, known triggers, and patient preferences regarding discussion. Avoid graphic detail. If deferred due to acuity, state: "Deferred due to [reason]; will reassess when stable.")

Medical History, Allergies, and Review of Systems

• Active medical problems: [Conditions affecting psychiatric care or medication choices]
• Past surgical history: [Relevant surgeries]
• Care providers: [Primary care and key specialists]
• Allergies: [Allergen and reaction type] (Distinguish true allergy vs intolerance.)
• Focused ROS: [Pertinent positives/negatives relevant to presentation and medication safety]

Medications

Pre-admission medications: [Name, dose, route, frequency, indication, last dose taken, adherence pattern] (Note source and any discrepancies identified. Do not infer doses; document uncertainty.)

Reconciliation Status: [Completed with [sources] / Partial; pending [what] / Unable due to [reason]; will complete within 24h]

Changes on Admission:

• Continued: [Medications with brief rationale]
• Held: [Medications with brief rationale]
• Discontinued: [Medications with brief rationale]
• Initiated: [Name, dose, route, frequency, indication, rationale]

Social and Family History

• Living situation and supports: [Residence, household composition, caregivers, dependents]
• Functioning: [Work/school status and recent changes]
• Stressors: [Relationship stressors, housing/food insecurity, financial issues]
• Legal issues: [Charges, probation, parole]
• Access to weapons/firearms: [Access details]
• Cultural/spiritual factors: [Factors relevant to engagement/care]
• Military history: [Service details] (Include if relevant.)
• Family psychiatric history: [First-degree relatives with mood disorders, psychosis, SUD, suicide, violence] (Include when relevant to diagnosis or risk.)

Physical Examination

[Focused physical and neurologic exam findings; weight/BMI] (If deferred, state: "Physical exam deferred; will be completed by [provider/service] within [timeframe].")

Objective Data

• Vitals: [Temperature, HR, BP, RR, SpO2, pain score]
• Labs/Studies: [Pertinent results reviewed; pending items with follow-up plan]
• Toxicology: [Results]
• Other: [EKG/QTc, pregnancy status, withdrawal scale scores (CIWA-Ar, COWS)] (Include as applicable.)

Mental Status Examination

• Appearance: [General appearance and grooming]
• Behavior/psychomotor: [Motor activity, eye contact]
• Attitude/cooperation: [Engagement with examiner]
• Speech: [Rate, rhythm, volume, tone]
• Mood: [Patient-stated mood in quotation marks]
• Affect: [Range, intensity, congruence, stability]
• Thought process: [Coherence, organization]
• Thought content: [Suicidal ideation, homicidal ideation, delusions, obsessions]
• Perceptions: [Hallucinations, illusions; note command features if present]
• Cognition: [Orientation, attention, memory estimate]
• Insight: [Description]
• Judgment: [Description with behavioral examples]
• Reliability: [Assessment of reliability and limitations]

Assessment

[Integrative formulation] (Address biological, psychological, and social contributors; consider primary vs substance-induced vs medical etiologies; comment on acuity and severity; state when diagnoses are provisional and what will clarify them.)

Working Diagnoses:

• [Primary psychiatric diagnosis with specifiers]
• [Substance use diagnoses with specifiers]
• [Relevant medical diagnoses]

Strengths/Protective Factors: [At least two patient strengths or assets]

Risk Assessment

• Suicide Risk: [Current ideation, plan, intent, access to means, past suicidal behavior, protective factors]
• Violence Risk: [Recent threats/acts (past 6 months); lifetime serious violence if present]
• Self-Harm Risk: [Non-suicidal self-injury risk factors and recent behaviors]
• Other Risks: [Grave disability/self-care, elopement, withdrawal, falls] (Include as applicable.)

Overall Risk Level: [low / moderate / high / imminent] (Provide explicit rationale anchored to documented findings. If patient denial conflicts with collateral or observed behavior, document the discrepancy and justify precautions.)

Safety Precautions and Mitigation Plan: [Observation level, environmental precautions, contraband/sharps policy, room placement, monitoring frequency, withdrawal protocol, de-escalation approach]

Capacity and Legal Considerations

(Include this section when applicable.)

[Capacity to consent to admission and treatment; involuntary hold criteria and patient notification; guardianship/conservatorship and consent authority; duty-to-warn or protective actions taken]

Plan

(Organize by problem in order of severity/urgency.)

[Problem 1]

• Goals: [Goals for this problem]
• Interventions: [Medications with rationale and monitoring; therapy/groups; SUD treatment; medical workup/consults]
• Safety: [Safety measures relevant to this problem]
• Discharge criteria/aftercare: [Criteria and anticipated needs]

[Problem 2]

• Goals: [Goals]
• Interventions: [Interventions]
• Safety: [Safety measures]
• Discharge criteria/aftercare: [Criteria and needs]

Orders Summary: [Admit status, observation level, scheduled medications, PRN medications, labs, consults, nicotine replacement] (If using standardized order sets, note which set and any significant deviations.)

Collateral and Coordination

• [Collateral contacts with role, key information provided, and discrepancies]
• [Records requested/reviewed and pending items]
• [Handoff communications to nursing, social work, or other team members]