Inpatient Psychiatry Daily Progress Note (Child/Adolescent)

Date/Time of Evaluation: [date and time]

Patient: [name, MRN, DOB, age, pronouns if documented]

Unit/Room: [unit and room]

Hospital Day: [HD#, admission date]

Legal Status: [voluntary / involuntary]; [guardian/custody status if relevant to consent]

Primary Diagnoses: [psychiatric and active medical diagnoses]

Observation Level/Precautions: [current observation level and active precautions] (State only what is active today.)

Allergies: [allergy information] (Include only if new or clinically relevant today; otherwise omit this line.)

[One-line clinical summary: age, HD#, reason for admission, primary syndrome, interval trend, and why inpatient LOC remains necessary]

Interval History & Subjective

(Combine overnight events and today's interview. Emphasize interval changes relevant to safety, symptoms, functioning, and treatment response. Avoid restating static historical information.)

• Overnight report: [sleep quality, appetite, ADLs, peer interactions, redirection needed, rule violations, behavioral observations] (Include only updated or salient items. If no events, state "No acute overnight events reported.")
• PRNs given: [medication, dose, time, indication, response; non-pharmacologic interventions attempted] (Omit if none.)
• Significant incidents: [self-harm, aggression, elopement attempts, medical events] (If seclusion/restraint occurred, note dedicated documentation exists per policy and include one-line summary. Omit if none.)
• Patient interview: [chief concern in patient's words or clinician summary; current symptoms pertinent to admission; medication effects/side effects; unit functioning; coping skills used]
• Safety (patient-reported): [SI: ideation/intent/plan; HI; command hallucinations; elopement urges] (Use direct quotes for statements of intent, plans, commands, or threats.)
• Collateral contacts: [contact made with whom, mode, key content, outcomes/next steps] (If attempted but not obtained, document the barrier. Omit if none.)

(If patient was not interviewable, document the attempt, reason, and alternative data sources used. Do not infer subjective improvement without a stated source.)

Objective

• Vitals/Weight: [relevant vitals and weight] (Prioritize data pertinent to current treatment: antipsychotics, eating concerns, metabolic monitoring.)
• Labs/Studies: [pertinent results and actions taken for abnormals] (Omit if none today.)
• Medication Adherence: [scheduled medications taken / refused / held]
• Milieu Observations: [group participation, peer interactions, staff redirection needed, coping skill use, observed sleep/appetite/ADLs] (Use neutral, behavioral language.)

Mental Status Exam

(Note changes from baseline when present. If any element could not be assessed, specify what and why.)

• Appearance/Grooming: [description]
• Behavior/Psychomotor: [cooperation, eye contact, agitation/retardation]
• Speech: [rate, volume, prosody]
• Mood: [patient-stated]
• Affect: [range, intensity, congruence]
• Thought Process: [linear / goal-directed / circumstantial / tangential / disorganized]
• Thought Content: [SI/HI, delusions, obsessions, hopelessness]
• Perceptions: [hallucinations, command content if present]
• Cognition: [attention, orientation]
• Insight/Judgment: [assessment, developmentally framed]
• Impulse Control: [assessment]

Assessment

[Clinical synthesis: response to milieu/therapy/medications, family engagement, diagnostic impression with DSM-5/ICD-10 alignment, treatment response and tolerability, adherence issues] (Note diagnostic uncertainty if present.)

Risk Assessment

• Suicide/Self-Harm: [acute and chronic risk level; supporting risk factors; access to means in hospital and anticipated at home]
• Violence/Aggression: [risk level with supporting factors, triggers, recent behaviors] (Include only if relevant.)
• Elopement: [risk level and context] (Include only if relevant.)
• Protective Factors: [family engagement, future orientation, reasons for living, coping skills, therapeutic alliance]
• Precautions Alignment: [how current observation level and precautions match the risk formulation]

Medical Necessity: [explicit rationale for ongoing inpatient LOC: ongoing safety risk, need for intensive treatment/monitoring, active medication titration, lack of safe disposition] (State what changes would allow step-down or discharge.)

Plan

(Organize by problem, highest acuity first. Focus on what is being adjusted today; avoid restating unchanged plan elements.)

[Problem 1]: [status today]

• Medications: [start/stop/titrate with dose, schedule, indication, rationale; monitoring for side effects, vitals, labs, EPS] (Use safe numeric conventions; avoid trailing zeros and U/IU abbreviations.)
• Therapy/Skills: [individual/group/family focus; specific interventions]
• Milieu/Behavioral: [reinforcement strategies, staff approaches, privileges, behavioral expectations]
• Safety Precautions: [observation level rationale, sharps/ligature precautions, privilege level]
• Family/Systems: [meetings, consent discussions, school coordination, placement coordination]
• Legal/Administrative: [guardianship updates, court dates, mandated reporting] (Include only if relevant.)

[Additional Problems]: [status and today's interventions] (Include only if active today.)

Discharge Planning

• Target Disposition: [anticipated setting, estimated timeframe or criteria]
• Discharge Criteria: [sustained safety, coping skills demonstrated, medication stability, guardian agreement, follow-up arranged, lethal means counseling completed]
• Aftercare Pending: [outpatient appointments, school coordination, community resources]
• Barriers: [housing, placement waitlists, insurance, family conflict; mitigation steps]
• Education Today: [topics covered with patient/family]

Signature: [clinician name, credentials, date/time]

Attestation/Cosign: [supervising physician attestation] (Include only if required.)