Patient Name MR Number DOB

Psych Patient Name MR Number DOB Date Time Daily Progress Note-MS III S: 24 hour events… Pt. Subjective assessment of mood, psych symptoms, etc.. Information elicited from your daily interview with patient. O: Vitals: Tmax / Tcurrent / bp / hr / resp / O2 sats /accucheck I/O: usually not included unless FEN issues Phys. Exam: By systems if comorbid conditions present. Mental Status Exam: Appearance Behavior Mood Affect Speech Thought process Thought content Perceptions Cognition Judgment Insight A/P: ______ y/o male/female with Ppsych Hx of ________ PMHx of _______ now with ________ . Axis I: DSM IV Diagnosis Axis II: MR/personality d/o Axis III: Medical Axis IV: Social Axis V: Global Assessment of Function (GAF) List problems and plan to treat each. • Things to Know: • Keep an open mind! • Do not discard all your physical exam skills during psych! Many patients have comorbid conditions that require your diagnostic skills and attention. • Remember the value of group and individual psychotherapy. Meds aren’t the only treatment modality. • Social issues are very important to address (don’t forget to ask)—get social work involved early. You will have a lecture on the MSE during Psych orientation. • Books: • Lange Review of Psychiatry (more detail than Blueprints, and not too technical) • Blueprints in Psychiatry (OK, but lacking detail) • Quick Reference to the Diagnostic Criteria of the DSM IV (aka. Pocket DSM for looking up diagnoses) • Pre-test for Psychiatry (questions OK for test review)

Patient Name MR Number DOB

Patient Name MR Number DOB

Presentation Transcript

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Patient Mr. Smith

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