A psychiatric consult note is the psychiatrist’s answer to another team’s question, in the emergency department or on a medical ward: the history, the medical causes, the mental status, risk, the diagnosis, and numbered recommendations. Copy the free template, see an ED consult for first-episode psychosis and a ward consult for delirium after hip surgery, and check what goes in each part.
Blank psychiatric consult note template
FreePSYCHIATRIC CONSULT NOTE Patient: [Name, age, record number] Location: [Emergency department bay, or ward, unit, and bed] Date and time seen: [Date, time] Consulting psychiatrist: [Name, credentials, consult service] Requesting clinician: [Name, service, and how to reach them] REASON FOR CONSULT Question asked: [The requesting team's question, in their words] Clarified question: [The decision the team needs to make, after speaking with them] Urgency: [Emergent, urgent, or routine, and why] Course so far: [Why the patient is in the ED or the hospital, and what has happened since arrival] SOURCES Interview: [Seen alone or with others, for how long, and how well the patient could take part] Chart: [Notes, nursing observations, medication record, and results reviewed] Collateral: [Who was contacted and their relationship, with the patient's consent or the reason for going ahead without it] Reliability: [How far each source can be relied on, and why] HISTORY OF PRESENTING PROBLEM Onset and course: [When the change began, how fast, and whether it varies through the day] Current symptoms: [Mood, anxiety, psychosis, confusion, agitation, sleep, eating] Patient's account: [A short quote] Before presentation: [Stressors, missed medicines, substance use, new illness] PSYCHIATRIC AND SUBSTANCE HISTORY Psychiatric history: [Diagnoses, admissions, current psychiatrist or therapist, medication trials that matter now] Suicide attempts, self-harm, violence: [When, how, and the outcome] Substance use: [Each substance, amount, last use, past withdrawal seizures or delirium tremens] Drug screen and alcohol level: [Results, with times] MEDICAL CONTRIBUTORS Active medical problems: [Admission diagnosis, surgery, infection, pain, organ function] Medicines reviewed: [New, stopped, or changed drugs that act on the brain: sedatives, opioids, anticholinergics, steroids, with timing] Withdrawal risk: [Alcohol, benzodiazepines, opioids, with last use and signs] Delirium screen: [Tool used, such as the CAM or 4AT, with the result and an attention test] Results reviewed: [Vital signs, labs, ECG with QTc, imaging, and what is pending] MENTAL STATUS EXAM Alertness and attention: [Alert, drowsy, or fluctuating; months backward or another attention test] Appearance and behavior: [Grooming, eye contact, agitation, a sitter or restraints] Speech and thought process: [Rate, volume, coherence; linear, tangential, or disorganized] Mood and affect: [Mood in the patient's words; affect observed] Thought content and perception: [Delusions, suicidal or homicidal thoughts, hallucinations, responding to internal stimuli] Cognition, insight, and judgment: [Orientation, memory; insight and judgment] RISK ASSESSMENT Harm to self: [Thoughts, intent, plan, preparation, recent and past attempts] Harm to others: [Thoughts, threats, a named person, behavior since arrival] Risks on the unit: [Leaving against advice, falls, pulling out lines, self-neglect] Lethal means: [Firearms and stored medicines at home, and what was agreed] Risk formulation: [Current risk, the reasons, and what would change it] CAPACITY Decision in question: [The specific decision the team asked about, or not asked] Findings: [Understands the information, sees how it applies, reasons with it, gives a clear choice] Conclusion: [Has or lacks capacity for this decision now, who decides if not, and when to reassess] FORMULATION AND DIAGNOSIS Formulation: [Why this patient presents this way now: medical, psychiatric, substance, and social factors] Diagnoses: [Primary and other diagnoses, with specifiers] Differential: [Other causes considered, and why they are more or less likely] Answer to the question: [A direct answer in one or two sentences] RECOMMENDATIONS 1. [Most urgent: safety, observation level, or the medical workup] 2. [Medicine: drug, dose, route, timing, most in 24 hours, and when to stop] 3. [Monitoring: ECG, vital signs, labs, side effects, and who checks them] 4. [Non-drug measures and the environment] Observation and legal status: [Observation level; voluntary, or held under the law where you practice, with start and end times] If things change: [What to watch for, what to do, and when to call] DISPOSITION AND FOLLOW-UP Disposition: [Inpatient psychiatry, stay on the current unit, crisis stabilization, or home with follow-up] Consult team plan: [Following daily, seeing again after a set event, or signing off] Discussed with: [Requesting clinician, patient, family; how and when] Contact: [Pager or phone, and after-hours psychiatry cover] Signed: [Name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Emergency department, psychiatry consult, 70 minutes with the patient and family
From the emergency physician at 19:10: “New paranoia and hearing a voice. Medical workup done. Please assess for psychosis and need for admission.” Urgent: she is waiting in the ED. Clarified by phone: the team needs to know whether she can go home tonight, and where she should be treated. 22-year-old woman brought in by her mother and roommate after about 3 weeks of little sleep and fear that her neighbors are watching her.
Seen alone for 45 minutes, then with her mother for 25 minutes, at her request. ED notes, nursing observations, and results reviewed. Collateral from her roommate and her mother, both with her consent. No previous mental health records in the system. Accounts agree on the timeline; reliable apart from her beliefs about the neighbors.
About 6 weeks ago she began staying in her room and stopped answering friends. For 3 weeks she has slept 2 to 3 hours a night, sure that her upstairs neighbors watch her through the building’s wifi and her phone camera. Taped over her laptop camera and unplugged the router. Hears a man’s voice from the ceiling most days, describing what she is doing; it has never told her to do anything. Stopped going to her café job 2 weeks ago. Eating little, “only sealed food.” “I know how it sounds, but I can hear them talking about me.” No low mood or loss of interest before the beliefs began, and no spells of high energy or little need for sleep. No psychiatric history, treatment, suicide attempts, self-harm, or violence. Cannabis vape daily for a year, several times a day over the last 2 months “to calm down”; last use this morning. Alcohol 2 or 3 drinks a month. No stimulants, hallucinogens, or other drugs. Maternal uncle with schizophrenia. Lives with one roommate; finished a graphic design program last year. No legal issues.
No fever, headache, head injury, seizures, or recent illness. No prescription or over-the-counter medicines, supplements, or steroids. T 36.9 °C (98.4 °F), HR 92, BP 124/78, RR 16, SpO2 99% on room air. Weight 58 kg (128 lb), BMI 21. Neurological exam by the ED physician normal. CBC, electrolytes, glucose, creatinine, liver enzymes, calcium, and TSH normal. Urine pregnancy test negative. Urine drug screen positive for cannabinoids only. Blood alcohol undetectable. HIV and syphilis tests sent, pending. ECG: sinus rhythm, QTc 412 ms. Attention intact: months of the year backward without error. No sign of delirium, intoxication, or withdrawal. Brain imaging not needed tonight with a normal neurological exam; the inpatient team to decide on an MRI.
Alert, attention intact. Hood up, layered clothes in a warm room, hair unwashed. Guarded and scanning the room; cooperative once the door was closed. Speech soft, normal rate. Mood: “scared, and so tired.” Affect anxious, restricted, congruent. Thought process mostly linear, tangential at times when talking about the neighbors. Thought content: fixed belief that her neighbors monitor her through the wifi and her phone; feels the TV news sometimes refers to her. No suicidal or homicidal thoughts. Perception: a male voice commenting on her actions, no commands; paused twice as if listening. Oriented to person, place, and time. Insight partial: “Maybe I’m just exhausted.” Judgment fair: came willingly and wants help to sleep.
No suicidal thoughts, now or before; no self-harm. No thoughts of harming her neighbors, and has not confronted them. No firearms or other weapons at home. Risk factors: untreated first-episode psychosis, heavy daily cannabis, little sleep, poor eating. Protective factors: close mother and roommate, no history of violence or self-harm, wants help. Formulation: low current risk of suicide or violence; moderate risk of self-neglect, and of the illness worsening without treatment. Capacity not asked; she understands what admission involves, can say why it would help, and chooses it.
Six weeks of withdrawal and decline, then 3 weeks of persecutory delusions, a commenting voice, and insomnia, with a family history of schizophrenia and heavy daily cannabis use. No medical cause found on exam or tests, and no delirium. Diagnosis: unspecified schizophrenia spectrum and other psychotic disorder, first episode. Differential: cannabis-induced psychotic disorder, possible given the heavy use, and less likely if symptoms persist after several weeks without cannabis; schizophreniform disorder, as the course becomes clear; mood disorder with psychotic features, unlikely with no depressive or manic syndrome. Answer: she needs treatment in hospital, and agrees to voluntary admission to inpatient psychiatry.
1. Admit to inpatient psychiatry as a voluntary patient; bed requested. Until transfer, a quiet room in the ED with checks every 15 minutes; no one-to-one needed. 2. Aripiprazole 5 mg by mouth each morning, first dose tomorrow after the fasting bloods. Chosen with her for its lower risk of weight gain and prolactin effects; told that restlessness is a common early side effect. The inpatient team reviews the dose after about a week; many first-episode patients respond at 10 mg daily. 3. Lorazepam 1 mg by mouth at bedtime tonight for sleep, and 1 mg every 6 hours as needed for anxiety or agitation, no more than 4 mg in 24 hours in total. 4. Baseline monitoring: weight, BMI, and BP recorded; waist, fasting glucose or HbA1c, and lipids tomorrow morning; ECG done. Watch for restlessness, stiffness, or muscle spasms in the first days. 5. Follow up the HIV and syphilis results. Advised no cannabis. 6. With her consent, referral to the local early psychosis program before discharge. Legal status: voluntary; she does not meet criteria for involuntary admission under the law where we practice. If she asks to leave before transfer, the ED calls psychiatry to reassess first. If things change: call us for agitation, a wish to leave, new suicidal thoughts, or fever with stiffness.
Voluntary admission to the inpatient psychiatry unit; bed expected by 23:00. The working diagnosis, the plan, and aripiprazole’s side effects explained to her and, with her consent, to her mother, who will bring clothes and a phone charger. Discussed with the emergency physician in person at 21:05; plan agreed. Consult team signs off once she transfers; the inpatient psychiatrist takes over. Psychiatry on call until then.
Orthopedic ward, consultation-liaison psychiatry, day 2 after surgery
From the orthopedic team at 08:30: “Agitated overnight, pulled out his IV, shouting that he’s being held prisoner. New psychosis? Please advise on sedation.” Urgent: today. Clarified with the resident: they want the cause, how to keep him safe, whether he can refuse care if he tries to leave, and whether discharge home on day 3 still stands. 70-year-old man, day 2 after an elective right total hip replacement for osteoarthritis.
Seen at the bedside at 10:15 for 30 minutes; could take part only in short spells. Chart, medication administration record, nursing notes, and overnight vital signs reviewed. Collateral from his wife at the bedside, his named decision-maker. His own account unreliable at present; his wife and the chart reliable.
No memory problems before surgery, by his wife: manages the household accounts and drives. Retired electrician. Surgery under spinal anesthesia, uneventful; first night settled. Last night from 22:00: restless, then shouting that he was in a prison camp; pulled out his IV at 01:30 and tried to climb over the bed rails. Seeing “men in the corner.” Drowsy and muddled this morning, briefly clearer when his wife arrived. No psychiatric history, and no hallucinations or paranoia before this admission. Alcohol: 2 beers most evenings for years, by his wife; last drink 3 days ago, the evening before surgery. No other substances. Hypertension, type 2 diabetes, benign prostate enlargement, and hearing loss; his hearing aids are at home.
Since surgery: oxycodone 10 mg as needed, 6 doses in the last 24 hours; diphenhydramine 25 mg at night for sleep, given both nights; oxybutynin 5 mg three times daily, started on day 1 for bladder spasm after the catheter came out; lorazepam 1 mg given twice overnight for agitation, after which he became more confused. Home tamsulosin not restarted. No bowel movement since surgery. Bladder scan this morning 720 mL. T 37.6 °C (99.7 °F), HR 88, BP 142/80, RR 18, SpO2 95% on room air. No tremor or sweating. Hemoglobin 9.8 g/dL (98 g/L), from 13.9 g/dL (139 g/L) before surgery. Sodium 133 mmol/L. Glucose 9.1 mmol/L (164 mg/dL). Creatinine normal. ECG today: sinus rhythm, QTc 438 ms. Chest clear; wound clean and dry. Alcohol withdrawal unlikely with his low intake and no tremor, sweating, or fast heart rate.
Alertness fluctuating: dozes off mid-sentence, then startles and tries to sit up. Attention poor: months of the year backward, stopped after 3. In bed, gown off one shoulder, picking at the sheets. Speech mumbled and rambling. Mood: “they won’t let me go home.” Affect frightened, labile. Thought process disorganized, losing the thread. Thought content: believes the ward is a prison camp; no suicidal or homicidal thoughts expressed. Perception: sees men in the corner of the room; picks at the air. Oriented to person only; gave the year as 1998 and the place as “the plant.” Acute change since surgery, fluctuating over the night. 4AT 11, positive for delirium. Insight absent; judgment impaired.
No suicidal thoughts. Main risks: falls, pulling out lines, and dislocating the new hip if he climbs out of bed. Struck out at a nurse once while being redirected at 01:30; no injury. Capacity, as asked: at present he can’t take in or weigh information about staying in hospital, so he lacks capacity to refuse care and leave. If he tries to leave, the team acts in his best interests under the law and hospital policy where we practice, with his wife involved. Reassess daily as the delirium clears.
An acute, fluctuating change on day 2 after surgery, with poor attention, disorganized thinking, altered alertness, and visual hallucinations, in a man with no previous memory or psychiatric problems. This is delirium, not a new psychosis. Likely causes, several at once: anticholinergic drugs, diphenhydramine and oxybutynin; lorazepam; urinary retention with tamsulosin held; opioids, with pain still poorly controlled; constipation; blood loss anemia; and lost sleep and missing hearing aids. Infection possible but not shown. Diagnosis: delirium, mixed type, multifactorial, after surgery. Differential: alcohol withdrawal, unlikely as above; an underlying dementia unmasked by surgery, to check once the delirium clears. Answer: treat the causes, stop the sedatives, and keep an antipsychotic for severe distress or danger only. Discharge on day 3 is unlikely.
1. Bladder: in-and-out catheter now, then bladder scans every 6 hours under the ward’s retention protocol. Restart tamsulosin 0.4 mg by mouth daily. 2. Stop diphenhydramine, oxybutynin, and lorazepam. No benzodiazepines unless alcohol withdrawal appears; no sleeping tablets. 3. Pain: acetaminophen 1 g by mouth every 8 hours, scheduled; oxycodone 5 mg by mouth every 4 hours as needed, offered before physiotherapy. Pain also drives delirium, so don’t withhold it. 4. Bowels: senna 2 tablets at night and polyethylene glycol 17 g daily until his bowels open. 5. Urinalysis and urine culture, given the retention and the temperature; repeat CBC and electrolytes tomorrow. No brain imaging needed: no fall, no head injury, no focal signs. 6. Hearing aids and glasses on, his wife bringing the hearing aids today; clock and calendar in view; lights and blinds open by day, dark and quiet at night; no routine observations from midnight to 05:00 if stable; out of bed with physiotherapy today; family visits, especially evenings; remove the IV if fluids aren’t needed. A sitter at night instead of restraints; bed at its lowest. 7. Only for severe distress or danger to himself or others, after the steps above: haloperidol 0.5 mg by mouth, or intramuscularly if he can’t take it by mouth, repeated once after 1 hour if needed, no more than 2 mg in 24 hours. Not for sleep or restlessness alone. Don’t give if QTc is above 500 ms; repeat the ECG after any dose; keep potassium and magnesium normal. Stop it when the agitation settles, and don’t continue it at discharge. If things change: call us if agitation persists despite these steps, if he needs haloperidol more than twice in a day, or if tremor, sweating, or a heart rate above 100 appear.
Stays on the orthopedic ward; discharge on day 3 not advised. Delirium explained to his wife: common after surgery, usually clears over days as the causes are treated, and her visits and familiar things help. Discussed with the orthopedic resident in person at 11:00; all recommendations agreed and ordered. Consult team follows daily until the delirium clears. Before discharge: a memory screen once he is clear, and a note to his primary care clinician asking for a cognitive screen in 3 months, as delirium can be the first sign of a memory problem. Contact: consultation-liaison psychiatry pager; psychiatry on call after hours.
The question the team asked, the decision they actually need to make, and how soon. Many psychiatry consults arrive as a vague request.
Avoid: “Psych eval, please” as the question. Call the team, and write down what they need to decide.
Where each part of the history came from. In the ED or on a ward, the patient is often not the best source.
Avoid: Mixing what the patient said with what family or nurses reported. Label each source, especially when they disagree.
What in the body, the medicines, or a substance could explain or worsen the presentation. This is the section that sets a consult apart from an outpatient evaluation.
Avoid: Taking “medically cleared” on trust. Read the vital signs, the medication record, and the results, and test attention yourself.
What you observed, and your judgment of the risk of harm, written so the team knows what to watch for on the unit.
Avoid: An MSE that skips alertness and attention. In a medically ill patient, those two findings separate delirium from a primary psychiatric illness.
Only when the team asks, and only for the decision they name. Capacity belongs to one decision at one time.
Avoid: “Lacks capacity” with no decision named. A patient can lack capacity to refuse surgery and still choose what to eat.
Why this patient presents this way now, and a direct answer to the question.
Avoid: A diagnosis with no answer. The team needs to know what to do, not only what to call it.
Numbered, most urgent first, and specific enough for the team to order. Then where the patient goes, and whether you keep seeing them.
Avoid: “Consider an antipsychotic.” Write the drug, the dose, the most in 24 hours, what it is for, and when to stop it.
New confusion, hallucinations, or agitation in a medically ill or older patient is delirium until shown otherwise. Test attention, read the medication record, and name the medical causes before you name a psychiatric one.
An antipsychotic or a benzodiazepine for behavior, with no causes treated, keeps the delirium going. Benzodiazepines make most delirium worse; keep them for alcohol or benzodiazepine withdrawal.
“Adjust medicines” or “consider haloperidol” leaves the team guessing. Write the drug, dose, route, the most in 24 hours, the reason, and when to stop.
The team asked whether she can go home, or whether he can refuse care. Answer that first, in a sentence, before the formulation.
Name the observation level, whether the patient is voluntary or held, when a hold ends, and what to do if the patient asks to leave. Nurses act on this section overnight.
Vero Scribe writes the consult note in your template from the interview, with the patient’s consent, or from your dictation afterward. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
The requesting team and its question, your sources, the presenting problem, psychiatric and substance history, medical contributors such as delirium, medicines, and withdrawal, a mental status exam, a risk assessment, capacity if asked, your formulation and diagnosis, numbered recommendations, the disposition, and your follow-up plan.
A psychiatric evaluation is the full first assessment of an outpatient or a new psychiatry admission, and you own the plan. A consult note answers another team’s question about their patient, so it leads with that question, looks harder at medical causes, and ends with recommendations that team carries out.
The part of psychiatry that cares for patients on medical and surgical services, and in many hospitals the emergency department. Common questions are delirium and agitation, depression or anxiety in medical illness, risk after an overdose, capacity, withdrawal, and psychiatric medicines in people with medical illness.
Check alertness and attention first. Delirium starts over hours to days, fluctuates, and impairs attention, often with visual hallucinations, in someone medically ill or on new medicines. A primary psychosis usually leaves attention and orientation intact. A screen such as the CAM or 4AT helps; record the result, and look for medical causes before a psychiatric diagnosis.
Write the observation level, such as checks every 15 minutes or constant observation, and why. Say whether the patient is voluntary or held under the mental health law where you practice, when a hold started and ends, and who must review it. Then say what the team should do if the patient asks to leave.
Yes. Copy it, or download it as a Word or text file. No account needed.
The full first psychiatric assessment, with a structured mental status exam and a risk formulation.
The MSE on its own, in standard order, with normal and abnormal words for each domain.
Follow-up and medication management visits, tracked by target symptoms, side effects, and risk.
The written assessment of an adult referred for possible ADHD: symptoms, childhood onset, scales, differential, and plan.
Assessments, follow-ups, and consultation letters, drafted from the visit for your review.
Psychiatric visit notes, patient context, and follow-up in one workspace.
Admissions, daily rounds, and discharge documents for the teams you consult for.
The codes used most often in psychiatry.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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