PSYCHIATRIC 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]