Template (sparse) - Psychiatry Inpatient Admission Note (Dragon fields)

# Psychiatry Inpatient Admission Note

Resident admitting: [My Name] MD

Attending staff: [Staff Name] MD

Admission Date: [Admit Date]

First: [First Name]

Last: [Last Name]

Sex: [Female]

Pronouns: [She/Her]

Age: [Age]

DOB: [YYYY/MM/DD]

HCN: [Health Card Number]

HCN V.: [Health Card Version]

MRN: [Hospital Medical Record Number]

Tel: [Patient Telephone]

Contact Tel: [Patient Primary Contact Telephone]

PCP: [Primary Care Provider of Record]

## IDENTIFYING INFORMATION:

[Identifying information]

### Admitted from:

[Emergency Department BIBP.]

## SUBJECTIVE:

[Subjective report when assessed]

[Subjective relevant history]

## OBJECTIVE:

[Relevant history from collateral sources]

[Summary of relevant medical records]

### Safety assessment:

[Safety Assessment]

Suicidal ideation:

Risk Factors: [Single, unstable housing, trauma history, drug use, rational thinking loss, hopelessness.]

Protective Factors: [Admitted to psychiatric hospital.]

## MENTAL STATUS EXAMINATION:

[Narrative MSE]

Appearance:

Behaviour: 

Motor:

Speech:

Mood:

Affect:

Thought Process:

Thought Content:

Perceptual Disturbances:

Cognition

-Memory: [Short, medium, and long-term memory grossly intact.]

-Attention: [Grossly intact.]

-Fund of Knowledge: [Average fund of knowledge.]

Insight into illness

-Understanding:

-Appreciation:

Judgement:

## MEDICATIONS:

[Medications]

### Admission Medication Reconciliation [Completed] [by writer].

### ALLERGIES:

[NKDA]

## INVESTIGATIONS:

[No new/relevant investigations.]

## IMPRESSION:

[Brief identifying information]

[Admission diagnosis][Secondary diagnoses][Relevant comorbidities]

[Admission rationale]

[Suitability for voluntary admission]

[Safety concerns while in hospital]

## PLAN:

1. Legal status: [Voluntary admission]; [Capable for psychiatric decision making]; [Financial capacity assessment deferred].

2. Admission Dx: [Diagnosis.]

3. Admitting Psychiatrist: [Dr. Attending MD FRCPC]

4. Safety: [No acute safety concerns.]

5. Diet: [DAT.] [No food allergies.]

6. Activity: [AAT.]

7. Privileges: [Unit privileges. No passes.]

8. Vitals: [Daily BP, HR, Temp, Pain Scale, BM tracking.]

9. Nursing Orders:

  A. Observation: Close Observation Q15 minutes.  

  B. Orient to unit and perform safety checks.  

  C. Weight, height, and waist circumference once. 

  D. Update EMR profile and photographs.  

10. Medications: [Admission Medication Reconciliation Reviewed and Approved.]

11. Investigations: [CBC, Lytes, Extended-Lytes, Lipid Pannel, Calcium Pannel, Iron Pannel, LFT's, Iron Studies, B12, RBC Folate]

12. Referral: [Referred to unit hospitalist for admission assessment.]

13. Disposition: [For continued assessment, diagnostic clarification, medication optimization, stabilization, and discharge to home.]