Psychiatry Quick Entry by zwftoTP

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									Seen with ****** at ***** on *****

Presenting Complaint:
   

Self Harm Specific Points:
     Method:
     Intoxication:
     Efforts to avoid detection:
     Note left:
     Affairs in order:
     Planning:
     Previous attempts:
     Age:
     Employment:
     Relationship status:
     Education:
     Mental health:
     Alcohol and drug misuse:
     Institutionalisation
     Understanding of likely outcome of actions:
     Protective factors

History of Presenting Complaint:


Past Psychiatric History:
    

Medical history:
  

Allergies:
    

Medications:
    

Family History:
    

Personal History:
       Birth:
       Childhood:
       School experience:
       Qualifications:
       Employment history:
       Relationships:
       Abuse:

Social History:
    Housing:
          Debts:
          Current relationships:
          Alcohol:
          Smoking:
          Drug use:
          Interests:
          Religion:

Forensic History
    

Premorbid Personality:


Mental State Examination

          Appearance:
          Speech:
          Affect:
          Mood:
          Thought Content:
          Abnormal Perceptions:
          Delusions:
          Cognition:
          Orientation: Orientated in time, place and person
          Attention: Able to recall ***** (/7) digits forward and ***** (/3) reversed
          Concentration: Able to reverse ***** (/12) months of the year
          Short term memory: Intact
          Long term memory: intact
          Intellectual capacity: Intelligence seems ***** although not formally tested

Insight:


Formulation / why now (predisposing, precipitating, perpetuating, protective)
          Precipitant:
          Predisposing factors:
          Perpetuating factors:
          Protective factors:

Summary:


Differential diagnosis:
    

Risk


Management Plan:
  

								
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