follow up ed consult

							                                                                             Follow-Up ED Consult
Hospital:
              Patient consents to this evaluation by Telemedicine

Name: (Last)                                                 (First)                                     (MI)                 Date of Last Consult:

             SSN:                                                 Other ID:                                       Visit No (After Initial Consult:)
                                                                            Reason for F/U Consult
     Same as Previous reason for Initial Consult
     Change in Sensorium

     New Reason

                                                                                            Interval History




                                                                        Mental Status Examination
Sensorium                              Alert:                Oriented:                      Other:         (describe)
Appearance                                      Appropriate for Patient:                    (if not, describe)
Behavior                                                  Cooperative:                      (describe)
                                                                             Guarded:       (describe)
                                                                        Suspicious:         (describe)
                                                                              Hostile:      (describe)
                                                                               Other:       (describe)
Psychomotor Abnormalities                                         None:                      Other:         (describe)
                                                Appropriate for Patient:                     (if not, describe)
                                                     Attention:   Intact:                    (if not, describe)
                                                 Concentration: Intact:                      (if not, describe)
                                                      Memory:     Intact:                    (if not, describe)

Judgment                                                          Good:             Fair:      Poor:        (describe)
Insight                                                           Good:             Fair:     Poor:         (describe)
Emotion                                             Mood:    Euthymic:                                (if not, describe)
                                                   Affect: Appropriate:                               (if not, describe)
Thought Content                                    Hallucinations: No:                        Yes:          (describe)
                                                        Delusions: No:                        Yes:          (describe)
Thought Process                                  Logical/Goal directed:                       Distractible:          LOA:       FOI:
(*) Suicidal Ideation                                                  No:                    Yes:          (describe)
(*) Homicidal Ideation                                                 No:                     Yes:         (describe)
                                                                  None:                        Face:          Lips/Tongue:      Trunk:
                                                            Extremities:                                    (describe)
                                                              Tics: No:                         Yes:        (describe)
                                                                  Other:                                    (describe)

     Other

                                                                                                                                                      BAR CODE




SCDMH FORM
JAN. 09 (FM 03 23 09) DUKE - 02 Pg.1
                                               (*) DSM-IV Diagnosis   (Must include both code and description)

     Axis I



    Axis II



   Axis III



   Axis IV


  GAF
                                                                      Recommendations

                Psychiatric hospitalization not indicated at this time
                                                                  Medication recommendations
                              Mental Health Medication                              Dosage                       Frequency   Amount




    follow-up Psychiatric appt

    follow-up substance abuse appt

    follow-up medical appt

    social services

    community assistance

    shelter

    residential program

    family supervision

    safety precautions

    emergency plan

    legal

    other




                                                                                                                             BAR CODE




SCDMH FORM
JAN. 09 (FM 03 23 09) DUKE - 02 Pg.. 2
     Further evaluation needed
    labs

    consults

    diagnostic tests

    additional info

    other




     Psychiatric/substance abuse hospitalization indicated
    voluntary

    involuntary




                                                          Interim Management
                                                        Medication recommendations
                             Mental Health Medication           Dosage               Route          Frequency




    environmental

    social

    other




Signature                                                                                    Date


                                                                                                                BAR CODE




SCDMH FORM
JAN. 09 (FM 03 23 09) DUKE - 02 Pg. 3