patient interview hp i
TRANSCRIPT
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8/19/2019 Patient Interview Hp i
1/1
Name: Age:
CC:
HPI: current sx, depression/mania/psychosis screen, safety, compliance, stressors, EtOH/rugs !inc "/d#
Past Psych Hx: !including su$stance a$use#:Inpt/Outpatient, %ed &rials, 'uicide/(iolence
)amily Hx: !mental illness, su$stance a$use,suicide#
'ocial Hx: !education, income/employment/disa$ility, li*ing situation, marriage/partner/+ids, legal,
hx trauma/a$use#
P%H: !remem$er to as+ a$out &I#
Allergies:
%eds:
%'E: appearance, $eha*ior, speech, mood, affect,thought process, content, memory/concentration,
insight and -udgment
.: Put the case together "ith a good linermentioning the lead diagnosis0 &hen gi*e supporting
positi*es and negati*es from the inter*ie" and %'E to
support your lead diagnosis and other diagnoses on yourdifferential0 %ention that you "ould li+e more info
!collateral/la$s# to ma+e an accurate diagnosis0 1emem$er
su$stance induced d/o and psych sx secondary to medical
pro$lems0
Axis I0 Psychiatric d/o including 'u$stance a$useAxis II0 Personality d/o and de*elopmental disorders
Axis III0 %edical Pro$lems
Plan:0 Admit/ischarge Patient
20 'afety 3e*el
40 %edical "+ up !la$s/imaging#50 Collateral information
60 %edications to start/continue
70 &hin+ a$out dispo issues !all pts need a safe d/c plan including appropriate outpatient care and a safe
place to li*e#0 &his may include shelter, group home placement, case manager, psychiatrist 8/9 psychotherapist, su$stance a$use treatment,
psychosocial reha$ !day program/clu$house#0