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Admission History and Physical - Initial Psychiatric Examination


Last Review Date: 2/20/09

Last Review Date: 10/19/10

Last Review Date 08/31/11

SME: Medical Director



When completed

All patients admitted to inpatient units (acute and sub-acute care levels) receive a history and physical examination within 24 hours after admission. This is typically documented in the online document Initial Psychiatric Evaluation (IPE). In the event access to the online record is not available, the paper multi-page form for this initial assessment is the Initial Psychiatric Examination (IPE).

Note: If a pertinent history and physical has been performed at UT-HCPC within 30 days prior to admission, then a durable, legible copy of such history and physical may be placed in the patient's medical record and the Past History, Review of Systems and Physical Examination may be referenced and omitted or updated as appropriate.

If a physical examination of the patient has been completed within 30 days prior to admission and a copy is placed in the record, the Physical Examination may be referenced and omitted from or updated in the IPE as indicated. The copy must be signed and dated, and may be used provided that documentation is been made of all interim additions to the history, and any changes in physical/mental findings. This documentation is also required within 24 hours after inpatient admission.

Re-attempts to assess

If the patient refuses to be examined or is unable to be completely examined because of the symptoms of mental illness, an attempt must be documented within 24 hours and every 24 hours thereafter until the assessment is completed.

Physician responsibility

If a resident physician or other credentialed provider (rather than an attending physician) completes the initial assessment (IPE), the attending physician who has also examined the patient within the same time frame verifies it.

Verification:
The attending physician verifies the examination by doing the following:

Documenting his/her corrections (as indicated)

Co-signing the document

Writing an attending admission note referencing the IPE (and admitting orders) verifying the following:

Acknowledging the resident's note by the name of the resident

Key historical elements of the patient's present illness

Mental and physical state

Diagnoses

Medical decision making

Form elements

The following are the elements of the Initial Psychiatric Examination form:

Presenting problem/justification for admission including chief complaint

Past Family and Social History (PFSH)

Review of systems

Mental status examination

Physical examination

Admitting diagnoses and differential diagnosis

Assets

Problem areas

Actions

Signatures

Presenting problem/
justification for admission

Summarizes the course of the presenting problem(s)/justification for admission and may include the following:

Onset and other time invervals

Interventions

Reactions of others involved

Section framing: This section should be framed in 4 or more of the following dimensions:

Location

Quality

Severity

Duration

Timing

Context

Modifying factors

Associated symptoms

Chief complaint

A concise statement of the reason for the hospitalization. The statement should include one or two sentences from the patient, and/or significant others, as to reasons given for the patient needing admission using their own words if possible.

Past Family Social History

Summarizes the following for past psychiatric, medical, family, and social history. Each area must be addressed:

Any past psychiatric history that appears to have immediate relevance to the current clinical episode
Example
: History of affective disorder, schizophrenia, or other recurring psychiatric disorders.

Any major medical problems that have impacted or are currently impacting on the patient's condition

Any treatment that must be maintained for any current condition (current medications, dietary supplements, allergies)

Any history of past medical problems that may need immediate attention
Example
: Diabetes, asthma, cardiac problems, especially head trauma and substance abuse

Relevant family and social history, including assessment of trauma and abuse

Review of systems

A pre-determined checklist, part of the IPE, which complements findings in the physical examination, mental status examination, and/or the admissions nursing assessment parts I-IV.

Mental status examination

A brief assessment including the following in sufficient detail for measuring change at discharge:

General appearance/behavior

Gait, muscle tone, abnormal movements

Speech

Thought processes

Thought content

Perception

Mood/affect

Insight/judgment

Cognitive exam (orientation, attention/concentration, knowledge, abstractions, memory)

Estimated intelligence (high?, average?, low?, retarded?)

Physical examination

Notes review of vital signs, assessing for physical evidence of abuse and documents findings of the physical examination. Notes whether the primary examination was performed by a medical student, physician, or other credentialed provider.

Items to examine during the physical examination are listed below:

Item

Description

1

General Appearance

2

Skin

3

Lymphatics

4

HEENT/Neck

5

Chest/Lungs

6

Cardiovascular

7

Abdomen

8

Genitalia and Rectal, Pelvic,
When completed
: These examinations should be completed or referred later when indicated as determined by a body region specific review of systems.

9

Back/Extremities

10

Neurologic Exam as follows:

Cranial Nerves (state if intact and check how tested)

I. (by identification of a known substance)

II. (by distinguishing movements in the peripheral visual fields)

III, IV, VI. (by demonstrating extraocular muscle movements)

V. (by distinguishing sensation throughout the trigeminal nerve

distribution)

VII. (by demonstrated facial muscles of expression)

VIII. (by demonstrating bilateral hearing)

IX. (by demonstrating a gag reflex)

X. (by phonating guttural sounds)

XI. (by demonstrating a bilaterally symmetrical shoulder shrug)

XII. (by protruding the tongue without fasciculation)

Motor (include strength, involuntary movements)

Sensory

Reflexes

Gait/Romberg

Head circumference (child/adolescent only)

 

Admitting diagnoses

The admission psychiatric diagnoses is as follows:

List all applicable DSM-IV TR Plus Axis I diagnoses

List all applicable DSM-IV TR Plus Axis II diagnoses if known at the time

List all applicable DSM-IV TR Plus Axis III diagnoses. Include any major or significant medical (physical) problems for which the patient is currently under treatment, as described in the admission process and documents, or write "No Diagnosis"

List all applicable DSM-IV TR Plus Axis IV psychosocial and environmental problems

List the DSM-IV TR Plus Axis V (GAF)

Differential diagnosis

Documents a differential diagnosis as needed.

Assets

Lists the patient's assets in descriptive, not interpretive fashion, that can be used in the institution of treatment and development of the master treatment plan.

Example: Knowledge, interests, skills, aptitudes, experience, education, employment status, insight, cooperativeness.

Relevant items: The physician should move relevant items to the Multidisciplinary Problem Aggregate (MPA).

Problem Areas

The physician lists problems (symptoms), both physical and psychiatric, which form the psychiatrist's input to the online Master Treatment Plan .

Actions

Checks the appropriate boxes regarding actions undertaken.

Signature

Admitting resident or other credentialed provider:
Signature, date, and time are entered elctrnoically for documents completed online. In cases where a paper document must be used, the admitting resident or provider signs his/her legal name, as it appears in hospital records, and degree initials, then writes the date and time. The admitting clinician also prints his/her last name in the space provided.

Admitting Attending:
The admitting attending physician reviews and co-signs the IPE. Signature, date, and time are entered elctrnoically for documents completed online. In cases where a paper document must be used, attending physician writes a co-signature, using legal name and degree initials, prints name in the space provided, then dates and times the entry.

Forms

Initial Psychiatric Examination (IPE)

Related Standards

The Joint Commission : Provision of Care

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Harris County Psychiatric Center University of Texas Health Science Center