Last Review Date: 2/20/09
Last Review Date: 10/19/10
Last Review Date 08/31/11
SME: Medical Director
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.
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.
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.
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
Medical decision making
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
Admitting diagnoses and differential diagnosis
Summarizes the course of the presenting problem(s)/justification for admission and may include the following:
Onset and other time invervals
Reactions of others involved
Section framing: This section should be framed in 4 or more of the following dimensions:
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.
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
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
Relevant family and social history, including assessment of trauma and abuse
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.
A brief assessment including the following in sufficient detail for measuring change at discharge:
Gait, muscle tone, abnormal movements
Cognitive exam (orientation, attention/concentration, knowledge, abstractions, memory)
Estimated intelligence (high?, average?, low?, retarded?)
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:
Genitalia and Rectal, Pelvic,
Neurologic Exam as follows:
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)
Documents a differential diagnosis as needed.
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).
The physician lists problems (symptoms), both physical and psychiatric, which form the psychiatrist's input to the online Master Treatment Plan .
Checks the appropriate boxes regarding actions undertaken.
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.
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.
The Joint Commission : Provision of Care
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