Follow-Up ED Consult

Follow-Up ED Consult
Hospital:
Patient consents to this evaluation by Telemedicine
Name: (Last) / (First) / (MI) / Date of Last Consult:
Age: / SSN: / Other ID: / Alaskan NativeAmerican IndianAsianBlack/African AmericanMore than one raceNative HawaiianPacifici IslanderOtherWhite / 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 (REV. SEPT. 09) DUKE - 02 Pg.1
(*) DSM-IV Diagnosis (Must include both code and description)
Axis I
Axis II
Axis III
Axis IV
GAF
Explanation of diagnosis/thoughts
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 (REV. SEPT. 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 (REV SEPT. 09) DUKE - 02 Pg. 3