H&P Template

Name/MRN/Date:

MSE:
CC: Appearance: older/ younger stated age, fair/poor grooming/hygiene,
dressed in casual/hosp pj’s/obese/thin/atrophy; tattoos? Etc.
HPI: Why Now? Stressors? Mood? Behavior and eye contact:
poor/good/transient/intense eye contact
Muscle strength and tone: tremors / rigidity / PMA / PMR / EPS /
tardive dyskinesia / tics
ambulates/limps/whl chair/cane/walker
Speech: Rate: pressured / rapid / nml / slow
Rhythm: monotone / nml
Volume: low / high / nml
Mood: “________________________”
Affect: flat / blunted / constricted / guarded / anxious / irritable / dysphoric /
depressed / euthymic / elevated / expansive / labile
Thought Process: linear, logical, goal oriented / circumstantial / tangential
Thought Content: SI / HI / delusional thinking / paranoid / referential thinking /
somatic delusions / thought insertion / thought broadcasting
Psych ROS – symptom and duration Insight: poor / fair / limited / intact
MDD: depressed mood; S I G E C A P S /hopeless Judgment: poor / fair / limited / intact
Mania: euphoria, irritable; D I G F A S T Cognition
GAD: excess worry / restless / fatigue / irritable / ↓sleep Orientation (PPT): person / place / time
Panic: palp /sweat / tremors / SOB / choking / CP / N / dizzy Memory: remote / recent / deficits
Derealization / fear to lose control / fear death/impending doom / Attention/concentration: poor / fair / limited / intact / distractible
chill / hot flushes / tingling / Out of the blue / trigger?
PTSD: phobias / traumatic event / recur memory / dreams / reliving / MMSE: Yr, season, mo,day, date -5
distress with exposure / avoidance / physiological reaction St, county, town, hosp, fl -5
OCD Apple/table/penny -3
Phobias D-L-R-O-W -5
Psychosis: AH, VH, Delusions Apple/table/penny -3
Safety: SI / HI / weapons / hx of SA / hx of violence Pencil/watch -2
Substance: No ifs, ands, or buts -1
Alcohol: 3 step command -3
Tobacco: Close your eyes -1
Drugs: Sentence -1 Total = /30
Rehab/detox/AA: Design -1
Withdrawal:
Legal Charges: Relevant Labs:
QTc:
Past Psych History: Imaging:
Outpatient:
Dx / Providers
Prior Rx Assessment:
Inpatient psych hospitalizations: Psych Dx:
SA: 1.
2.
3.
Family Psychiatric Hx: Medical Dx:
Psychiatric diagnoses: 1.
Substance use disorders: 2.
Suicide attempts/deaths by suicide: 3.
Psychosocial Probs:
PMH:

Current Meds:
Allergies: Suicide Risk
Static factors: male, single, super young, older, white or native american, prior
Social History: attempts, family history
Relationships: divorced / married / single / children
Current Living Situation: mobile home / home / apartment, roomates? Dynamic factors: mental illness hx, emotional turmoil, suicidality, other
Education: psychosocial factors
Occupational History:
Military History:
Legal History:
Childhood: Abuse?

Medical ROS: (at least 4)