Child Psychiatry Consultation

Completed note

Patient Identification: 13-year-old adolescent presenting with several months of low mood and reduced school participation.

History of Present Illness:
The adolescent reports feeling sad most days for about two months, with lower energy and difficulty concentrating. Symptoms followed a change in peer relationships and have affected homework completion. A caregiver confirms increased time alone. No prior psychiatric treatment.

Past Psychiatric History:
- No prior diagnoses, hospitalizations, self-harm, or aggression reported

Past Medical History:
- No significant medical or surgical history reported
- Development and birth history not discussed

Medications:
- None reported

Allergies:
- No known drug allergies reported

Family Psychiatric History:
- Not discussed

Social History:
- Lives with caregiver
- School attendance continues; recent academic difficulty
- Has one supportive friend
- Substance use and legal history not discussed

Mental Status Examination:
- Calm and appropriately engaged
- Mood described as “down”; affect constricted
- Speech and thought process coherent
- No perceptual disturbance reported
- Alert, insight and judgment age appropriate
- Denies suicidal thoughts, self-harm, or intent to harm others

Physical Examination:
- Vitals not obtained
- No acute physical concern observed

Investigations:

Assessment & Plan:
adolescent with low mood and functional change, symptoms consistent with a depressive syndrome; further assessment is needed.

1) Low mood
- Complete symptom and safety monitoring with caregiver involvement.
- Recommend psychotherapy and regular sleep, activity, and school routines.
- Coordinate supports with school with family consent.
- Follow up soon to reassess symptoms and safety; seek urgent help for suicidal thoughts or rapidly worsening behavior.

Illustrative case with invented patient details. This is not a real patient record or clinical guidance. Review each note against your own consultation.

Clinical facts behind the note

Reusable template structure

Child and Adolescent Psychiatry Consult Note

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...]

History of Present Illness:
[Presenting psychiatric symptoms, onset, duration, severity, and impact on functioning]
[Relevant stressors, precipitating events, and context]
[Previous psychiatric history, treatments, and response]
[Collateral information from caregivers, teachers, or other sources]

Past Psychiatric History:
(hyphenated list)
- [Previous diagnoses]
- [Prior hospitalizations]
- [Past treatments and response]
- [Suicidal or self-harm history]
- [Aggression or violence history]

Past Medical History:
(hyphenated list)
- [Medical diagnoses]
- [Surgical history]
- [Developmental history]
- [Perinatal history]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- (e.g., Fluoxetine 10 mg oral daily)

Allergies:
(hyphenated list)
- [eg. No known drug allergies (NKDA)]

Family Psychiatric History:
(hyphenated list)
- [Relative: Psychiatric diagnosis or relevant history]
- (e.g., Mother: Major depressive disorder)

Social History:
(hyphenated list)
- [Living situation: who lives with patient, home environment]
- [School: grade, performance, attendance, supports]
- [Peer relationships: friendships, bullying, social supports]
- [Extracurricular activities]
- [Tobacco, alcohol, substance use: type, amount, frequency]
- [Legal involvement]

Mental Status Examination:
(hyphenated list)
- [Appearance and behavior]
- [Mood and affect]
- [Speech and language]
- [Thought process and content]
- [Perceptual disturbances]
- [Cognition]
- [Insight and judgment]
- [Risk assessment: suicidal ideation, self-harm, aggression]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Relevant physical exam findings]

Investigations:
(hyphenated list)
- [Investigation results with units] (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan)

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary psychiatric diagnosis]

#) [Assessment as a numbered item if multiple diagnoses or issues]
(hyphenated list with each corresponding plan item on a new line)
- [Investigations planned or ordered]
- [Pharmacological treatment plan]
- [Psychotherapy or behavioral interventions]
- [Family or school interventions]
- [Safety planning]
- [Referrals sent]
- [Follow up plan]
- [Return precautions]