Psychology Consultation Note

Template-structuur

Dit is de structuur die Notat volgt bij het schrijven van de notitie van het bezoek — u vult deze nooit handmatig in.

Clinical Psychologist Consult Note

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

Reason for Referral:
[Brief statement of reason for psychological consult, including referring provider if applicable]

History of Present Illness:
[Description of presenting psychological symptoms, onset, duration, severity, and impact on functioning]
[Relevant stressors, precipitating events, and associated features]
[Previous psychiatric or psychological interventions and response]

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

Past Medical History:
(hyphenated list)
- [Relevant medical conditions]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- [Include psychiatric and non-psychiatric medications]

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

Family Psychiatric History:
(hyphenated list)
- [Relative: Psychiatric diagnosis or relevant history]

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]
- [Relationship status and supports]
- [Education level]

Mental Status Examination:
(hyphenated list)
- [Appearance and behavior]
- [Speech]
- [Mood and affect]
- [Thought process]
- [Thought content]
- [Perceptions]
- [Cognition]
- [Insight and judgment]

Psychological Testing (if performed):
(hyphenated list)
- [Test name: results and interpretation]

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

#) [Assessment as a numbered item if multiple issues]
(hyphenated list with each corresponding plan item on a new line if mentioned)
- [Diagnosis and formulation]
- [Recommended psychological interventions]
- [Medication recommendations if applicable]
- [Counselling discussion]
- [Referrals sent]
- [Follow up plan]
- [Return precautions]