Scribd Logo
Upload

Welcome to Scribd!

  • 157 views

    CL-Psych Referral Form

    Uploaded by

    jlventigan
    This document is a consultation-liaison referral form from the Department of Psychiatry and Behavioral Medicine at the University of the Philippines Manila to evaluate a patient. It includes information such as the patient's name, age, sex, reason for admission, medical history, laboratory results, mental status exam findings, treatment plan, and expectations from the psychiatrist. The referring physician is requesting a psychiatric evaluation and opinion, as well as recommendations for treatment, management, and follow up.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd

    CL-Psych Referral Form

    Uploaded by

    jlventigan
    157 views3 pages
    This document is a consultation-liaison referral form from the Department of Psychiatry and Behavioral Medicine at the University of the Philippines Manila to evaluate a patient. It includes information such as the patient's name, age, sex, reason for admission, medical history, laboratory results, mental status exam findings, treatment plan, and expectations from the psychiatrist. The referring physician is requesting a psychiatric evaluation and opinion, as well as recommendations for treatment, management, and follow up.

    Original Description:

    Referral

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    DOC, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document is a consultation-liaison referral form from the Department of Psychiatry and Behavioral Medicine at the University of the Philippines Manila to evaluate a patient. It includes information such as the patient's name, age, sex, reason for admission, medical history, laboratory results, mental status exam findings, treatment plan, and expectations from the psychiatrist. The referring physician is requesting a psychiatric evaluation and opinion, as well as recommendations for treatment, management, and follow up.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    157 views3 pages

    CL-Psych Referral Form

    Uploaded by

    jlventigan
    This document is a consultation-liaison referral form from the Department of Psychiatry and Behavioral Medicine at the University of the Philippines Manila to evaluate a patient. It includes information such as the patient's name, age, sex, reason for admission, medical history, laboratory results, mental status exam findings, treatment plan, and expectations from the psychiatrist. The referring physician is requesting a psychiatric evaluation and opinion, as well as recommendations for treatment, management, and follow up.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    You are on page 1of 3

    PGH Form No P-450002

    upmed2010.bevho

    University of the Philippines Manila The Health Sciences Center DEPARTMENT OF PSYCHIATRY AND EHA!IORAL MEDICINE Taft Avenue, Manila PHIC Accredited Health Care Provider

    PHILIPPINE GENERAL HOSPITAL

    THIS IS A 2 PA!" #"$"##A% $&#M' P%"AS" $I%% UP A%% (%A)*S +T& (" ACC&MP%ISH", I) 2 C&PI"S-'

    P"e#$e %&'( #pp)op)&#%e bo*. . / "0er1ency +has to 2e seen 3ithin the hour. / #outine + to 2e seen 3ithin 24 hours)ote5 $or patients 3ho already have dischar1e plans, referrals 0ust 2e dropped at least 2 days prior to dischar1e for a thorou1h psychiatric evaluation'

    Patient6s Surna0e5 ,ate Ad0itted5 77777777 ,ate referred to Psychiatry5 Patient location5 8ard 9 Unit5 $or0 filled 2y5 #eferrin1 Physician5 Contact )o' of #eferrin1 M,5

    (ed5
    (printed name and signature)

    CONS+LTATION,LIAISON REFERRAL FORM


    Patient6s )a0e +Print-5
    Last First MI

    Case )u02er5 Address5

    A1e5

    Se:5

    MSS Classification5 Clinical I0pression +Pri0ary 8or;in1 I0pression-5

    Marital Status5 Tel )o'5 &ccupation5

    Re#$o-$ .o) Re.e))&-/ %o P$0'h&#%)0 1P"e#$e %&'( bo*e$23 I h#ve -o%ed $ome 'h#-/e$ &- m0 p#%&e-%4$ MSE 5h&'h &-'"ude$3 . / Speech and lan1ua1e pro2le0s . / Inattention . / A1itation and restlessness . / A2nor0al, increased, or decreased 2ody 0ove0ents . / ,epressed 9 e:pansive 9 irrita2le 0ood . / A2nor0al ran1e, intensity, and appropriateness of affect . / Irrelevance of thou1ht process . / Illusions, hallucinations, delusions . / Suicidal ideations 9 intent 9 atte0pts< self har0 . / Confusional states or sensorial chan1es . / ,isorientation . / Me0ory i0pair0ents . / Poor =ud10ent and insi1ht F)om m0 p)e"&m&-#)0 &-%e)v&e56 I h#ve e"&'&%ed # h&$%o)0 o.3 . / previous psychiatric illness . / alcoholis0, prohi2ited dru1 9 su2stance use 9 a2use . / 2ehavior that deviates fro0 pre0or2id levels . / decline in social 9 occupational functionin1 in the past year . / i0pair0ent in fa0ily relations, or interpersonal relationships 3ith si1nificant others M0 p#%&e-% e*h&b&%ed $ome beh#v&o)$ %h#% h#ve #..e'%ed h&$ .u-'%&o- 5&%h&- %he ho$p&%#" $e%%&-/ %h#% &-'"ude$3 . / refusal or nonco0pliance to treat0ent . / e:pressed issues related to death and dyin1 . / need for co0petency evaluation +to secure

    PGH Form No P-450002 rev02.09 upmed2010

    consent. / e:pressed issues re1ardin1 pre9post operative copin1 . / pro2le0s 3ith staff . / others +please specify-5 77777777777777777777
    RIEF

    HISTORY OF THE A O!E PRO LEM

    MEDICATIONS ON OARD (generic name and dosage) Steroids

    THIS PSYCHIATRY REFERRAL IS DISCLOSED TO3 a- PATI")T . / yes . / no If not, please state 3hy5 2- $AMI%? . / yes . / no If not, please state 3hy5 DO NOT 8RITE ELO8 +to 2e filled 2y Psych #IC-

    ,ate of &nset5 Manner of &nset5 . / sudden . / 1radual &ther associated sy0pto0s5 . / inso0nia . / lac; of appetite "ffects on function in hospital5 . / ne1lects 1roo0in1, eats poorly, etc' . / poor co0pliance 3ith treat0ent . / ne1ativistic to3ards staff . / disruptive in 3ard< to other patients
    RIEF MEDICAL HISTORY 1REASON FOR C+RRENT ADMISSION2 (you may attach patients clinical abstract)

    Anti asth0a ,iuretics Anti hypertensives Anti T( &thers5

    #esident in char1e5 ,ate #eceived5 ,ate $irst Seen5 LATEST LA ORATORY FINDINGS A:is I C(C5 A:is II Ti0e5 Ti0e5

    Si1nificant P" 9 )" findin1s5

    $(S9#(S5 *5 (U)5 AST5 Urinalysis5

    )a5 Creatinine5 Al2u0in5 A%T5

    A:is III

    A:is I@ A:is @

    Urine MAP +>uanti9>uali-5 "C!5 MENTAL STAT+S E7AMINATION A(!5 Cranial CT scan5 ""!5 %u02ar tap5 Thyroid function test5 &thers5 TREATMENT PLAN Please include procedures done/planned for the patient E7PECTATIONS FROM THE PSYCHIATRIST . / "valuation and &pinion . / Treat0ent 9 Co 0ana1e0ent . / Psycholo1ical support for5 + - patient Plan of Mana1e0ent . / Patient directed + - Psychophar0acolo1y + - Psychotherapy + - Individual, type + - $a0ily . / Consultee directed Specify5 . / Staff directed Specify5 ,isposition of patients . / &P, follo3 up . / 8ard A ad0ission . / ,ied . / HAA . / ,ischar1ed 3ithout notification

    PGH Form No P-450002 rev02.09 upmed2010

    + - fa0ily + - staff . / &thers +please specify-5

    . / )o intervention . / ,ischar1e fro0 service $inal date of si1n out5 ,ate dischar1ed5 Total B of days seen5 Total B of H,5

    You might also like