Psychiatric Intake Documentation

Admission form for recording psychiatric history, current symptoms, mental status exam findings, provisional diagnosis, and level of care determination.

Intake Overview

• Patient Identifier
  Enter the internal medical record number or other approved patient identifier. Do not enter SSN.
• Intake Date
• Intake Time
• Care Setting
• Referral Source
• Chief Concern
  Briefly describe the presenting concern in the patient's or referral source's words.

Consent and Disclosure

• Consent for Psychiatric Evaluation and Treatment
  Confirm that the patient or authorized representative has consented to the evaluation and documentation of clinical information.
• Privacy Notice Acknowledged
  Confirm acknowledgment of the applicable privacy notice and permitted use of PII/PHI for treatment, payment, and operations.
• Authorized Representative Present?
• Representative Relationship

Psychiatric History

• Prior Psychiatric Diagnosis
  List prior diagnoses only if known and clinically relevant.
• History of Psychiatric Hospitalization
• Hospitalization Details
  Include facility, approximate date, and reason for admission if known.
• Current Psychiatric Medications
  List current medications, dose, and adherence if known.
• Prior Treatment History

Current Symptoms and Risk

• Current Symptoms
• Symptom Duration
• Suicidal Ideation
• Homicidal Ideation
• Risk Details
  Document plan, intent, means, protective factors, and any immediate safety actions taken.
• Substance Use Concern

Mental Status Exam

• Appearance
• Behavior
• Speech
• Mood
• Affect
• Thought Process
• Thought Content
  Include delusions, obsessions, preoccupations, or other clinically relevant content.
• Perception
• Orientation

Provisional Diagnosis and Level of Care

• Provisional Diagnosis
  Enter the working diagnosis and, if used, the ICD-10 code.
• Recommended Level of Care
• Level of Care Rationale
  Explain how symptoms, risk, functional impairment, and supports informed the recommendation.
• Immediate Follow-Up Plan
  Include referrals, safety planning, medication plan, or next appointment if applicable.