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Custom Note Template: Psychiatric Evaluation for Inpatient or Emergency Setting

2/3/2018

5 Comments

 
Starting as an NP student, I realized the value of using templates for my notes. It ensures that I don't miss any important points - prompting me to a through assessment every time - no matter how tired/distracted/______ I am.

I've also learned to set it up with default normative answers - so the only things I need to edit are the abnormal findings of note. This lets me be efficient so I can spend more time with talking with patients and less time at my computer.

Finally, making such templates in an easily adapted format ie. Word, allows me to 'cut & paste' into any Electronic Medical Record (EMR) I might be using. If I'm lucky, said EMR will also let me save the template as a default in its own database. This is pretty often the case. 
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btb_template_er-intake.docx
File Size: 37 kb
File Type: docx
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This is template for an initial psychiatric evaluation (i.e. 90791 or 90792) in an emergency room or inpatient setting, though could be adapted to suit any care environment, I imagine.
It covers:
  • Identifying Information
  • Chief Complaint
  • History of Present Illness
  • ​Past Psych History
  • Past Medical History
  • Medications
  • Allergies
  • Family History
  • Psychosocial History
  • ROS
  • Lab Values
  • Mental Status Exam
  • Strengths & Limitations
  • Assessment & Diagnosis
  • Informed Consent
  • Expected Length of Stay
  • Impression & Recommendations, i.e. Treatment Plan
Using the Template

There are three options for inputting data:
  1. Fill-in-the-blank: Change the text prompt by typing in the text you want
  2. Drop down menu: Self-explanatory really. If you don't see an option yo like there is always Option 3.
  3. Free Type text: It is still a word document after all - type whatever you want - where ever you want. Write a novel if you'd like.

​After you've got the template completed to your satisfaction - 'select all' text (Ctrl A) and change the font color to black. And you are good to go!  

If you use this template, I'd love to hear your thoughts, feedback, recommendations!
​
No one person can know everything and a good documentation process can always be improved. 
5 Comments
Jennifer
2/6/2018 06:12:00 pm

Thank you for this excellent template! I'm currently in my first clinical rotation (outpatient) and looking for tools to incorporate into practice.

Reply
Valerie Herber link
4/2/2019 08:11:27 pm

I really like your template, very thorough and complete. I’m having issues trying to download and input it into a word document. Any suggestions please email me!! Thank you.

Reply
Roberta Plunkett link
2/7/2018 08:16:17 pm

I was unable to download your template on 3 different days, 2/5, 2/6, and 2/6. (It's a good template, btw---useful for outpatient as too.) Each time I clicked on the file name to download it, a game of some sort, "You're a Winner!!" would overtake the link, instructing me to click "here" and "there".....it was a virus! And I could not escape it. Then when I went to my downloads settings, I got "Could Not Download" when I clicked on your byb template name. Bummer.

Reply
Rhiannon
2/7/2018 10:43:05 pm

Thank you for your helpful feedback! I'll be emailing you a response and direct file copy shortly. I've contact support and will get this resolved ASAP!

Reply
Rhiannon (BTB Editor/Creator)
2/13/2018 08:00:03 am

Weebly support says:

"It sounds like the issue may be with the users' computer/browser rather than the file. Weebly will not alter or change your files in any way when uploaded to your site so if the file is virus free on your computer it will be virus free on your website."

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