CLINICAL PRESENTATION FORMAT - Community Clinic Association ...
CLINICAL/CASE PRESENTATION FORMAT DMH/DHS COLLABORATION PROGRAM
Demographic Information: This should be a very brief overview of the person for whom you are seeing psychiatric consultation to include:
? Name, age, marital status, gender, occupation, language, race, religion (if relevant);
? With whom does person live; ? Prior treatment for similar condition including hospitalization.
Chief complaint: Why the patient was referred in his/her own words.
Please be prepared to discuss the following with the consulting psychiatrist: ? Depressive symptoms
? Bipolar symptoms
? Anxiety symptoms
? Psychotic symptoms
? Substance Use/Abuse
? Other (Cognitive, Eating Disorder, Personality traits)
? Past treatment including response to treatment
? Safety/Suicidality
? Relevant psychosocial factors
? Medical problems
? Current medications
? Functional impairment(s)
? Patient goals
? Mental Health Diagnosis (If you are not quite sure of the specific diagnosis you may use an NOS diagnosis or defer until you are certain - if that is the case, seek consultation or supervision as your diagnosis should inform the treatment)
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