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Psychiatric consult note template
Built for inpatient, ED, and outpatient consults where the note must answer a focused question, document your assessment, and hand clear recommendations back to the primary team.
Template content
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Psychiatric Consult Note Consult Question / Reason for Referral - Referring service and specific question(s) to be answered. - Urgency and relevant clinical context provided by the primary team. Relevant History - Psychiatric, medical, substance, and social history pertinent to the consult question. - Current medications, recent changes, and adherence concerns. Collateral / Chart Review - Key findings from records, nursing notes, labs, imaging, or prior psychiatric notes as reviewed. Mental Status Examination - Appearance, behavior, speech, mood, affect, thought process/content, perception, cognition, insight, and judgment. Safety / Risk - Suicidal/homicidal ideation, agitation, capacity concerns if relevant, and risk formulation. Assessment - Diagnostic impression addressing the consult question. - Differential and contributing medical/substance factors when relevant. Recommendations - Numbered, actionable recommendations for the referring team (medications, monitoring, precautions, therapy, disposition). - What psychiatry will follow vs what the primary team owns. Plan / Follow-Up - Psychiatry follow-up plan, communication with referring provider, and pending items.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Leads with the consult question so the note stays useful to the referring clinician.
- Separates recommendations from narrative so action items are easy to find.
- Includes risk and capacity language when those drive disposition decisions.
- Works for telepsych consults and in-person liaison psychiatry visits.
- 1Inpatient psychiatry consults
- 2ED psychiatric consults
- 3Outpatient specialty-to-specialty referrals
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Consult Question Medicine requests evaluation for agitation, capacity for AMA, and medication recommendations in a 54-year-old with alcohol withdrawal history and new confusion. Relevant History Prior AUD; last drink reportedly 3 days ago. On CIWA protocol. No prior psychiatric hospitalizations. Family reports baseline mild anxiety. No known antipsychotic trials. Mental Status Alert, oriented ×2, intermittently inattentive. Mood “irritable,” affect labile. Thought process circumstantial. No clear delusions or hallucinations today. Insight limited regarding need for continued hospitalization. Safety / Risk No SI/HI. Mild agitation managed with redirection. Capacity for AMA currently impaired due to fluctuating attention and incomplete appreciation of risks. Assessment Delirium superimposed on alcohol withdrawal vs residual intoxication effects; rule out Wernicke. Anxiety disorder by history, not primary driver of current presentation. Recommendations 1. Continue CIWA and thiamine; hold new antidepressant until delirium clears. 2. Prefer low-dose quetiapine PRN for severe agitation over benzodiazepine escalation if CIWA controlled. 3. One-to-one observation while capacity remains impaired; reassess AMA capacity tomorrow. 4. Psychiatry will reassess in 24 hours; primary team to notify for escalating agitation or SI. Plan Reconsult tomorrow AM. Communicated recommendations to overnight medicine resident.
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