Documentation of Inpatient Care


The Guidelines for Psychiatric Documentation of Inpatient Care were drafted by the Professional Practices Committee of the Texas Society of Psychiatric Physicians and adopted by the TSPP Executive Council on September 17, 1995. An amendment to this document was approved by the TSPP Executive Council on May 28, 2000.

The intent of the guidelines is to assist Texas psychiatrists in achieving a level of clarity and specificity in medical record documentation that will allow them to focus on treatment issues while trying to successfully negotiate the growing demands of utilization review organizations.



The psychiatric evaluation of the inpatient is the cornerstone of the data base which determines need for admission, accurate diagnosis, treatment planning, and approaches. It must therefore be presented in logical order and contain specific information about patient complaints and symptoms.

The psychiatric physician should strive to gather and document all the following information, taking into account the immediate appropriateness, necessity, and availability of the information.

These Guidelines are not considered to be prescriptive for all patients due to the wide variety of circumstances associated with the presentation of patients for psychiatric care.

History, Physical and Psychiatric Evaluation (Must be done within 24 hours of admission):


Identifying Data (can be done on face sheet)

1. Patient’s name
2. Age
3. Address
4. Sex
5. Date of birth
6. Next of kin
7. Who to contact in an emergency
8. Legal status of admission (voluntary or involuntary)

Source of Information

Chief Complaint

1. Succinct statement of complaint
2. May document referral source

Present Illness

1. Reason for admission must be clearly documented
2. Date of onset of illness and course of illness
3. Enough data to justify the admitting diagnosis
(a). Include signs and symptoms patient has or
(b). Symptoms does not have which are common for the diagnosis
4. Precipitating circumstances, stressors, and conflicts
5. History of patient’s emotional, behavioral, social and cognitive function
6. Present psychiatric medication
7. Allergies to medications

Past Medical History

1. Description of previous psychiatric episodes
2. Description of previous psychiatric treatments
3. Past psychiatric hospitalizations
4. Medications used before

(Note: Additional areas may need to be addressed for children)

Other Medical History

Family History

1. Pertinent facts about the family of origin
2. Marital history of each marriage
(a). Children
(b). Document emotional problems of spouse and/or children
3. History of psychiatric or physical problems in the immediate and extended family

Social History

1. Level of education achieved
2. Employment history
3. Sexual preference and behavior
4. Daily activities
5. Developmental history
6. Pertinent legal history

Review of Systems

1. General – fever; chills; lethargy; allergies; drug, alcohol or drug use; endocrine, etc.
3. Respiratory
4. Cardiovascular
5. Gastrointestinal
6. Genitourinary
7. Gynecological
8. Neuromuscular

Mental Status Exam

1. Appearance and State of Consciousness
2. Behavior
3. Affect and Mood
4. Speech
5. Thought Processes and Thought Content
6. Presence or absence of major psychiatric symptoms
(a). Hallucinations
(b). Delusions
(c). Paranoid ideation
(d). Suicidal ideation
(e). Homicidal ideation
7. Orientation for person, time and place
8. Memory – recent and remote
9. Attention and concentration span
10. Judgement
11. Insight
12. Estimate of intellectual capability

Physical Examination

1. Vital Signs – pulse, blood pressure, respirations, and weight (can be recorded in initial nursing assessment)
2. Skin
4. Neck
5. Chest
6. Heart
7. Abdomen
8. Genitalia
9. Pelvic
10. Lymphatics and blood vessels
11. Back and extremities
12. Neurological
(a). Cranial nerves
(b). Sensory function
(c). Motor function
(d). Deep tendon reflexes
(e). Gait and coordination

Diagnostic Impression

1. Use current DSM
2. May have paragraph summarizing the impressions drawn from history and physical evaluation

Assessment of Strengths and Weaknesses

1. Ability to function
2. Social support network
3. Skills and interests

Initial Treatment Plan

1. Treatment goals which are observable, measurable, and relevant
2. Therapeutic interventions to achieve goals and objectives of initial treatment plan
3. Medications
4. Level of monitoring (1:1, q 15 minutes, etc.)

Estimated Length of Stay

1. Preliminary discharge plan


Discharge Criteria

Discharge Summary (Done within 30 days of discharge):

Final Diagnosis

1. Use current DSM

Brief History

1. Summary of symptoms leading to admission
2. Summary of stressors

Summary of Mental Status

Summary of Physical Exam

Lab and X-ray Data
Psychological Testing, if Done

Course in Hospital

1. Progress related to each problem
2. What medications and other therapeutic interventions were used
3. Complications

Condition on Discharge


1. Follow-up treatment
2. List of medications when discharged
3. Diet
4. Physical activities
5. Referrals to others or to another person



1 On May 28, 2000, the TSPP Executive Council approved a name change of the Professional Standards Committee to the Professional Practices Committee.