SITUATION

- Patient's Name: [PATIENT'S NAME]

- Age: [PATIENT'S AGE] years old

- Gender: [PATIENT'S GENDER]

- Diagnosis: [PRIMARY PSYCHIATRIC DIAGNOSIS]

- Reason for Consultation: [BRIEF DESCRIPTION OF REASON FOR CONSULTATION]

BACKGROUND

- Medical History: [BRIEF OVERVIEW OF MEDICAL HISTORY INCLUDING RELEVANT PSYCHIATRIC HISTORY]

- Current Medications: [LIST OF CURRENT PSYCHIATRIC MEDICATIONS AND DOSAGES]

- Allergies: [PATIENT'S KNOWN ALLERGIES, IF ANY]

- Psychosocial History: [BRIEF SUMMARY OF PATIENT'S PSYCHOSOCIAL HISTORY]

ASSESSMENT

- Mental Status Examination: - Appearance: [DESCRIPTION OF PATIENT'S APPEARANCE] - Behavior: [DESCRIPTION OF PATIENT'S BEHAVIOR] - Mood/Affect: [DESCRIPTION OF PATIENT'S MOOD AND AFFECT]

- Thought Process/Content: [DESCRIPTION OF PATIENT'S THOUGHT PROCESS AND CONTENT]

- Cognition: [ASSESSMENT OF PATIENT'S COGNITIVE FUNCTIONING]

- Risk Assessment: - Suicidal Ideation: [DESCRIPTION OF ANY SUICIDAL IDEATION]

- Homicidal Ideation: [DESCRIPTION OF ANY HOMICIDAL IDEATION]

- Other Risks: [ANY OTHER IDENTIFIED RISKS]

RECOMMENDATION

- Specific Consultation Request: [CLEAR STATEMENT OF WHAT CONSULTATION IS REQUESTED FOR]

- Urgency: [LEVEL OF URGENCY FOR CONSULTATION, IF APPLICABLE]

- Proposed Interventions: [LIST OF PROPOSED INTERVENTIONS OR ASSESSMENTS]

- Follow-up Plan: [INSTRUCTIONS FOR FOLLOW-UP AND NEXT STEPS]