Demographic Data   
Patient’s age and patient’s gender identity 
IT MUST BE HIPAA compliant. 

Chief Complaint (CC): 
Place the patient’s CC complaint in Quotes 

History of Present Illness (HPI): 
Reason for an appointment today. 
The events that led to hospitalization or clinic visits today.  
Include symptoms, relieving factors, and past compliance or non-compliance with medications 

Any adverse effects from past medication use 

Sleep patterns – number of hours of sleep per day, early wakefulness, inability to initiate sleep, inability to stay asleep, etc. 
Suicide or homicide thoughts present 
Any self-care or Activity of Daily Living (ADL) such as eating, drinking liquids, self-care deficits, or issues noted? 

Presence/description of psychosis (if psychosis, command or non-command) 
Past Psychiatric History (PSH):  

Past psychiatric diagnoses 
Past hospitalizations 
Past psychiatric medications use 

Any non-compliance issues in the past? 
Any meds that didn’t work for this patient? 
Family History of Psychiatric Conditions or Diagnoses: 
Mother/father, siblings, grandparents, or direct relatives 
Social History:? 
Include nutrition, exercise, substance use (details of use), sexual history/preference, occupation (type), highest school achievement, financial problems, legal issues, children, and history of personal abuse (including sexual, emotional, or physical). 
To medications, foods, chemicals, and others.  
Review of Systems (ROS)?(Physical Complaints): 

Any physical complaints by the body system? (Respiratory, Cardiac, Renal, etc.)  
Mental Status Exam: 

This is not a physical exam. 
Mental Status Exam (MSE) 
Assessment (Diagnosis) 
Two (2) differential diagnoses with ICD-10 codes. 
Must include rationale using DSM-5 Criteria (Required)  

Why didn’t you pick these as a major diagnosis? 
Working Diagnosis 

Final or working diagnosis (1), with ICD-10 code.  
Must include rationale using DSM-5 criteria required – Which symptoms/signs in the DSM-5 the patient matches mostly) 

Treatment Plan (Tx Plan):  

Pharmacologic:  Include complete information for each medication(s) prescribed 
Refill Provided:  Include complete information for each medication(s) refilled 

Patient Education: 
Including specific medication teaching points 

Was the risk versus benefit of the current treatment plan addressed for meds or treatment 
Risk versus benefit of non-FDA approved for working diagnosis – Off-label use of medication education to patient addressed? 

Make Decision for prognosis: Good, Fair, Poor 
Provide brief statement lending support for or against the decided prognosis. 

Therapy Recommendations: 

Type(s) of therapy recommended. 
Did you recommend follow-up with a Psychiatrist, PCP, or other specialist or healthcare professionals? 

When is the subsequent follow-up?

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