Description

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

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). 
Allergies:  
To medications, foods, chemicals, and others.  
Review of Systems (ROS)?(Physical Complaints): 

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

This is not a physical exam. 
Mental Status Exam (MSE) 
Assessment (Diagnosis) 
Differentials 
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) 

Plan 
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? 

Prognosis: 
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. 
Referral/Follow-up: 
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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