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?
Include the rationale for the F/U recommendation or referral.
