IDENTIFYING INFORMATION:

Name/age:(initials only)

Marital status:

Ethnicity or race:

Date of appointment:

Individuals present: (include providers)

Location of visit: (in person or via telehealth – include the location of patient like home, work, etc.)

Purpose of visit: (comprehensive psych assessment, follow-up appointment with medication management and psychotherapy, etc.)

DIAGNOSES AND CURRENT MEDICATIONS:

Diagnoses: (if available from the past note, include all psych diagnoses in DSM-V format with appropriate specifiers and modifiers)

Current Medications:

CHIEF COMPLAINT:

Reason for visit:

HISTORY OF PRESENT ILLNESS/INTERVAL HISTORY:

(Current symptoms, mode of onset, symptom severity, pertinent positives and negatives, precipitating/aggravating/alleviating factors, impact on life, changes since the last visit if applicable)

Mood:

Anxiety:

Sleep:

Appetite:

Suicidal Ideation/Self-Harm:

Homicidal Ideation:

Physical activity:

Coping skills:

Looking forward to:

Current and upcoming stressors:

Psych ROS:

Psychosis: (AH/VH?, Paranoia?)

Mania: (Grandiosity? Decreased need for sleep?)

Any other pertinent information:

SOCIAL HISTORY:

Employment/finances:

Relationships/support:

Current living situation:

MEDICAL:

Current medical issues:

Past medical issues and surgeries:

Current medications: (include medication, dose, route, frequency, etc. and all including supplements and OTC medications)

1. (list all)

Allergies:

Medication adherence: (can be in percentage form like 100%)

Medication side effects:

REPRODUCTIVE:

First date of last menstrual period:

Contraception method:

Pregnant: (Yes/No, if yes, include additional information)

Lactating: (Yes/No, if yes, include additional information)

Sexual concerns:

SUBSTANCE USE:

Caffeine use:

Alcohol use:

Tobacco/nicotine use:

Cannabis use:
Illicit drug use:

MENTAL STATUS EXAM:

General Appearance:

Psychomotor:

Attitude and Behavior:

Level of Consciousness:

Orientation:

Speech:

Language:

Mood:

Affect:

Thought Content:

Thought Process:

Perceptions/Psychosis:

Intellect/Fund of Knowledge:

Concentration/Attention:

Abstract Thought:

Judgment:

Insight:

Memory:

PSYCHOTHERAPY NOTE:

Psychotherapy Time: (Include the exact time and number of minutes spent with the patient in psychotherapy).

Target Symptoms:

Treatment goals:

Type of therapeutic intervention:

Session overview:

Towards Goals:

OBJECTIVE ASSESSMENT:

Symptom scales/questionnaires used, score, and interpretation:

(If the patient is taking an atypical antipsychotic an AIMS score should be documented.)

Laboratory results:

CLINICAL IMPRESSION/FORMULATION/MEDICAL DECISION MAKING:

(The detailed formulation should include; patient demographics, pertinent history, presenting problem, interval history if follow-up appointment, treatment plan including the rationale for continuing the current treatment plan or any changes made.)

Provided education about diagnosis, risks, benefits, alternative treatments, and possible side effects and adverse reactions. The patient verbalized understanding and provided consent for medication and treatment plan as outlined below.

DIAGNOSIS:

All diagnoses should be DSM-V diagnoses and include pertinent specifiers and modifiers.

PLAN OF TREATMENT:

(For all medications include all applicable prescribing information including medication name, dose, formulation (tablet, capsule, ampule, etc.), directions including route, frequency, and indication, and the quantity ordered.

Examples: Zoloft (sertraline) 50 mg tablet. Take 0.5 tablet (25 mg) by mouth at bedtime for 6 nights, then increase to 1 tablet (50 mg) at bedtime for depression #30.

For all psychotherapy should include specific recommendations (individual, family, couples, group, etc., and modalities like CBT, DBT, ACT, etc.).

For all diagnostic tests and labs (when, where, and who will administer).

For all referrals include specific provider type and reason for referral.)

1. (use as many numbers as indicated for your patient)

TREATMENT GOAL(s): (should be specific and measurable)

PROGNOSIS: Good/Fair/Poor

FOLLOW UP: (timing)

The case was reviewed and discussed with (include preceptor’s name) who concurred with assessment, clinical impression, and plan of treatment.

Complete Answer: